Dr.

Abo Al- Mawaheb

 Maxillofacial Prosthodontics
 It is a branch of
Prosthodontics
concerned with
restoration and
replacement of intra-
oral and associated
facial structures by
artificial substitutes
 Maxillofacial Prosthodontics
 These structures may
be missing or
mutilated as a result
of surgery, trauma,
and congenital or
developmental
defects
 Maxillary Defect
 It is a disruption in the
continuity of the
normal oro-nasal
partition
These Types of Maxillofacial Defects :
I- Congenital defects:
 cleft lip, cleft palate, missing ear and facial
cleft
II-Acquired defects:
 caused by surgery, pathology or accidents
III- Developmental defects:
 prognathism or retrognathism
Maxillofacial Prosthetic Appliance
 Requirements of Maxillofacial Appliance
1. Must be easily seated in
place comfortably
2. Must be Securely retained
3. Must be durable and easily
cleaned
4. The material used must be
easily adjusted and altered
if needed
 Classification of Maxillofacial
Appliances
They are classified according to its site into
1-Intra-oral appliances
 Obturators
 Stents
 Splints
 Resection Appliance
2-Extra-oral appliances
3-Combined intra-oral and extra-oral
appliances
4-Cranial and facial restorations
 Intra-oral prosthesis

10
11
 Extra-oral prosthesis

An artificial nose is attached Ocular prosthesis replaces

with medical-grade
12 a missing right eye.
adhesive
 Combination prosthesis

Patient after operation with

extensive maxillary-facial defect

Left (facial Facial prosthesis and The patient;s face and

prosthesis) Right obturator held chewing function have
(an obturator) together by magnets been restored
 Maxillofacial Team
 Management of patients with acquired or
congenital defects involves cooperation and
coordination of care among members of
interdisciplinary medical team
1. Plastic surgeon
2. Prosthodontist
3. Orthodontist
4. Speech Therapist
5. Psychologist
6. Social Worker
7- Dental technician
8-Otolaryngologist (ear-nose-throat
specialist)
 1-Plastic surgeon
 Responsible for
 His skill in repair and surgical
reconstruction of deformities is valuable in
treatment planning and the final success of
surgical rehabilitation of the patient
 This decision should be based on
1. determination of the patient's need
2. the assessment and evaluation of the
case
3. the functional benefits gained by
surgical reconstruction
 2-Prosthodontist
 In inoperable cases
 Artificial restoration is
the only way for
rehabilitation of
maxillofacial patients
 The prospective patients
for head and neck
surgery who are
candidates for any
maxillofacial prosthesis
should be seen by the
maxillofacial
Prosthodontist for
diagnosis and
pretreatment evaluation
before surgery
 2-Prosthodontist
 coordination
between the plastic
surgeon and the
Prosthodontist is
necessary
 Structures that
provide valuable
support, retention
and stability for the
prosthesis should
be preserved
 3-Speech Therapist
 The role of speech
therapist is to
correct defective
speech caused by
palatal defects

 In congenital cleft:
 it is so important because the normal
speech pattern is not formed
 so even with correction of the anatomical
defect the patient needs speech therapy to
break the abnormal pattern first and to
learn normal speech
 3- Speech Therapist
 In acquired cleft palate:

 The speech returns to normal immediately

after the correction of the defect because
the speech pattern is already formed
 Speech therapist will help the patient to
articulate the words correctly before and
after surgery
 4- Otolaryngologist
 He will assist in the
evaluation and management
of ear infections and hearing
loss that may be side effects
of child's cleft abnormality

5- Orthodontist
 He plays an important role
in treatment of
malocclusion associated
with cleft lip and palate
patients especially in the
mixed dentition
 6- Psychologist
 To help the patient to accept the problem
with a proper perspective
 To improve the morale and psychological
attitude of the patient
 To gain the patient's co-operation in the
course of treatment
7- Social Worker
 To provide guidance and counseling for the
child and the family in dealing with the socia
and environmental aspect of cleft
abnormality
 To guide the patient for his future life after
the treatment
 8- Dental technician

 cooperation and coordination

between the Prosthodontist and well
trained dental technician is vital in
constructing successful appliances
needed for these cases
Any Question…….. ?!
 CONGENITAL
DEFECTS
Dr. Abo Al-Mawaheb Ebrahim
 Congenital defects Acquired defects

