Maxillofacial Prosthetics Theory and Practice

MAXILLOFACIAL PROSTHETICS
THEORYANDPRACTICE
Mostafa Fayad
Assistant Lecturerof Removable Prosthodontic
Faculty Of Dental Medicine
Al-Azhar University
Cairo-Egypt
2010
1st ed
Table of contents
Subjects
1 intro Maxillofacial Prosthetics
2 Cleft Lip and Palate
3 mandibular defects
4 Maxillofacial Splints
5 Maxillofacial Stents
6 Radiation
7 Trismus
8 Immediate Denture
9 Snoring
10 Total and Partial Glossectomy
11 Extraoral Maxillofacial Prosthesis
12 Speech
13 Retention of Maxillofacial Prosthesis
Scope of Maxillofacial Prosthetics
Maxillofacial prosthetics is the art and science of anatomic, functional and
cosmetic reconstruction of missing or defective parts of the maxilla, mandible and/or face
by using a non living substitutes.
Maxillofacial prosthetics is the branch of Prosthodontics concerned with the
restoration and or replacement of intra-oral and associated facial structures by artificial
substitutes.
The structures may be missing or mutilated as a result of surgery, trauma, and congenital
or developmental defects.
Maxillofacial Prosthesis: any prosthesis used to replace part or all of any
stomatognathic and/or craniofacial structure.
Objectives of maxillofacial prosthetics
The most important objectives of maxillofacial prosthetics and rehabilitation include:
1 -Restoration of esthetics or cosmetic appearance of the patient.
2- Restoration of function and speech.
3- Protection of tissues.
4- Therapeutic or healing effect.
5- Psychologic therapy.
Types of maxillofacial deformities
1- Congenital : as cleft palate, cleft lip, facial cleft and missing ear.
2- Acquired: as accidents, surgery and pathology.
3- Developmental: as prognathism and retrognathism.
Classification of maxillofacial restorations according to its sits
1- Intra-oral restorations: e.g. obturators, stents and splints.
2- Extra-oral restorations: e.g. radium shield and restoration of missing eye, nose or ear.
3 - Combined intra-oral and extra-oral restoration.
4- Cranial and facial restorations:
a. cranial onlays and inlays used in cranioplasty to compensate for lost cranial
bone.
b. Intra- mandibular implants: Used to support or retain a restoration replacing
missing part of mandibular bone.
The maxillofacial team
The maxillofacial prothetist serves as a member of a team for planning rehabilitative
treatment for patients with maxillofacial defects.
These maxillofacial team including:-
1- Plastic surgeon.
2- Speech therapist.
3- Dental specialists:-
a- Prosthodontist.
b- Orthodontist.
c- Oral surgeon.
d- Dental technician.
4- Radiotherapist.
5- E.N.T (Ear, Nose and Throat) specialist.
6- Physical specialist.
7- The psychiatrist.
Cleft Lip and Palate
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Cleft Lip and Palate prostheses
Normal Anatomy:
a- Maxilla is a pyramidal-shaped bone. It consists of a body which forms the mid face
and four processes. These processes are the frontal and zygomatic processes upwards and
the alveolar and palatine processes downwards. The alveolar process carries the anterior
and posterior teeth. The palatine process forms the anterior two thirds of the hard palate.
The maxilla has several distinct anatomical areas.
The nasal spine is the anterior projection of the maxilla and alveolus.
The alveolar process of the maxilla surrounds the palate and houses the teeth.
a- The palate is composed of the maxillary and palatine bony plates. The palatine
process of maxillary bone forms the anterior two thirds of the palate and the horizontal
maxillary plate of palatine bone constitutes the posterior third of the hard palate. They
are both divided into right and left by a longitudinal midline suture.
The anterior part of the palate is formed of the anterior alveolar process carrying the
anterior teeth and the premaxilla.
Blood vessels and nerves exit from the incisive foramen anteriorly and the greater
and lesser palatine foramina postero-laterally.
The incisive canal is located posterior to the incisors, and transmits the lesser palatine
artery, one of the distal branches of the internal maxillary artery.
Posteriorly and laterally along the palate is the greater palatine foramina, which
transmit the greater palatatine artery, a branch of the internal maxillary artery.
The palate itself is formed from the maxilla, the horizontal process of the palatine
bone and the pterygoid plates.
c- The soft palate is the unossified part of the palate. It attaches to the posterior rim of
the hard palate. Medially, a posterior extension, the uvula or the velum extends
downwards and acts as a valve for the pharyngeal cavity.
The soft palate contains a series of muscles , numerous minor salivary glands and
some lymphatic tissues and a dense network of elastic fibers which together with the
muscles of the pharynx form a sphincter that opens and closes the orifice between the
nasal cavities superiorly and the oro-pharyngeal cavity inferiorly.
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The soft palate attaches to the posterior portion of the hard palate and
interdigitates with the lateral pharyngeal wall via several muscular attachments. From
the naso-pharyngeal to the oral cavity surface, the muscles of the soft palate consist of:
- the palatopharyngeus, - the salpingopharyngeus,
- the levator and tensor palatini, - the muscular uvula,
- the palatoglossus - the superior constrictor muscle.
The tensor veli palatini tenses the palate, but is not believed to play a major role in
palatal elevation.
The levator veli palatini is responsible for palatal elevation. Also may pull the lateral
pharyngeal walls down and back.
The salpingopharyngeus is a consistently small muscle with probable minimal effects
upon palatal and tubal function.
The superior constrictor muscle is the primary sphincter of the pharyngeal phase
(Velopharyngeal Closure) of swallowing and is responsible for preventing regurgitation
into the nasopharynx (velopharyngeal insufficiency, VPI) .
Muscle Origin Insertion Action
levator veli
palatini
temporal bone,
Eustachian tube
palatine aponeurosis elevates soft palate
tensor veli palatini
medial pterygoid plate of
the sphenoid bone
palatine aponeurosis tensionof the soft palate
musculus uvulae hard palate palatine aponeurosis
palato glossus palatine aponeurosis tongue
raising the back part of the
tongue
palato pharyngeus
palatine aponeurosisand
hard palate
Upper border of thyroid
cartilage(blends with
constrictor fibers)
pulls pharynxand larynx
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Structures of the Hard Palate:
-Premaxilla
- IncisiveForamen
-Palatine Processes
- Posterior Nasal Spine
Structures of the Soft Palate
-Velum (Soft Palate itself)
- Muscular Uvula
The Pharynx:
The pharynx is a simple, funnel shaped tube wide at the head and narrow at
esophageal end. The pharynx has three muscles superior, middle and inferior constrictors.
The action of the pharynx is complex but basically it contracts from side to side and its
posterior surface moves forwards. It is capable of local contractions at various levels,
which are mainly used in speech, and also peristaltic type of contractions which are
employed during swallowing.
The shape and action of the soft palate and pharynx in speech and swallowing are
different
Dark line illustrates position of soft palate and
posterior pharyngeal wall during speech. Dotted line
illustrate position of both when swallowing. Note
marked shift of pharyngeal wall in swallowing
position.
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Palato (velo) pharyngeal mechanism(Palato (Velo) Pharyngeal Sphincter)
The velopharyngeal mechanism is a coordinated valve formed by the muscles of
the soft palate and pharynx.
Muscles forming the velo-pharyngeal sphincter
Muscles forming the velo-pharyngeal region are, (fig.3):
1-Muscles forming the palate, these are:
-Levator veli palatini muscle -Tensor veli palatini muscle
-Palato glossus muscle -Palato pharyngus muscle
-Uvula muscle, which is the intrinsic muscle of the velum
2-Muscles forming the pharynx, these are:
-Superior constrictor muscle -Salpingo pharynges muscle
-Palato pharyngus muscle which has two portions, the pharyngo palatal
portion and the thyro-palatal portion
The levator veli palatini muscle and the superior constrictor muscles play the
dominant role in velo-pharyngeal mechanism especially during closure of the nasal
cavity. The levator veli palatini muscle is a long muscle and provides a wide range of
movement necessary in moving the velum from the relaxed rest position to a fully
elevated position
Palato (Velo) Pharyngeal mechanism
The velum acquires three positions to perform the valve action required during
swallowing and speech, these are:
1-The relaxed position of the velum (uvula)
This is the relaxed position of the velum. It is required during normal breathing. The
velum is dropped downwards to keep the oro pharynx and naso pharynx opened to allow
for both oral and nasal breathing.