 Detected at birth  Occur after birth

due to trauma,
infection, or tumor
resection
 Confined to the line of
fusion between palatine  Occur anywhere in
and pre- maxillary
the palate
processes (Y- shaped
fusion of the
processes)
 It may occur as
 Once it started, it
continues along the confined area in the
suture midline, with
complete fusion of
 Normally the oral and nasal cavity are
separated by a complete partition (the
palate) which prevent communication
except at the most posterior end through a
well coordinated velo-pharyngeal sphincter.
 The palate is formed
due to fusion of
palatine process and
the median nasal
process
 The fusion starts at
the future position of
the incisive papilla
and continues
anteriorly and
posteriorly till
complete fusion
occurs (Y- shaped
 Palatal Development

 It begins at 5 th week intra-uterine (W.I.U)

 completed by the end of 12 th W.I.U.
 Develop from two primordial structures:
1. primary palate (median nasal process )
Develops at the end of the 5 th W.I.U.
2. Secondary palate
Begins at 7 th W.I.U
 primary palate
 Develops at the end
of the 5th W.I.U.
• Develops from the 2
median nasal
processes
 It gives rise to
1. PREMAXELLA [part of the hard palate
anterior to the incisive foramen]
2. The upper lip
3. The anterior part of the maxillary
alveolar process and the incisor teeth
A- Median nasal process
B- lateral nasal process
C- maxillary process
 Secondary palate
 Develops from the
2 lateral palatine
processes
posterior to the
incisive foramen
 Fusion begins at
9th W.I.U and
completed by the
12th W.I.U.
 Gives rise to the hard and soft palate
 The palate
 The incisive
foramen
remains the
embryologic
border between
1ry and 2ry
palate
• From this meeting point (the incisive
foramen) union of median and lateral
nasal processes progresses in 2
routes in the form of Y-shaped
 The palate
 Anteriorly
To form the Premaxilla,
upper alveolar ridge and
lip
 Posteriorly:
To form hard and soft
palate
 Lack of fusion
between the
embryologic
processes leads to
what is called clefts
Congenital Cleft Lip And Palate