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2-Closure of the nasal cavity
Velo pharyngeal mechanism is required for closure of the nasal cavity during
swallowing and for production of letters produced in the oral cavity. This mechanism is
achieved as follows:
-The middle third of the velum curves upwards and backwards in an attempt to contact
the posterior wall of the pharynx at or above the level of the plane of the palate at the
level of the atlas vertebra. This is done by the action of the levator veli palatini muscle.
This is aided by the contracted state of both the tensor veli palatine muscle and the uvulae
muscle that adds bulk to the nasal surface of the velum.
-However, this pull of the velum is not enough to achieve adequate closure between
soft palate and pharynx.
For this reason the pharynx shares in palato pharyngeal mechanism by:
*Movement of the posterior wall of the pharynx forwards. This is done by the action of
the superior constrictor muscle aided by the pharyngo palatalportion of the palato
pharyngus muscle.
*Movement of the lateral walls of the pharynx medially to close the last gap between the
lateral aspect of soft palate and lateral walls of pharynx. This is done by the action of the
salpingo pharynges muscle.
*The posterior pharyngeal muscles contracts strongly and produces a bunch-up forming a
prominent ridge or pad called Ridge of Passavant. This helps to approximate the soft
palate and pharynx,
Ridge of Passavant
The ridge of Passavant is a horizontal roll of muscles on the posterior wall of the
pharynx forming a bunching-up of the posterior pharyngeal wall. It is present at the level
of the palate which corresponds to the level of the atlas vertebra. It is usually more
evident in patients with soft palate defects as a compensating mechanism to aid in speech
and swallowing. It also serves as a guide for placement of soft palate prostheses
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3-Closure of the oral cavity
Velo pharyngeal mechanism is required for closure of the oral cavity. This is required
to permit exit of air through the nasal cavity during sucking and pronunciation of sounds
as M and Ng as in sing. This mechanism is achieved as follows:
-The thyro-palatal portion of the palato pharyngus muscle pulls the soft palate downward
towards the tongue.
-The tensor veli palatini muscle flattens the dome-shape of the soft palate.
-The tongue is forced upward and backward.
-The palato glossus muscle contracts and completes the palate tongueapproximation.
It function as follows:
1-Velopharyngeal closure: It is required for normal deglutition and the production of
some speech sounds such as plosives (e.g. P&D). This closure occurs by the following:
a-The middle of the soft palate curves upwards an backwards as an attempt to contact
the posterior wall of the pharynx. This action is done by the levator and tensor palatini
muscles.
b-The posterior wall of the pharynx moves forward by the action of the superior
constrictor and the palatopharyngeous muscles forming the ridge of passavant. This
ridge is a horizontal roll of tissues on the posterior wall of the pharynx corresponds to
level of the atlas vertebra. It occurs during speech and swallowing and serves as a
guide for placement of soft palate prosthesis.
c-The lateral walls of the pharynx move medially by the action of
the salpino pharyngeous muscle.
2-Velopharyngeal opening:
This occurs during normal breathing and for pronunciation of
vowels and nasal consonants in a varying degrees. It is a relaxed
position; the soft palate drops downward to keep the oropharynx and nasopharynx
opened.
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Velopharyngeal insufficiency:
Palato pharyngeal insufficiency is a condition characterized by abnormal anatomy
of the palate in the form of absence, short length or cleft in the tissues of the soft palate.
This could be congenital, or due to acquired causes as resection of soft
palate or lateral pharyngeal wall. This condition results in inability to
perform palato pharyngeal mechanism.
Prosthetic rehabilitation is achieved by palato-pharyngeal obturator
(speech bulb) or by meatle obturator.
Nasal sounds
Velopharyngeal incompetence:
Palato pharyngeal incompetence is a condition characterized by
normal anatomy but ineffective or absent motor function (tissues are
functionally impaired) resulting in impaired palato pharyngeal
mechanism. This usually results due to neurological disorders as
poliomyelitis affecting oro-pharyngeal structures through affection of
any of the nerves of the pharyngeal plexus which includes fibers from
the IX, X and XI cranial nerves. It could also be due to diseases as
multiple sclerosis or tumors, or due to traumatic head injuries. Oral sounds
Palato pharyngeal incompetence usually results in speech disorders in the form of
hyper nasality or reduced speech intelligibility.
Palato pharyngeal incompetence is diagnosed by easily lifting the soft palate by a tongue
depressor, by nasal endoscopy or by airflow pressure measurements.
Prosthetic rehabilitation is achieved by a palatal lift device.
Development of Palate
The development of the palate begins in the fifth week and is completed in the
twelfth week intrauterine. It develops from:
1-The primary palate is derived from the median nasal process and the maxillary
process and gives rise to:
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a-The upper lip.
b-The premaxilla; the part of the hard palate in front of the incisive foramen
c- The anterior part of the alveolar process and the incisors.
2-The secondary palate: is derived from two horizontal lateral palatine (nasal)
processes or palatine shelves. It gives rise to:
a-Hard palate posterior to the incisive foramen.
b-Soft plate.
At about the end of the eighth gestational week, the shelves elevate, make contact,
and fuse with each other above the tongue Failure of union at any stage will result in a
cleft palate and or lip.
Because the secondary palate arises from the lateral palatine processes which fuse
in the midline, vascular, lymphatic, and neural elements are divided at the midline. This
phenomenon explains why unilateral palatal and paranasal sinus tumors rarely
demonstrate contralateral lymphatic spread. The midline also serves as an effective
anatomic barrier for resistance of local tumor extension and often serves as the medial
surgical margin in resection of palatal and paranasal sinus tumors.
Palatal cleft development
The union of the primary palate, the secondary palate and the nasal septum begins
at the meeting point of the premaxilla and the two lateral palatine processes (incisive
foramen). From this point of meeting union progress anteriorly and posteriorly in a Y
shaped suture. Anteriorly, to form the premaxilla, anterior alveolar ridge and upper lip
and posteriorly to form hard and soft palate.
Congenital clefts occur during embryological growth due to arrest of development
and failure of fusion between the embryonic processes.
Incidence of cleft lip and palate
Cleft deformities of the palate are among the most common congenital
malformations. A cleft palate can be diagnosed as early as the 17th week of gestation by
means of ultra-sonography. Although many studies exist, the exact environmental and
genetic factors that play a role are still largely unknown. However, the following can be
concluded:
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1- The incidence of clefting has a racial differences. However, the average incidence rate
is one in every 700 born has some form of clefting.
2-Unilateral clefts are more common than bilateral clefts of the lip and palate.
3-Left side cleft forms 70% of unilateral clefts.
4-The incidence of clefts in males is twice that in females.
Development of the palate, shown from beneath (left) and in coronal section (right).
(a) 7th week; (b) late 8th week; (c) 10 weeks. Swellings on the medial aspect of the maxillae grow
downwards either side of the tongue (a), then swing medially to form horizontal palatal shelves (b);
these fuse with each other and with the nasal septum by breakdown of the apposed epithelial seams
(c). e, eye; es, epithelial seam; hps, horizontal palatal shelf; mn, medial nasal swelling; mx,
maxillary process; nc, nasal conchae; ns, nasal septum; pp, primary palate; r, rugae; uv, uvula; vps,
vertical palatal shelf
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Definition : A cleft palate may be defined as a lack of continuity of the roof of the
mouth. It may be congenital or acquired.
A] Congenital cleft palate
It is a lack of continuity of the roof of the mouth though the whole or part of its length in
the form of fissure extending anteroposteriorly.
Etiology : Congenital cleft palate results from lack of fusion of embryological processes
which would normally unite during the 6
th
to 10
th
weeks of embryonic development. The
exact cause of the clefts is unknown but it may be:
1- Abnormal position of the embryo,
2- Pressure from the amniotic fluid,
3- Failure of the tongue to drop,
4- Persistence of epithelium at the junction of the two palatal halves.
Hereditary and environmental factors influence the induction of the cleft palate:
1-Hereditary: There is widespread agreement that a hereditary bases exsists in about 20
to 30 % of all cases of clefts of lip and palate.
2- Environmental factors and teratogenic agents (predisposing factors):
Nutritional deficiency or cortisone administration has never been proved to be
teratogenic in humans. The principal environmental causes are:
1- Oxygen deprivation and glucose deprivation .