 Definition
 Lack of fusion of the
embryological processes
which normally unite during
the inter-uterine growth to
form the lip and palate
 The child can have cleft lip,
cleft palate or both
 Congenital Cleft palate
 Definition
 Lack of continuity of the
roof of the mouth through
the whole or part of its
length in the form of a
fissure extending
Anteroposteriorly
• The degree of cleft can
vary greatly from bifid
uvula to severe cleft
involving both the soft and
hard palates
 Congenital Cleft lip
 Definition
 It is an abnormality in
which the lip does not
completely form during the
fetal development
 The degree of cleft vary
from notching of the lip to
severe opening from the lip
up to the nose
 It may be unilateral or
bilateral
 Incidence of the Cleft
 The general accepted
incidence rate is 1-700
of infants were born
 Unilateral cleft is more
common than bilateral
clefts of the lip
 Left-sided clefts
compromise 70% of
unilateral clefts
 Incidence of clefts is
twice in males than in
females
 Etiology of Clefts
 The specific cause of many birth
defects is unknown
1. The abnormal position of the embryo
2. Pressure of the amniotic fluid
3. Failure of the tongue to drop
4. Persistence of epithelium at the
junction of the two palatal shelves
5. multiple genes inherited from both
parents and environmental factors
 Factors affecting induction of
cleft palate
I. Hereditary or genetic factors
II. Environmental factors such as :
1. Endocrine factors
 Hormonal disturbance or cortisone
therapy influence cleft formation
2. Chemical irritation
 Mothers exposed to chemical irritation As
hypoxia and hypervitaminosis ( vit. A )
3. Radiation and x-ray
4. Nutritional insufficiency
 Dietary deficiency as (vitamin A &
riboflavin)
5. Infection and disease
 Infectious disease of the mother and
German measles
6. Stress and Anxiety
 Disturb fetal circulation with first
trimester of pregnancy
 Classification of clefts
 Clefts can be classified into
three broad classification
1. Cleft lip without a cleft palate
2. Cleft palate without a cleft lip
3. Cleft lip and cleft palate
together
 Cleft lip with or without cleft
palate is generally more
common in boys
 cleft palate occurring alone
more common in girls
 Veau's classification
 Veau's classification system
depends on the extent of the
cleft
A. Group I : cleft of the soft palate
only
B. Group II : cleft involving the
hard palate and soft palate
C. Group III : cleft involving the
soft palate to the alveolus
involving the lip
D. Group IV : complete bilateral
clefts
 Disabilities associated with
cleft lip and palate
1. Improper feeding and mastication
 Babies cannot perform sucking
 Masticatory function is impaired due to
missing teeth and malocclusion causing
malnutrition and debilitation
2. swallowing
 Fluids and food will regurgitate to the nasal
cavity
3. Esthetics
 It causes a distorted facial appearance
4. General health
 Deteriorated due to inefficient feeding and
mouth breathing
4. psychological trauma
5. speech
 Children with clefts suffer from incompetent lips
and\or inadequate velo-pharyngeal closure
 The air stream is necessary for production of
sound will escape through the nose rather than
through the oral cavity
 Vowels and Nasal consonants are the only sounds
that are not affected by cleft palates
 speech problem is more complicated in congenital
defects than in acquired defects as speech is a
learned process
 Sequence of treatment
I- Presurgical phase
 Assess the severity of the case
and counselling
 Feeding devices
II- Surgical treatment
 Lip repair
 Palatal repair
III- Orthodontic treatment
IV-Definitive prosthetic treatment
 I-Pre-surgical phase
 It Starts at birth and continue up to 3
months
 it includes
1. Assess the severity of the case and
counselling
2. Reassure the parents
3. Feeding
 nutrition is necessary for growth
 It helps infant's preparation for the
1st surgery
 According to the TYPE and SEVERITY of the
cleft, a variety of feeding devices are
available
 I- Feeding device
 Infants with cleft lip only can
feed normally
 Infants with cleft palate the
feeding problem is more
significant and should use
feeding device
 it includes
1. A soft nipple
2. Cross-cut nipples
3. Longer nipples
4. The squeezable bottle
5. Feeding Appliance
 I- Feeding Appliance
 It is a custom made
plate covering the
palatal defect
 It is in the form of
acrylic plate attached
to the neck of the
feeding bottle
 Or it may be designed  It helps in
with a wire handle to
feeding of cleft
allow the mother to
push the plate against
palate infants
the cleft in order to during the pre-
obliterate it during palatal surgery
breast feeding period
 Function Of Feeding Plate
1. It obturates the cleft and restores the
separation
2. It creates a rigid platform towards which the
baby can press the nipple and extract the
milk
3. It facilitates feeding and reduces nasal
regurgitation
4. It reduces the incidence of choking
5. It helps to position the tongue in correct
position
6. It prevents the tongue from entering the
defect
7. It helps in speech development
8. It reduces the passage of food into the naso-
pharynx hence reducing the incidence of otitis
media and naso- pharynhgeal infections
 Fabrication Of Feeding Plate
1. Primary impression
2. A special tray
3. The final impression
4. Master cast
5. The wax pattern
6. Flashing, de-waxing
and feeding plate was
fabricated with heat
cured clear acrylic
7. 10 inch silk suture
was passed through
and tied to the
feeding plate
 Hold the feeding(plate) appliance

1. By parent's finger
during feeding
2. Attached to the
feeding bottle
3. Hold by stuck
sheets (Plastic
sheet / Steristrips)
 A. Lip repair
 It is the treatment of
choice for congenital
defects
 Timing of surgery
 depends on THE
RULE OF TEN

 10 pounds in weight.
 10 weeks old
 Hemoglobin count of 10.
 A. Lip repair
 The 1st surgery for the lip is
performed at AROUND 3 MONTHS in
order to:
1. Facilitate feeding
2. Improve appearance.
Lip repair without excessive
tension will help to:
1. Establish favorable contour in
the premaxillary area
2. Narrow the palatal cleft (if
present)
 II- Palatal Repair

1. To enhance development of speech

2. Proper swallowing and breathing
3. Decrease dento-alveolar deformities
4. Maintain proper maxillary growth
 Timing of surgery
 It varies from 12 months to 4 years,
depending on the width of the cleft
 surgery on the palatal shelves should
not be performed too early to allow
Palatal shelves continue to grow to
 III- Orthodontic Treatment
 Principles Of Orthodontic Treatment
1. Expansion of maxilla
 Done by using a palatal
expansion device done
at the age of 7 years
 To correct segment
position and cross-bite

2. Monitoring eruption of
teeth
3. Decision to leave the
missing lateral space
opened or not
 Indications Expansion of maxilla
1. Preoperatively for
cases having
complete unilateral
or bilateral
collapsed clefts
2. To align lateral
segments of the
palate
3. Diagnostic aid to
assess the need for
speech progress
 Expansion device of maxilla
 It consists of two parts
1. Palatal part
 composed of 2 separate
lateral sections united
by expansion devices
covering the hard palate
2. Pharyngeal part
(speech aid)
 To achieve improvement
in speech and
deglutition
 Bilateral Cleft Palate Appliance:
activation of the appliance causes the
anterior portion of the appliance to be
drawn posteriorly reducing the
prognathic segment
 IV- Definitive Prosthetic Treatment
 The initial Prosthodontic care is to
fabricate a well-fitting interim R.P.D.
I. Rehabilitation of patient undergo
surgical treatment
 Indications :
1. Failure of surgery to close the defect
2. Movement of soft palate is inactive
3. When a transitional prosthesis is
required
4. Incompetent palatopharyngeal
closure
II. Rehabilitation of Un-operated Patient
 Indications :
1. Wide soft palate defect
2. Wide hard palate
defect
3. Debilitated patient
4. Cases requiring
expansion prosthesis
5. Partial or complete
paralysis of soft
palatal
6. When surgery is to be
delayed to allow for
proper growth
 III.Prosthetic Rehabilitation For
Adolescents And Adults
1. Fixed partial dentures (FPD)
2. Removable partial dentures
(RPD)
3. Complete denture (CD)
4. Maxillary overdenture (Max.
OD)
5. Osseointegrated implants
(Imp.)
6. Speech aid appliance
 1. Fixed partial dentures (FPD)
 Most prosthodontists prefer to restore
all anterior fixed units (at 25 Y)

2. Removable partial dentures (RPD)

 The same designs of normal
patients EXCEPT for patients
with Velopharyngeal
deficiencies, where the R.P.D
must support
 R.P.D must support
1. Palatal lift prosthesis
2. Obturator prosthesis
 Prosthodontist must
consider the long lever
arm created by the
extension specially in
Kennedy Class I Or II
Cases which need
adequate indirect
retention
 3. Complete denture (CD)
The problems encountered due to:

1. The reduced size of

the cleft maxilla
2. Excessive inter-arch
space
3. Lack of bony palate
4. Poor alveolar ridge
development and
shallow depth of
the palate
5. Scarring from lip
closure
 4. Maxillary overdenture (Max. OD)

 May be supported by

1. The remaining
teeth
2. Combination of
remaining teeth
and implants
3. Implants alone.
 5. Osseointegrated implants
(Imp.)
 patient with an alveolar
cleft is usually missing
the permanent lateral
incisor on the side of the
cleft.
 An implant- supported
restoration to replace
the missing lateral
incisor
  Advantages of implant- supported
restoration
1. Abutment tooth
preparation is not
required with the
decreased possibility of
damage to the dental pulp
2. Increased loading of the
abutment teeth is avoided
3. The implant in the
alveolar cleft may
transfer functional
forces to the graft
which could decrease
resorption of the graft
 SPEECH
PROSTHESES