2- Nutritional deficiency e.g. Vitamin A and riboflavin deficiency.
3- Infectious diseases of the mother during pregnancy e.g. Acute virus infections as
German measles..
4- Cortisone therapy and hormonal disturbance as in pituitary dysfunction.
5- Radiotherpy and excessive X-ray exposure to the mothers pelvic area during early
pregnancy.
6- Chemical irritation e.g. hypervitaminosis A and hypoxia to the pregnant mother.
7- Stress and anxiety during the first trimester of pregnancy, since these conditions result
in excessive production of adrenal hormons (cortisone) which has been shown to induce
clefting in mice.
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The present of environmental factors together with the hereditary background may
increase the incedance of cleft lip and palate.
Types of Congenital cleft palate
Clefts may be isolated malformations or may be a part of a syndrome. Clefts of the
palate, alveolus and lip (CLAP) are:
Syndromic types are by definition associated with other malformations (At last
count, more than 300 syndromes were associated with CLAP).
Syndromic etiologies include:
- Single gene transmission such as trisomies.
- Teratogenic causes such as fetal alcohol syndrome; or
- Environmental causes such as maternal diabetes mellitus
Non-syndromic CLAP is a diagnosis of exclusion, and is considered to be of
multifactorial inheritance with known predicted rates of recurrence.
Syndrome: major malformations which appear unrelated but are frequently found
to have a common etiology.
Sequence: anomalies occur together the primary anomaly causes the first to
happen.
e.g., Pierre Robin Sequence - failure of mandible to grow in utero causes a u-shaped cleft
of the soft and hard palate but not the alveolar ridge.
Classification of cleft palate:
Victor Veau s classification
It is generally accepted and give more details of cleft palate.
class I. Clefts involving soft palate only.
Class II. Clefts involving soft and hard palates up to incisive foramen.
Class III. Clefts of soft and hard palates, right forwards through alveolar ridge and
continues into lip on one side.
Class IV. Same as Class III only associated with bilateral hare- lip.
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Veaus classification of cleft palate.
Olin's classification:
Group I. Cleft lip only: unilaterally or bilaterally with nasal deformity.
Group II. Cleft palate only: part of the soft palate, or the entire soft and hard palate may
be involved.
Group III. Clefts of lip and palate involve the alveolar ridge. Patient may have unilateral
or bilateral clefts
Group IV. Clefts of the lip and alveolar ridge not involve the palate (Rare occurrence).
Harkin's classification:
Patients areclassified according to the degree of the cleft into:
Bifid uvula.
Cleft of the soft palate.
Cleft of soft and hard palate extending through the palatal bones.
Cleft of the soft and hard palates extending to the incisive foremen.
Cleft of the soft and hard palates extending through the alveolar process and lip on
one side.
Davis classification: (1922) (Not used now) Classification depends on the extent of cleft
Group 1: all clefts of the lip
Group 2: All posterior alveolar clefts.
Group 3: complete cleft of alveolar ridge, palate & lip.
Stark's classification (1958) (The most widely used today).
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Disabilities associated by the presence of cleft palate
The basic disability of a cleft palate results from inability to close well the
nasopharynx from the oropharynx. Patients with a cleft lip or palate have numerous
associated problems, such as the following:
1. Esthetic problem: due to
- Basic anatomic deformity - Deficient facial growth
Abnormal appearance of the child occurs due to the presence of labial cleft and facial
deformity due to improper or early surgical repair of palatal cleft. Trauma to the growth
center of bone during surgery leads to reduction of the forward growth and lateral
dimension of the maxilla.
2-Improper mastication: The masticatory function is impaired because babies cannot
suck due to lack of negative pressure, food escape through the nasal cavity and the
presence of missing teeth and malocclusion.
3-Swallowing: Swallowing is impaired when cleft occurs in both hard and soft palate.
The baby should be placed in upright position and a special nipple is used during feeding.
4. Dental problems
-Missing, malformed, and supernumerary teeth -Malocclusion
5. Speech problems (see speech& Palato (velo) pharyngeal mechanism)
-Velopharyngeal incompetence - Secondary articulation disorders
6. Otologic problems
- Eustachian tube dysfunction - Chronic ear disease
- Hearing loss
7-General health: The general health of the child is affected due to inadequate nutrition
and mouth breathing.
8-Psychological problems: Children with clefts have difficulty in adjusting with society.
They may withdraw or turn aggressive.
9- Additional congenital anomalies.
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Diagnosis and examination of cleft palate:
The patient should be examined by all maxillofacial specialists.
Maxillofacial team
The management of patients with acquired or congenital defects involves the
cooperation of the following team members:
1- Plastic surgeon: The role of plastic surgeon is important in treatment planning and
surgical reconstruction of deformities.
2-Prosthodontist: Prosthodontic treatment may be required in inoperable cases and in
case of failed surgery.
3-Speech therapist: The role of speech therapist is to correct defective speech
caused by the palatal defects.
4-Orthodontist: The orthodontist treat malocclusion associated with cleft lip and palate.
5-Psychologist: Help the patient to accept the problem, and to improve patients attitude
and cooperation in the course of treatment.
6-Social worker: Discusses the problem with parents, educate them about the problem
and guide the patient for his future life.
7-Dental technician: Construct the prosthetic appliance.
The following procedures facilitate the diagnosis:
1- General case history including all information about the cleft and anomalies.
2- Clinical examination and photographs.
3- Construction of study cast.
4- Radiographic procedures includs full mouth x-ray, bit wings, occlusal and
cephalometric x-rays.
5- Medical, surgical, speech, and psycological recording.
N.B. Study casts, photographs and radiographic data are recorded periodically to help the
dentist to study the growth and development patterns of oral-facial-cranial structures and
to observe the effects of surgical and orthopedic treatment.
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Diagnosis and treatment planning are carried out through the maxillofacial team.
Full consideration should be given to the following:
1-Type and width of the cleft.
2-Position and relation of the maxillary segments to each other.
3-Form of the maxillary arch and its lateral and antero-posterior dimensions.
4-Length, thickness and mobility of the soft palate.
5-Perforations remaining in the hard and soft palate and labial sulcus after surgery.
6-Posterior and lateral pharyngeal wall activities size of naso-pharynx.
7-Floating premaxilla.
8-Number of missing teeth in line of cleft, malformed and malposed teeth and partially
erupted teeth.
9-Constricted maxilla.
10-Condition of tonsils and adenoids.
11-Growth and development of thechild, mental attitude and general health must also be
considered.
12-Speech articulation of the patient, his voice quality and hearing acuity.
Treatment planning:
Any child born with cleft palate should be examined by the plastic surgeon,
orthodontist, the prosthetist and the speech therapist, in consultation and a combined plan
of treatment is formed .
I-Pre-surgical treatment phase
This phase starts at birth and may continue till surgical repair is performed.
Treatment in this phase includes:
-Psychological support to the parents provided by the social worker and the
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nurse to encourage parents to correctly care for their child.
-Teaching parents how to care for and clean the defect.
-Teaching parents how to feed the infant to ensure proper nutrition necessary for
growth and development. Ensuring that feeding requires longer time and patience
compared to normal infants. Feeding devices could be selected from among the wide
variety present in the market.
Infants with cleft lip most often feed normally only slight milk leakage which
can be overcome by using a bottle with broad base nipple to seal the defect during
feeding. They can also be breast fed.
Infants with cleft palate are usually more difficult to feed due to their inability to
generate and maintain vacuum and loss of negative pressure required for sucking. This
may cause early fatigue and improper feeding. For this reason using squeezable bottles,
soft nipples with cross cut openings rather than tiny holes are recommended to allow for
easier flow of nutrients. Long nipples can also be used in order to be placed posterior to
the defect. Feeding spoons which are deep and with long pointed tips can also be used.
2- Surgical management of congenital cleft palate
The following shouldbe taken into consideration:
1- Surgical closure is the treatment of choice for congenital defects.
2- Lip repair is usually performed 6-12 weeks after birth to facilitate feeding and improve
appearanceif the infantsphysical health allows.
3- Repair of the cleft palate is performed after 1-4 years (usually 2 years). Early repair
of the cleft palate should be avoided to permit for the growth of the palate with narrowing
of the cleft and to permit for development of enough tissues for closure.
4- Surgical repair of the soft palate is superior to the fitting of a prosthesis. But if the cleft
is too wide and the muscular remnants poorly developed it is better to treat the cleft
entirely by prosthetic obturator.
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If surgery can only produce a non-functional united soft palate, the prosthetic
obturator should be performed instead of surgery because the problem of fitting an
obturator in cases with repaired nonfunctional soft palate is greater than in those cases
which not surgically treated.
If a pharyngoplasty has been performed, asurgical repair of pharynx should be
performed before the end of the second year because the child commences to talk
between the second and third years and if repair is delayed beyond this time faulty habits
of speech will develop which are too difficult to eradicated.
If it is decided that surgery is unlikely to be successful the first obturator should be
fitted at the end of second year.
If the cleft of hard palate is too wide it is better to cover it by obturator because
surgiacal repair will certainly result in contraction of the dental arch and the orthodontic
treatment will reopen the cleft.
3- Prosthetic management of congenital cleft palate
Objectives of cleft palate prosthesis:
1- Restoration of masticatory apparatus.
2- Restoration of speech.
3-Prevent foods from enter the nose and prevent nasal secretion from enter the mouth.
4- Improve the esthetics of the patient by restoring the missing part of ridge and teeth.
5- Improve psychological condition of the patient.
Indication of maxillofacial prosthesis:
Generally, surgical correction of cleft palate is better than prosthetic treatment However,
there are some situations in which a prosthsis may be the treatment of choice as:
A-In unoperated cases:
1. A wide cleft with a deficient soft palate that cannot function properly after
surgery.
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2. A wide bilateral hard palate cleft. In such cases surgical repair of the soft
palate can be performed and an obturators is constructed for the hard palate.
3. Partial or complete paralysis of the soft palate remnants.
4. In patients with neuromuscular disease affecting the soft palate and pharynx
resulting in velopharyngeal incompetence.
5. Absence of the premaxilla.
6. Patients with poor general health.
7. The cleft palate may be temporarily closed with speech aid, when surgery is
delayed.
8. When orthodontic appliance (e.g. expansion appliance or appliance to correct
teeth position) is indicated.
B- In operated cases:
1-Failure of surgery to close the defect completely.
2-When the soft palate movement is inactive or completely absent or the soft
palate is short causing incompetent palatopharyngeal closure.
3-A transitional prosthesis to provide certain function, e.g. feeding appliance or
appliance to activate the soft tissues of the pharynx for function.
Contra-indications for maxillofacial prosthesis
1- Easability of surgical repair
2- Uncooperative patient and parents.
3- Uncontrolled dental caries as rampant caries.
4- Mentally retarded patient.
5- Lack of dentist who has had training in cleft palate prosthodontics.
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Prosthetic devices used in management of congenital cleft
palate
1-Obturators (discussed later)
An obturator is an appliance, which corrects openings in the hard palate, soft
palate or both. The prosthetic treatment consists of the construction of an obturator or an
artificial palate for closing the cleft and restoring the function of speech and swallowing.
2-Orthopedic treatment
Early orthopedic treatment of any patient should be underten on the basis of a joint
decision of the surgeon, the orthodontist, and the prosthodontist.
The orthopedic appliances are of two types:
a- The passive or holding type.
b- The active or expansion type.
The type of appliance will be determined by the configuration of the cleft.
1- If any degree of collapse is manifested, an expansion appliance is placed.
2- If the collapse is primarily in the anterior region, a fan type of split acrylic
appliance is used.
Splint acrylic appliance (Fan type) B. The cast before and after treatment .
3- If it appears that the arch is collapsed throughout its length, a straight Jack
screw appliance is used
J ack screw appliance.
Mostafa Fayad 20
4- If the cleft configuration is wide or if the segments appear in an ideal
relationship, a holding appliance is used. These case are operated on as soon
as the holding appliance is placed.
All appliances, whether active or passive, are fabricated and inserted prior to lip closure.
After the maxillary appliance has the segments is good alignment, the plastic surgeon
restores lip continuity.
Expansion type prosthesis
An expansion prosthesis may be used preoperatively for complete unilateral or
bilateral collapsed palate clefts. These prosthesis used to guide the maxillary segments
into proper spatial relations with each other and with the mandibular arch prior to
surgery. The segments can be gradually separated by an expansion prosthesis to create a
space for the premaxilla or to stabilize the parts in a normal position with or without bone
grafting.
In the period of expansion several successive prosthesis may be constructed
considering the growth and possible eruption of the teeth.
Indications:
1-In patients having complete unilateral or bilateral collapsed cleft, to align the
lateral segments of the palate before surgery.
2- To assess and diagnose the need and progress in speech that will be achieved by
surgery.
The expansion prosthesis is consists of palatal portion and pharyngeal portion.
a- The palatal portion composed of two separate lateral sections covering the hard
palate and united by expansion device. In the predental eruption period. The
prosthesis cover the alveolar ridge and extend to the mucobuccal fold. When the
teeth are erupted the prosthesis is extended to the lingual surface of the teeth and
retained by wire claspe.
b- The pharyngeal portion may be constructed in some cases to improve the speech
and deglutition.
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3- Combined prothesis and orthodontic appliance:
In case of malposed teeth an orthodontic appliance may be combined with a
prosthesis to move malposed teeth into a more favorable alignment. A speech appliance
prosthesis could be designed for patient receiving full band orthodontic treatment.
Obturators used for treatment of congenital cleft palate
1- Preoperative devices for children:
- Feeding devices
- Expansion prosthesis.
2- Cleft palate prosthesis for adolescent:
Fixed pharyngeal obturator.
3- Cleft palate prosthesis for adult (definitive obturator)
I-Prosthetic rehabilitation of congenital cleft palate (in children)
1- Feeding devices:
In case of cleft lip the infant can feed normally with a bottle or breast. To prevent
milk leakage the finger is placed over the lip cleft or a broad base nipple is used.
In case of unilateral alveolar cleft the nipple should be pointed toward the
unaffected side.
For cleft palate the infant cannot suck. A syringe is used or a specially designed
bottle and nipples, while the infant in a semi-upright position. Soft nipples, crosscut
nipples, or long nipples and squeeze bottles can be used. In somecases an obturators
attached to the nippleis used.
The importance of feeding appliances:
1- Most infants with cleft lip and palate are unable to nurse from the breast
or bottle. Since normal suckling is impossible, a more upright position
of the baby, and a bottle with large hole nipple may compensate for the
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slow flow of milk or fluid associated with defective suckling.
Sometimes Nasogastric tube is used for feeding.
2- The repeated pressure of the tongue on the nipple forces it upwards
against the edges of the cleft and tends to increase the width of the cleft.
All these difficult conditions make the construction of the feeding device
essential to separate the oral cavity from the nasal cavity and thus , facilitate food
intake and reduce irritation prior to surgical closure.
Construction:
The feeding devices consists of an acrylic plate, constructed from a low fusing
compound impression.
A mass of softened compound is placed on suitable tray or on the convex surface
of the spatula and mould it to the shape of block of the needed size. Then compound is
inserted into the baby s mouth to the back of the pharynx and with light upward and
forward movement, so that the edges of the cleft leaves their marks on the block.
The compound impression is taken out by moving the spatula from the front to
back and then downward and forward. The impression is poured in stone and allowed to
set before separation. A plate of softened wax is adapted on the lingopalatine surface of
the model formed the palatine wings of the obturator. The wax is replaced by acrylic
resin using the routine method of flasking, then finishing and polishing are done.
The plate can be designed to be attached to the neck of feeding bottle to cover
the cleft during bottle feeding. Or the acrylic plate can be made with a wire or acrylic
handle to be held by the mother to cover the cleft during breast feeding.
2-Expansion prosthesis
The expansion prosthesis (described before) may be constructed with pharyngeal
portion to improve the speech and deglutition.
II-Prosthetic rehabilitation of congenital cleft palate for adolescents
Dental considerations for adult cleft patients
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Oral disfigurement is not gross nowadays due to advances in the management of
newborns and infants. Problems associated with rehabilitation of cleft adult or adolescent
patients
-Missing or malformed incisors is the most common dental defect associated with cleft.
-High smile line exposing residual soft tissues which become unaesthetic if
bridges are to be constructed. Hence, removable partial dentures are constructed.
-Cleft alveolus that is unreconstructed by bone grafts results in movement of the two
segments of maxilla which results in break of cementing cement if fixed bridges are
constructed. Hence, removable partial dentures are constructed.