Dr. Abo Al-Mawaheb Ebrahim

Anatomy And Physiology Of Palatal
And Pharyngeal Muscles

▪ The palatal and

pharyngeal
muscles are the
muscles required
for normal
deglutition and
production of some
speech sounds
 Pharynx
▪ The pharynx is a
simple funnel shaped
tube
➢ The Posterior pharyngeal
wall
▪ It has a forward
bulge called Ridge of
Passavant
▪ The constrictor
muscles are arranged
by inter locking fibers
 Pharynx
▪ The upper part of
the pharynx is
formed by the
superior muscles
which is
concerned with
both speech and
swallowing
▪ While its lower
part is concerned
with swallowing
only
 Ridge of Passavant
▪ It is a horizontal ridge or
cushion "cross roll" on
around the lateral and
the posterior
pharyngeal wall at the
horizontal level of the
hard palate that bulges
forward during speech
and swallowing
 Ridge of Passavant
▪ It corresponds
to the level of
Atlas vertebra
▪ It serves as a
guide for proper
placement of
soft palate
obturator
prosthesis
▪ It is visible by
the presence of
 Velopharyngeal function (Sphincteric
action)
▪ It is a precise
coordinated valve
formed by several
muscle groups
▪ At rest the soft palate
drops downwards so
that the oropharynx and
naso-pharynx are
opened allowing for
normal breathing
 Velopharyngeal function

▪ The velopharyngeal
sphincter is opened
in certain speech
sounds as vowels
and nasal
consonants
Closure of the nasal cavity from the oral
cavity
▪ This closure is required as in
deglutition and plosive sounds

▪ Soft palate (middle 1/3):

▪ It arcs upwards and
backwards to contact
the posterior
pharyngeal wall at the
plane of the palate
 Closure of the oral cavity from the
nasal cavity and the pharynx
▪ This closure is required during
A. Sucking

▪ During sucking closure of the oral

cavity by the lips anteriorly and the
soft palate and the tongue posteriorly
creates negative intra-oral pressure
necessary for flow of milk
 Closure of the oral cavity from the
nasal cavity and the pharynx
B. Speech
▪ In pronunciation of
the nasal sounds (M,
N and "ing" ) are
produced with the
soft palate lowered
allowing the air
stream to escape
through the nose
 Closure of the oral cavity from the
nasal cavity and the pharynx
• In the (M) sound
the escape of air
is totally through
the nose
• in the ( N ) and
"ing" sounds the
air escapes
partially through
the nose and
partially through
the mouth
 Speech
▪ Speech
▪ It is formulated,
perceived and decoded
unique to human
▪ There are no organs for
speech per se
▪ It is a learned process
developed over years
start at age of 2 years
and takes up to 6.5 years
in girls and 7.5 years in
boys to master it
 Components of speech

1.Respiration
2.Phonation
3.Resonation
4.Articulation
5.Neurologic integration
6.Audition
 Speech And Maxillofacial Prosthesis
▪ In palatal defects
▪ The plosive (B, P, T, D, K) sounds are
the most affected sounds
▪ the seal will be broken and pressure
can't be built up
A. Resonance disturbances is manifested
1. Excessive nasal resonance (hyper
nasality) As in
➢ velopharyngeal insufficiency (Patients
with acquired effects)
➢ velopharyngeal incompetence
2. Insufficient nasal resonance (hypo
nasality)
B. Articulation deficiencies are manifested
1. Distortion
2. Substitution
3. Omission
▪ Velopharyngeal insufficiency
▪ The patient has inadequate, short length of
the soft palate for closure
▪ Causes: Congenital or developmental
defects.
▪ velopharyngeal incompetence
▪ The patient has normal velopharyngeal
tissues but these tissues are not able to
perform velopharyngeal closure
▪ Causes: neuromotor disorders
 APPLIANCES USED FOR SOFT
PALATAL DEFECTS
I. Obturators of Total Soft Palatal
Defects (Speech Obturator /
speech bulb / speech aid)