-Early surgeries lead to scarring which hinders growth of maxilla leading to discrepancy
in size of maxilla and its relation to the mandible.
-Lack of early orthodontic treatment.
-Dental neglect and poor oral hygiene.
-Inadequate vertical dimension of occlusion.
Proper dental care, oral hygiene measures, osteotomy to reposition maxilla in a
downward and forward position and interim dentures to restore vertical dimension are
lines of treatment that may precede prosthetic rehabilitation.
Temporary appliances are usually constructed for adolescents till they reach complete
growth. A temporary appliance is a great aid to the prosthodontist to assess and determine
the best design providing an esthetics, mechanical and functional prosthesis. It is also
considered an educational tool for the patient.
However, it may sometimes be required to construct metal removable partial dentures
for patients between 11 and 20 years where esthetics and retention are primary demands.
In this case a self-cleansing restoration with margins ending as far as possible from the
gingival margin and natural teeth should be designed.
Definitive appliances are usually constructed at the age of 20 after complete growth
and bone grafts if present, are mature.
Definitive appliances to obdurate clefts may be attached to a partial denture, a
complete denture or an overdenture depending on the condition and number of teeth.
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For partially edentulous patients with surgically repaired clefts removable partial
dentures with similar designs as non-cleft patients are constructed. However, patients
with palato pharyngeal deficiencies, the partial denture will be extended to the
pharyngeal cavity as a speech aid which may in turn exerts a long lever arm especially in
free end saddle cases. Thus, the design of partial denture needs to be altered to provide
additional direct and indirect retention.
For completely edentulous patients, several problems may arise during complete
denture construction as the maxilla of these patients tends to be smaller in size compared
to the normal sized mandible. This is usually due to reduced forward and downward
growth of maxilla. These problems are:
1-Reduced bony support due to small maxilla.
2-Increased inter arch space.
3-Lack of adequate denture support and stability.
4-Inadequate retention due to ineffective posterior palatal seal due to scar
issue if surgery was previously performed.
5-Scarring of lip tissues which may affect anterior border seal and exerts a
backward push on the denture, thus affecting denture retention.
Appliances for habilitation of congenital cleft palate (for adolescents):
1-Fixed pharyngeal obturator (speech aid)
The fixed pharyngeal obturator is an extension of a denture projecting into the
pharynx to the level of the anterior arch of the atlas bone or Passavant s ridge. The
obturator is shaped so that it can be gripped by the pharyngeal walls.
They are temporary appliances usually constructed for adolescents (between 11-20
years) till they reach complete growth.
Normal lateral growth of the palatal bones necessitates replacement of this
prosthesis occasionally. Intermittent revisions of the obturator section can assist in
maintenance of palatopharyngeal closure.
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It is a space filling prosthesis, designed to be held in the lower region of the
nasopharynx to compensate for the tissue deficiency. It acts as a core against which
palatopharyngeal musculature can form a seal.
N.B. Passavant's ridge is a horizontal ridge or cushion around the lateral and posterior
walls of the pharynx at the horizontal level of the hard palate coinside with the anterior
tubercle of the atlas vertebra. It is a compensatory factor associated with cleft palate that
help in reducing the diameter of palatopharyngeal orifice.
The passavants ridge is present in few cases and used as a reference point to place
the pharyngeal section of the fixed pharyngeal obturator.
Objectives:
The prosthesis must establish a competent naso-oral separation to satisfy the
following objectives:
1-Socially acceptable speech.
The prosthesis must help the patient to acquire normal speech pattern. For
reasonable speech articulation and resonance there must be adequate dental
relation together with adequate oronasal separation.
2-Restoration of masticating apparatus.
Help in mastication and increases the efficiency of chewing and confine the
food material in the oral cavity. Help in deglutition and prevent the seepage of
fluids to the nasal cavity during the act of swallowing.
3-Prevent the seepage of nasal secretion into theoral cavity.
4-Facial esthetics and dental harmony.
Improve the esthetics of the patient.
Restoring the missing, malposed and improve the articulation of the teeth to
establish dental esthetics.
5-Improve psychological condition of the patient.
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Fixed pharyngeal obturator requirements:
1- The prosthesis must be designed to suit the patient regarding his oral and facial
condition, masticatory function, and speech.
2- The prosthesis must preserve the remaining structures wrong design of the
maxillary portion will result in premature loss of the hard and soft tissues and
further complicating prosthetic habilitation.
3- The prosthesis requires greater retention and support. In adult cases, crowing and
splinting of the abutment teeth increases retention and, support.
4- Closed vertical dimension in more suitable in the cleft palate patients.
5- Minimum weight should be kept. The material used should be easily repaired and
altered.
6- Soft tissue pressure in the velar and nasopharyngeal areas by the appliance must
be avoided.
7- The prosthesis must not be displaced by velum, lateral and posterior pharyngeal
wall muscle activities or tongue movement during swallowing and speech
production.
8- Pharyngeal section should be properly placed. The superior surface of the
pharyngeal section must be at the level of the palatal plane.
Preparation of the patient for prosthetic treatment:
The oral cavity should be prepared before the construction of the speech aid
prosthesis as follow:
1-Decayed teeth are preferably restored with full coverage to prevent recurrence of
decay and to shape the teeth in the desirable form to support and retain the speech
aid in position.
2-Every tooth in the cleft palate patient should be saved to avoid problems of
retention.
3-Teeth needing extraction or other surgical treatment should be preferably done
before the construction of the speech aid.
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4-Orthodontic treatment to expand the arch or approximate the two segments and
correct malposed teeth are done at this stage if possible.
5-Gingivectomy for partially erupted teeth is recommended to expose the clinical
crown to be used for retention.
Sections of speech aid: The speech aid consists of three sections; palatomaxillary
section, palatovelar section and pharyngeal section.
a-The palatomaxillary section:It covers the cleft of the hard palate, and may
be constructed in the form of partial or complete denture. In general the
number of retainers is increased.
b- The palatovelar section or tailpiece: It supplements the palatal cleft and
must remain in lateral contact with the soft palatal muscles during function or
rest.
c- The pharyngeal section (speech bulb): It extends posteriorly into the
pharyngeal cavity to be surrounded by the sphincteric action of the
pharyngeal muscles during swallowing and speech.
Sections of speech and (a) Palatomaxillary, (b) Palatovelar, ( c) Pharyngeal.
Construction:
Preliminary impression:
Prior to taking the impression the undercuts in the palatal cleft is packed with
vaseline gauze. An alginate impression is taken in a suitable stock tray and cast is poured.
Final impression:
An acrylic special tray is constructed and the final impression is taken with rubber
base or alginate impression material. The deep undercuts in the hard palatal cleft should
be packed with vaseline gauze prior to taking impression.
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Recording jaw relation:
If the patient is edentulous the upper denture should has an upward extension that
engages undercuts in the cleft to help retention.
If the patient is dentulous the working model is surveyed and the cleft in the hard
palate filled in with plaster of paris to reproduce the contour of a normal palate. On this
prepared model a record block is constructed. J aw relation is recorded in the usual
manner and the casts are articulated.
The artificial teeth are set in positions demanded by appearance and occlusion.
At the try-in the usual points are checked and a wire loop made of German silver
or stainless steel is bent and attached with sticky wax to the base of the trial denture. This
loop should be adjusted by bending and altering its position in the wax until it lie along
the center of the cleft of the soft palate, without contact with its remnants or with the
posterior pharyngeal wall when a prolonged ah is sounded. If the loop is made of
German silver wire, it will be more easily adjusted than if made of stainless steel.
In some cases where difficulty to the wearing of the denture is
anticipated it is desirable to leave the wire loop off the denture and
allowing the patient to wear the denture for few weeks until it is quite
comfortable. The wire loop may than be added to the denture with cold
cure resin to avoid the induce of extra strains in the acrylic by a second
processing.
Denture with wire loop
After the denture has been completed and fitted, a tailpiece must be made and
attached to the back edge of the denture and positioned at a level just below the soft
palate when assumes fully relaxation. If the tailpiece is positioned at higher level,
discomfort and pressure sores will occure when the soft palate relaxes. If on the other
hand the level of the tailpiece is much below that assumed by the relaxed soft palate, then
it will cause discomfort by obstructing the movements of the tongue.
For locating the plane of the tailpiece a piece of pink base plate wax is attached
to the back edge of the denture with sticky wax, this wax should be wide and long enough
to cross the soft palate into the pharynx.
The denture carrying the wax is then inserted into the mouth and the patient is
instructed to relax and breath through the nose. After few minutes the wax will be
Mostafa Fayad 29
moulded by the relaxed soft palate above and the tongue below to conform to the plane
and contour of the relaxed palate. The denture is removed and the wax is chilled
thoroughly. The denture is then replaced into the mouth and the plane of wax in relation
to the relaxed soft palate is checked with the mouth open.
If there is any appearance of the wax supporting the soft palate, the shaping
technique as previously described should be repeated. When the plane and contour of the
wax is satisfactory, a plaster model is cast under the palatal side of the wax and extending
under the denture to enable it to be located. After the plaster set, the wax is removed, and
replaced by thin mix of cold cure resin. The back of the denture should be roughened to
ensure a firm union between the denture and the cold cure resin.
The velar section can also be constructed after few weeks from using the denture
by attaching a piece of base plate, which act as a tray, to the posterior part of the upper
denture with suitable relief for the zinc oxide impression paste. During taking the
impression the patient should hold his head in a vertical position to prevent the escape of
the material into the naso-pharynx.
Construction of speech bulb
A piece of soft modeling compund is added on the wire loop that attached to the
end of the velar section. The denture with the soft compound is inserted into the mouth
and the patient is requested to swallow, say ah move his head up and down and then
from side to side while the compound is still soft. A drink of warm water or hot tea will
facilitate swallowing. The denture is removed, cleaned, dried and the compound is
inspected and reheated then reinserted in the mouth and the patient is asked to do the
same previously described movements using stick compound to correct the impression
section by section .
Impression wax softened in water bath maintained at 51 - 64 C painted over the
green compound with a brush. The denture carrying the compound and wax is inserted to
the patient s mouth and the same previously described movements are performed. The
prosthesis is removed and reinseted several times with gradual adjustment to the speech
bulb until a satisfactory functional impression is made. The impression wax has the
advantage that it can stay soft in the mouth for relatively long period for better
regestration of the functional movement. The size of the bulb should be adjusted until the
patient can breath clearly through the nose and produce acceptable nasal sounds. If the
patient is sensitive enough to produce a gag reflex, the speech bulb should be made
underextended using self curing resin, allowing the patient to wear the denture for few
Mostafa Fayad 30
weeks until he is accustomed to the underextended bulb, then the final impression of the
speech bulb is taken.
The black gutta-percha can also be used to make impression for the speech bulb.
This material can be fully adjusted to fit the movements of the pharynx and palatal
remnants before being processed in acrylic resin. The
black gutta-percha has the advantage of remaining
soft enough to be moulded by the pharyngeal
musculature for about 5 minutes after each heating,
while at the same time remaining sufficiently viscous
to support its own weight. It is therefore deformed by
muscular pressure and then retaines the shape
impressed on it by that pressure. The final details
shouldbe register by zinc oxide paste. Speech bulb moulded in gutta-percha
A special large flask is used for curing the tailpiece into clear acrylic, resine.
If the speech bulb is not too large and the deture is well retained, the speech bulb
can be made of solid acrylic. If however, the speech bulb is large ,or if the denture is
poorly retained due to there being only a few nature teeth present in the upper jaw or if it
is a full upper denture, then the speech bulb should be madehollow to reduce the weight
of the appliance.
Correction of the speech bulb
If the speech bulb need correction, the tissue conditioning or functional material is
applied to the bulb portion and the prosthesis is inserted into the mouth. The patient can
use the speech aid at home under normal conditions. The advantage of this is that at home
the patient can make the normal phisiologic movement without stress. While in the clinic
the patients are usually exaggerate there movement which may lead to inaccurate
impression.
when the palate is cleft a problem of how a fixed obturator which can fit the cleft in
both the functions of speaking and swallowing will developed.
The solution of this problem may include the following. In relation to the function of an
obturator it is suggested that :-
- The patient must learn new speech habits.
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- The gripping of the bulb during swallowing is a basic principle which must be
mastered
- The action in producing the palatal consonants is horizontal instead of vertical
and involves the gripping of the pulb as in swallowing.
The plane of location of the obturator must be in the plane of action of the
palatopharyngeal sphincter or bulge of passavant so the individual can gripping it with
his ring or sphincter mechanism and squeezing the remnants of the soft palate against it.
In practice an obturator is shaped by luting a piece of softened gutta-percha to a wire loop
or tail piece extending from the posterior border of the denture along the midline of the
cleft into the pharynx. The gutta-percha is then shaped by the muscles as they function.
Special Obturator Prostheses:
1- Hinged pharyngeal obturator
2- The palatal lift prosthesis
3- The meatal obturator
1- Movable (Hinged) pharyngeal obturator
The hinged pharyngeal obturator is similar to
the speech aid, it consists of three sections. However
the velar portion is attached to the posterior border of
the denture by a hinge and its lateral borders are shaped
to be gripped be the ruminants of the soft palate and
moved with them. The pharyngeal section is activated
by lateral pharyngeal musculature.
Delabarre (1820) emphasized the importance of the normal soft palatal movement
during biologic and activities and constructed a prosthesis a soft rubber velar as in the
more simple hinged type obturator. Although these prosthesis were mobile under
influence of the cleft soft palate, the movement was more similar to mechanical
movements than to physiologic function.
Mostafa Fayad 32
Disadvantages
a- The hinged obturator fail to achieve noraml physiologic soft palate movement.
b-The hinge is a source of weakness and frequently gets out of adjustment.
The mobile rubber prosthesis:
This prosthesis was constructed with a soft rubber velar section. The movement was more
similar to mechanical movements than to normal physiologic function.
2-The Palatal Lift Prosthesis
This type of prosthesis is designed to displace the soft palate superiorly and
posteriorly to assist the soft palate to close with the peripheral pharyngeal tissues.
Indications
a-Neurologic diseases as myssthenia gravis, cerebrovascular accidents, traumatic
brain injuries, and bulbar poliomyelitis.
b-Injuries to the soft palate as following adenoidectomy, tonsillectomy, or maxillary
resections.
c- Postsurgical cleft palate with insufficient length and movement.
Contraindications
1- If adequate retention is not available.
2- If the palate is not displaceable.
3- Uncooperative patients.
The objective of the palatal lift prosthesis
-To displace the soft palate tothe level of normal palatal elevation enabling closure by
pharyngeal wall action
-In cases where the length of the soft palate is unsufficient to effect closure after
maximal displacement, the addition of an obturator behined the displaced soft palate
may be necessary.
Mostafa Fayad 33
This prosthesis may used as a diagnostic aid to assess the possible improvement in
speech. Some clinicians believe that the use of a palatal lift on an interim basis may
stimulate flaccid soft palate to increase functional activity.
A Anatomically normal but
paralyzed soft palate,
B Palatal lift prosthesis in
position elevating soft palate to
produce palatopharyngeal
closure.
A Congenital anatomic
insufficiency of palatopharyngeal
region,
B Palatal lift obturator in position
elevating soft palate and obturating
palatopharyngeal space.
The advantages of palatal lift prosthesis
a-The gag response is minimized (because of the superior position and the sustained
pressure of the lift portion against the soft palate.
b-The tongue is not changed (because of the superior position of the palatal
extension.
c- The access to the nasopharynx for the obturator (if necessary)becomes easier.
d-The lift portion of the prosthesis may be extended gradually to help patient
adaptation.
e-Useful treatment for surgically risky patients.
Construction
The impression is taken using custom tray that extended with baseplate wax to
record and displace the soft palate superiorly. A suitable partial denture framework is
Mostafa Fayad 34
fabricated and verified. The retentive meshwork or wire loop is extended to cover the
anterior two thirds of the soft palate. Modeling plastic is added to the retentive meshwork
until the appropriate displacement of the soft palate is achieved. Then a thermoplastic
wax is used to record tissue detail. If displacement of the soft palate does not achieve
adequate obturation the obturator can be extended behind the deficient soft palate.
It is important to insure that the lifting force does not create soreness and the force of
displacement does not have an adverse effect on the supporting dentition.
3- Meatal obturator prosthesis
Meatus obturator has extension of the posterior border of maxillary section
upward and backward to close the posterior openings of the nose. It is used when there is
very large cleft to reduce the resonance of the nasopharynx.