II. Palatal lift prosthesis

III. Meatal Obturator

 Speech Obturator
Definition
▪ It is a design similar to
partial denture with
extension away from
the hard which act as a
core against which the
palatopharyngeal
musculature can form
a seal
▪ Speech Obturator consists of 3 parts
1. Palatal portion
Cover the hard palate
and retained by clasps
1. Velar portion
replace the body of soft
palate
1. Speech bulb
the functional
component providing
contact with the
pharyngeal musculature
 Speech Obturator
Fabrication
1. The stock tray is
extended with base
palate wax then
alginate impression is
taken to record the
defect accurately
2. The secondary
impression is made
after mouth preparation
3. The metallic framework
is Constructed with cast
wire loop extension into
the defect
4. The wire loop should
be
➢Extend into the soft
palatal defect slightly
above the palatal bone
➢Doesn't contact activated
Velopharyngeal
musculature
5. Modeling compound
impression is addad to the
loop
The patient is instructed to:
▪ Extend and flex the head (30°)
▪ Move his head to the left and
right
▪ Speak and swallow
➢ These movements activate the
remaining velopharyngeal
musculature and mold the
modeling plastic
4. Scrap the modeling
compound
to allow for addition of
fluid wax for final
impression
5. Wax and the prosthesis
is left in the patient's
mouth for 5 minutes
during which functional
movement are repeated
6. The final impression
is removed from the
mouth and chilled with
cold water
7. The final impression
should have
1. Convex superior surface
2. Concave lateral and
inferior surface
8. Boxing of the impression
to pour a new cast
"altered cast impression"
9. The altered cast
is processed in clear AR
and well polished
9. The prosthesis is adjusted
By using PIP blanched mucosa can be
seen through the transparent AR
8. Speech should be checked by phonetic
tests
▪ If sound is hypo-nasal indicates a tight
prosthesis
▪ If sound is Hyper-nasal indicates an ill
fitting prosthesis
▪ Plosives To allow movement the velar
and the pharyngeal portion should be
checked
9. Delivery of the prosthesis
 Movable pharyngeal Obturator
▪ To allow movement the
velar and the pharyngeal
portion
▪ A hinge is placed
between the palatal and
velar portion or
▪ The velar portion is
made from soft rubber
AR
▪ These movements are
not physiologic
 Palatal lift prosthesis
▪ Definition:
▪ It is used for patients
with velo-pharyngeal
incompetence who
exhibits compromised
motor control of the soft
palate as in
1. Myasthenia gravis, Cerebro-vascular
accidents
2. As a sequel following adenoidectomy
, tonsillectomy or maxillary resection
 ▪ Objective:
▪ To displace the soft palate
to the level of normal
palatal elevation enabling
closure by pharyngeal wall
action
▪ Advantages of palatal lift prosthesis
1. The gag response is minimized
2. The physiology of the tongue is not compromised
due to the more superior position of the palatal
extension
3. The access to the nasopharynx for obturator (if
necessary) is facilitated
4. The lift principle has application to many patients
who cannot be treated with palatal surgery.
 Palatal lift prosthesis
Fabrication
1. The custom resin tray
is extended with base
plate wax
2. A partial denture frame
is fabricated with
retentive meshwork or
wire loops extending
3. Modeling plastic is
added to the retentive
meshwork
until the appropriate
displacement of the soft
palate (it should look
like "beaver tail" after
molding

4. Impression wax is used

5. Speech should be monitored
 Palatal lift with obturator
prosthesis
▪ It is used in patient with
partial maxillectomy defect
▪ After obturation with a
silicone bulb the speech
remain hypernasal due to the
loss of innervation to
remaining soft palate
▪ the palatal lift with obturator
bulb is added then speech
returned to normal
 Meatal Obturator
▪ Definition
▪ It is an obturator extends
superiorly and posteriorly
from the hard palate border
separating the nasopharynx
and nasal cavities at the
level of the posterior
Choncae
▪ A drilling hole 5 mm in
diameter in the obturator is
essential for air emission
Any Question…….. ?!

Thank You
Acquired Maxillary Defects

Dr. Abo Al-Mawaheb

Ebrahim
 Etiology Of Acquired Maxillary
Defects
I. Trauma
II. Disease
III. Surgical Resection
 Trauma
1. Sharp instrument
2. Gun-shot
3. Comminuted
fracture of the
maxilla
4. Motor vehicle
accident
5. Suicide attempt
 Disease
1. Cancer
2. T.B.
3. Syphilis
4. Osteomyelitis of the palate
5. Secondary fungal infections in
immune-suppressive or severely
debilitated patients
6. Suction disc
 Surgical excision
▪ Surgical
removal of
1. Malignant
tumor
2. Benign tumor
involving the
palatal structures
 Disabilities associated Of
Acquired Maxillary Defects

I. Speech
II- Swallowing
III- Psychological trauma
VI- Appearance
 Speech

▪ Constant air escape through

the nose lead to hyper nasality
of speech
▪ These patients do not require
speech therapy after prosthetic
treatment because they had a
learned speech pattern
 Swallowing
1. Nasal regurgitation
(fluid leaking into the nasal cavity)
2. Difficulty in swallowing of solids
or liquids

Psychological trauma
▪ Loss of a part of the face lead to
severe psychological trauma
which deprive the patient from
all their social contacts
 Appearance
1. Appearance is greatly
affected due to loss of
support of the facial
structures
2. Sometime, surgery
extend to the inferior
border of the orbit
leading to disfigurement
of the face and lowered
the level of the eye
which may lead to
diplopia
 Classification Of Acquired Maxillary
Defects
I. According to location
▪ Anterior, posterior, median,
or lateral
II. According to size and site
of defect
1. Unilateral total maxillectomy
(hemi-maxillectomy)
2. Unilateral partial
maxillectomy
3. Bilateral total maxillectomy
4. Bilateral partial maxillectomy
 Armany's Classification of maxillary
defects
▪ According to the defect location and its relation
to the remaining teeth
Class I: lateral defect reaches the midline
Class II: lateral defect doesn't reach the midline
Class III: median defect
Class IV: lateral defect crosses the midline

Class V: posterior defect with anterior teeth remaining

Class VI: anterior defect with posterior teeth
remaining
 Prosthetic Rehabilitation Of
Acquired Maxillary Defects
▪ Indications
1. Large defects that
cannot be corrected by
surgery
2. When there is a
possibility of
recurrence
3. Large soft palatal
defects as they are
difficult to restore
surgically with normal
function
 Obturators
▪ Definition
▪ It is a prosthesis used to
close a congenital or
acquired opening in the
palate
▪ Phases of prosthetic
rehabilitation for a patient
with acquired surgical
defect of the maxilla
1. Surgical obturator (Immediate obturator)
2. Interim obturator (2-4 weeks post-surgical)
3. Definitive obturator (3-4 months after surgery)
 Surgical obturation

▪ Definition

▪ It is the
placement of
prosthesis at
or immediately
after the
surgery
▪ It is modified
to
accommodate
for the rapid
soft tissue
change which
occur within
the defect
during healing
of the wound
 Objective of surgical
▪
obturation
To restore and maintain
oral function at a
reasonable level during
the postoperative period
until healing is completed
▪ Surgical obturation is
achieved by
1. Immediate surgical
obturator
2. Delayed surgical obturator
 Immediate surgical obturator

▪ It is constructed
on a maxillary
cast obtained
before surgery
 Immediate surgical obturator
▪ Advantages
A. Functional
1. Provide a matrix on
which the surgical pack
placed
2. Enable the patient to
speak and deglutition
postoperatively
3. Earlier removal of the
nasogastric tube
 Immediate surgical obturator
B. Hygienic
▪ The obturator
separates the
surgical site
from
contamination
with oral
contents thus
reducing the
local infection
 Immediate surgical obturator