The meatal obturator establishes closure with nasal structures diagonally above
the hard palate terminus. The obturator extends superiorly and slightly posteriorly from
the hard palate border and separates the oral and nasal cavities at this level
There are no movable tissues in this area and closure is established against the
turbinates, the residual vomer (if present) and the roof of the nasal cavity.
The position of meatal and conventional obturators in relation to palate plane.
Indications
a-This type of obturator may be indicated for patients with extensive defects of the
soft palate with a very active gag reflex.
b- For edentulous patients when retention is a problem.( when horizontally extended
speech aid is thought to be result in prosthesis displacement by leverage action.
Mostafa Fayad 35
A meatus obturator should be considered when the posterior extension of fixed
obturator prosthesis is likely to result in prosthesis displacement. Since the vertical
extension is closer to the palatal portion of the prosthesis, less torque is placed on the
palatal portion, thus decreasing the tendency to dislodge.
Advantages
a- Lesser in weight comparing to the conventional obturator.
b-The downward displacement force from the obturator extension is closer to the
supporting tissues of the parent prosthesis. This result is less lever action.
Disadvantages
a- The obturator does not enable the patient to control nasal air emission because it
ispositioned in an area devoid of muscle function.
b-Distortions in nasal resonance occar, because the oral cavity and oral pharynx are
increased in size and the nasal cavity is proportionally reduced.
Construction
The definitive maxillary prosthesis is constructed first, and a wire loop is attached
to the palatal end of the prosthesis. Modeling plastic is added to the wire loop to mold the
obturator. Head, speech, and swallowing movements are unnecessary because there are
no movable tissues in this area. The obturator is reduced 1mm and refined by
thermoplastic wax.
Over extension should be avoided because nasal mucosa is delicate and will not
withstand stress. After processing two small holes or hole approximately 5mm in
diameter should be drilled through the obturator to permit nasal breathing. An alternate
method is to reduce the lateral dimensions of the obturator until nasal breathing is
restored.
4- Silicone retentive obturator:
Indications:
a) Congenital clefts.
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b) Acquired defects.
c) More retention is required.
Material: Siliconeor rubber latex.
Technique of construction.
5- Fixed Prostesis (Stabilize Premaxilla).
6- Snap-on Prosthesis:
Types:
a) with speech pulp. b) without speech pulp.
8- Unconventional speech aid prosthesis:
Two sections: Nasal portion Denture.
9- Titanium self tapping implants:
Position: Alveolus Ptrygoid plates.
10- Root coping (attachments) Telescopic crown with rest.
II-Prosthetic rehabilitation of congenital cleft palate for adults
Definitive obturators for adults
Definitive appliances are usually constructed at the age of 20 years, when growth
and development is complete and bone graft, if present, is mature.
A definitive prosthesis is usually made for a patient whose experience with a
diagnostic one has been successful and surgery is contraindicated.
Obturators are attached to a partial denture, complete denture or an overdenture.
A- Partially edentulous patients
The design of the partially edentulous patients in cleft patients is similar to partial
dentures in normal patients. However, the partial denture is extended to the pharynx in
Mostafa Fayad 37
cleft patients. This extension exerts a long lever arm, which call for additional direct and
indirect retainers.
In the presence of scar tissue on the palate, the borders of major connectors should
follow the scar tissue rather than crossing them, with minimal beading.
The center of rotation of the partial denture.
B- Completely edentulous patients
The problems associated with completely edentulous cleft patients are:
1-The size of the maxilla is reduced due to reduced downward and forward growth
of the maxilla.
2-Increased inter-arch space also occurs as a result of maxillary growth reduction.
3-Lack of adequate support, retention and stability; due to lack of adequate bony
palate, lack of effective posterior palatal seal due to scarring, shallow depth of the
palate and poor alveolar ridge development.
4-Scarring in labial vestibule, in case of lip closure, affects peripheral seal and
denture retention.
B. Acquired palatal defects
While congenital clefts are confiend to the lines of union of the different
embryonic processes of the palate, the acquired defect may occur any where in the palate.
The cleft may involve the alveolar process, tuberosity, the hard palate and/or the soft
palate, half the upper jaw or more. Nasal and adjacent tissues may be involved.
Causes of acquired defects
1-The commonest cause is radical surgical removal of tumors (malignant or benign)
of the palate and paranasal sinuses.
Mostafa Fayad 38
2-Trauma by accidents from pencil, gunshot, severe compound comminuted
fracture.
3-Pathalogical conditions, like osteomyelitis of the palatal bone, syphilis,
tuberculosisand radium burns.
Disabilities associated with acquired maxillary defect
I- Function:
a-Speech: It is markedly changed after surgery by increased hypernasal speech.
These patients do not require speech therapy after prosthetic treatment because they
had a learned speech pattern.
b- Swallowing: Swallowing may be difficult, foods and fluids regurgitates into the
nasal cavity.
II- Appearance:
Disfigurement of the face and Diplopia may occur if the surgery extends to the
inferior border of the orbit.
III- Psychological Trauma:
The psychological impact of loss of part of the face is very severe on these
patients.
Rehabilitation of acquired maxillary defects
I- Surgical rehabilitation:
It is the best line of treatment, but it is limited to the following cases:
1- If the defect is the result of trauma.
2- In small size defects.
3- Tumors unsusceptibleto recurrence.
II- Prosthetic rehabilitation:
Mostafa Fayad 39
It is indicated in the following cases:
1-Large defects which is difficult to be corrected surgically.
2-Tumors with susceptibility to recurrence.
Phases of prosthetic treatment:-
1- Initial phase (surgical obturation):
The prosthesis should be placed at surgery or immediately thereafter. It restores and
maintains oral function at reasonable levels during the post-operative period until
healing is completed.
2- Second phase starts 3-4 months after surgery when the surgical site becomes stable
dimensionally thus permitting construction of the definitive prosthesis.
Obturators used for treatment of aquired cleft palate
1- Immediate surgical obturator.
2- Delayed surgical obturator.
3- Definitive obturator..
1- Immediate surgical obturator:
This obturator is constructed presurgically and inserted immediatelly after surgery
in the operating room. It is in the form of simple acrylic plate with retaining clasps or
holes in the flanges for wiring to remaining teeth or to available bony structures.
This obturator is particularly suitable for dentulous patients requiring a partial or
total maxillectomy as the remaining teeth used to help retention of the prosthesis. It must
not be removed before 7-10 days after surgery.
Advantages of immediate obturator
I- Functional:
Mostafa Fayad 40
1- The prosthesis provides a matrix on which the surgical packing can be placed.
2- Permits the patient to speak and swallow more normally by reproducing
normal palatal contour and by covering the defect.
3- Allows earlier removal of the nasogastric tube.
4-It can carry a skin graft or medicaments in the proper relationship to the
surgical cavity.
II- Hygienic:
The prosthesis reduces oral contamination of the wound during the immediate post
surgical period, reducing the incidence of local infection.
III- Psychological:
1-It decreases the psychologic impact of surgery by reproducing the contours of
the lost oral structures and maintain the function.
2-It helps to reduce the hospitalization period and thus reduce the costs of
hospitalization..
3- Restores the patient's self-image by reproducing the contours of the lost oral
structures and allows the patient to function in social environment.
Principals relative to the design of immediate surgical obturators
1- If it is possible the surgeon should leave the posterior edge of the hard palate &
tuberosity. Otherwise the soft palate will be flabby and often drop inferiorly.
2- The obturator should terminate short of the skin graft-mucosal junction. As
soon as the surgical packing is removed., extension into the defect may be
accomplishedwith tissue conditioning or interim soft lining materials.
3- The prosthesis should be simple and light in weight.
4-The prosthesis for dentulous patients should be perforated at the interproximal
extension to allow the prosthesis to be wired to the teeth at the time of surgery.
Mostafa Fayad 41
5-Normal palatal contours should be reproduced to facilitate postoperative speech
and deglutition.
6- A couple of wire loops is attached to thefitting surface in cases of big tumor.
7- Posterior occlusion should not be established on the defect side until the surgical
wound is well organized. If the three maxillary anterior teeth included in the
resection, they may be added to the prosthesis to improve esthetics.
8- The existing complete or partial denture may be modified for use us an
immediatesurgical obturator. The flange at the defect should be reduced and the
posterior teeth removed prior to surgery. Tissue conditioning material may be
used toimprove adaptation at the time of surgery.