C. Psychological

1. The prosthesis decreases the

psychological impact of the surgery
2. The prosthesis restores the
patient's self image
3. The prosthesis reduce the period of
hospitalization
 Immediate surgical obturator
▪ Principles Of Design

1. Should be simple and

light in weight
2. Should terminate
shorter than the skin
graft-mucosal junction
3. Normal palatal
contour to allow
speech and deglutition
 Immediate surgical obturator

▪ Principles Of Design
4. No posterior
occlusion
5. If there is an old
denture can be used
6. The fitting surface
have a wire loops to
hold the lining
material
 Retention of Immediate surgical
obturator
▪ For Dentulous patients

1. Perforated at the
inter proximal
extensions
2. light wire clasps
3. buccal retaining
flange
 Retention of Immediate surgical
Obturator

▪ For edentulous patients

▪ wiring of the prosthesis

to remaining bony
structures

1. peri-alveolar (circumferential wiring)

2. circum-zygomatic wiring
3. wiring to the anterior nasal spine)
 Construction of Immediate surgical
obturator

A. Impression procedures
1. Tray modification
2. Material used (rapid-setting
irreversible hydrocolloid)
B. The cast is altered
1. The proposed surgical margins are
outlined on the cast
2. The tumor is scrapped
3. The teeth are removed
4. The residual ridge is trimmed on the labial
and buccal surface to reduce the stress
on the soft tissue closure.
 ▪ Wire retainers
1. Clasps are adapted on the standing
teeth
2. Edentulous upper jaws retained by
wires to the zygomatic bone
▪ Waxing up and Processing of acrylic
Obturator is processed in
transparent acrylic resin
▪ Surgical room procedures
1. The surgical obturator is
immersed in disinfectant
2. If the surgery is more extensive
add lining material
▪ Edentulous upper jaws retained
by wires to the alveolar bone
▪ Postoperative care
▪ 7-10 days post surgery
▪ the prosthesis and packing
are removed
▪ The prosthesis is cleaned
and occlusal adjustments
are made
▪ The lateral extension and
anterior aspect of the
obturator adjusted to be
short than the skin graft
mucosal junction
▪ Postoperative care
 Delayed surgical Obturator

▪ It is an
alternative to
immediate
surgical
obturator that
placed 7 to 10
days
postsurgically
 Delayed surgical Obturator

Technique of construction
I. Tray selection and modification
1. The surgical packing is removed
2. A soft metal stock tray with short
flanges
3. In the area of the defect the flange
removed or bent medially
4. All flanges are covered with
peripheral beading wax and wax is
added to support impression
material
▪ Impression making
1. Major medial
undercuts and other
sensitive areas
blocked-out with
Vaseline gauze
2. An impression is
carried out using
alginate impression
material
▪ In dentulous patients
1. It fabricated as
immediate obturator
2. Anterior teeth if
missing are replaced
for esthetic
3. Posterior occlusion
should be avoided
4. As healing proceeds
posterior occlusal
ramps with self-cure
resin to help the
patient to retain the
prosthesis in position
▪ In edentulous patients
1. It is preferable to
utilize the patient's
existing maxillary
prosthesis as a
delayed surgical
2. Labial and buccal
extensions were
reduced
3. Maxillary denture is
relined with reline
material
4. Obturator portion is
hollowed to reduce
 Interim Obturator
▪ It is made 2-4 weeks
after the initial surgery
▪ It is used serves to
bridge the gap
between the surgical
and definitive
Obturator
▪ It is considered when the defect has
stabilized to the point that the
continuous changes will be minimal
▪ Reasons for constructing
1. The periodic addition of lining
materials increases the bulk and
weight of the prosthesis
2. Addition of anterior and posterior
denture teeth
3. A well-made interim obturator can
serve as a backup prosthesis
 Interim Obturator
▪ It is made 2-4 weeks
after the initial surgery
▪ It is used serves to
bridge the gap
between the surgical
and definitive
Obturator
▪ It is considered when the defect has
stabilized to the point that the
continuous changes will be minimal
Any Question……..
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