The technique of construction
First, the abutment teeth should be surveyed and if there retentive undercuts do
not appear to be adequate., tooth modification should be made, which may include re
contouring. dimpling or placement of restorations.
Upper and lower alginate impressions are made in a perforated stock trays. The
maxillary impression tray must be modified to allow for the size of the tumor so it
should extended posteriorly with baseplate to record a significant portion of the soft
palate in the impression. The patient should be placed in an upright position so that the
soft palate assumes a relatively normal and relaxed position. If the patient has an active
gag reflex, it is useful to use topical anesthetics and fast-setting alginate.
It is important to make an accurate impression of the vestibular depth .on the
resected side so that the approximate position of the skin graft mucosal junction can be
determined.
The upper and lower impressions are poured in stone and the maxillary cast is
dublicated for future reference. The casts are mounted on a suitable articulator with the
aid of a jaw relation record.
The surgeon and prosthodontist should discuss the surgery together and outline
the proposed surgical margins on the upper cast. The lateral boundary is usually the
labial and buccal reflex and the medial boundary is the midline of the palate. The
questionable extensions are the anterior and posterior margins.
Mostafa Fayad 42
Try to persuade the surgeon to leave the posterior edge of the hard palate and
tuberosity. It is better to encouraged the surgeon to make the anterior incision through the
socket of an extracted tooth instead of between adjacent teeth.
A- Margins of proposed surgical resection are outlined on the cast. B- Teeth included in the resection are
removed and cast is trimmed for fabrication of immediate surgical obturator.
The maxillary cast is altered to conform to the proposed surgical resection. Teeth
on the area involved are cut away from the cast, but alveolar height is maintained. Any
elevation on the cast representing the palatal swelling should be removed to give a
normal palatal contour. The residual alveolar ridge is trimmed moderately on the labial
and buccal surface to reduce the stresson the soft tissue closure.
If the pterygoid hamulus is removed during the maxillectomy procedure, the
attachment and/or function of the tensor veli palatine, buccinator, and superior constrictor
muscles can be compromised due to the medial collapse of the distolateral portion of the
defect. In this case the cast should be reduced 2 to 3 mm medially.
The wire retainers are adapted and the prosthesis is waxed, invested and
processed in clear acrylic resin , then finished and polished in the normal manner.
A couple of wire loops is added at the fitting surface to hold the lining material.
Clear resin is preferred because the extensions and possible pressure areas can be
easily seen at surgery.
Holes are drilled in the buccal flanges when it is supposed to wire the obturator to
the zygomatic arches and/or anterior nasal spine.
Prior to surgery the obturator is immersed in a disinfectant solution, the required
instruments are autoclaved, and the dental material are sterilized with gas.
Mostafa Fayad 43
In most cases the obturator is easily fitted and secured. The lateral extension of
the obturator should be adjusted short of the skin graft-mucosal junction to avoid pressure
to this area. The lateral and anterio aspects of the obturator should be reduced until
correct facial contours are abtained without creating tension during closure.
The surgical packing will accommodate for most discrepancies. However, if the
surgery was more extensive than planned it is preferable to add a thick mix of soft
denture liner to the obturator. If the deficiencies are modest, a thinner mix of the soft liner
or tissue conditioning material is used.
In the past autopolymerizing acrylic resin or impression compound were used for
major additions to the obturator at surgery. However, resin is difficult to manipulate and
the free monomer has adverse effect on raw tissue surfaces. Impression compound
deteriorates easily intraorally, especially if used in conjunction with tissue-conditioning
materials.
If a weber-Fergusson exposure is used, the prosthesis should be inserted before
closing the cheek flap then the defect is packed with gauze and the cheek flap is closed. If
a transoral surgical approach is used, the defect should be packed prior to inserting the
prosthesis.
Retention can be obtained in dentulous patients by wiring the prosthesis to
existing teeth. Inedentulous patients the obturator is wired or pinned to the alveolar ridge
and zygomatic arches and /or anterior nasal spine.
After 7 to 10 days postsurgically
The prosthesis and packing are removed. The obturator is cleansed; the
wire retainers and minor occlusal discrepancies are adjusted.
A new application of tissue conditioning material may be made to improve
adaptation , seal and comfort.
The patient is dismissed for one week with the instruction regarding the
irrigation and cleaning of the surgical defect properly.
Usually the patient is seen every 2 weeks and the tissue conditioning
material changed to suite for tissue contracture. It is better to remove and
Mostafa Fayad 44
change all of the lining material to reduce bacterial contamination and
mucosal irritation.
2-Delayed surgical obturator:
It is an alternative to immediate surgical obturator that placed 7 to 10 days
postsurgically. It is the treatment of choice for edentulous patients with extensive surgical
defect.
The technique of construction
I- Tray selection and modification:-
1- The surgical packing is removed.
2- A soft metal stock tray with short flanges and clearance of 1/4 inch exists in all
dimensions is selected.
3- In the area of the defect, much of the flange may be removed or bent medially.
4- All flanges are covered with peripheral beading wax and additional wax is added
in the area of the defect to provide support for the impression material.
II- Impression making:
Major medial undercuts and other sensitive areas should be blocked-out with
Vaseline gauze. The gauze is used to limit the extension of the impression material
into the defect. An impression is carried out using alginate impression material in
the modified ray. The impression should be removed gently to avoid pain during
removal.
IV- Prosthesis fabrication:
In dentulous patients: -
1-The prosthesis will be fabricated as the immediate obturator, from acrylic resin
base with wrought wire clasp.
2-Anterior teeth, if missing, can be included for esthetic reason.
3- Posterior occlusion should be avoided to reduce the movement of the acrylic
resin extension against tissue, but as healing proceeds, posterior occlusal ramps
Mostafa Fayad 45
can be established with addition of self-curing resin to help the patient to retain the
prosthesis in position.
4- The prosthesis is delivered and adjusted using pressure indicating paste and
articulating paper. If it fits well and is well retained, it is not necessary to add
temporary lining material.
In edentulous patient: -
It is preferable to use the patient own maxillary denture as a delayed surgical
obturator, with the following modifications: -
1- The labial and/or buccal flanges of the denture are shortened on the side of
defect.
2- The existing denture is inspected to insure that it well adequately obturates the
surgical defect.
3- Self-cure acrylic resin may be added to the denture to cover the margin of
resection on the soft palate.
4- After adjustment of the denture the obturator should be lined with relining
material.
Instructions to the patient:
1- The patient should not remove the obturator at nights. The obturator remains in
place except for brief periods while cleaning the defect and the prosthesis. If the
obturator is removed for extended periods of time, the patient may have difficulty
reinserting it.
2-Patients are instructed to use a soft toothbrush and hand soap to clean the
prosthesis. Effervescent types of denture cleansers should be avoided, as they will
cause blistering of the soft lining materials of the post-surgical prosthesis.
3- The patient should visit the prosthodontist monthly for evaluation of the fitting of
the prosthesis and cleaning of the maxillary sinus.
3-Definitive obturator:
It is constructed 3-4 months after surgery. The timing will very depending on
many factors. The timing will vary depending on:
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1- The size of the defect.
2- The progress of healing.
3- The prognosis for the tumor.
4- The effectiveness of the present
obturator.
5- Thepresence or absence of teeth.
The prognosis of definitive obturator depends on (Treatment concepts):
1- Defects classification : Maxillary defects have been conveniently classified according
to the defect location and its relation to the remaining teeth by Aramany, 1978.
Aramany classification of maxillary defect
2- Movement of the prosthesis: If the maxillary alveolar ridge and teeth are involved in
the resection the obturator will displaced superiorly with the stress of mastication and
will tend to dropwithout occlusal contact.
3-Tissue changes: Dimensional changes will occur specially during the first year after
scar contracture. The obturator portion should be made of acrylic resin to facilitate
rebasing if required.
4- Extension into the defect: The degree of extension of the prosthesis into the defect
will depend on the requirements of retention, stability and support. If the remaining
maxillary structures give adequate retention, stability and support, a lettel extension into
the defect will be required. The presence of teeth enhances the retention, stability and
Mostafa Fayad 47
support so generally the use of the defect in edentulous patients is more extensive than
dentulous patient.
5-The weight of the prosthesis: Bulky areas should be hollowed to reduce weight to
avoid unnecessary stress to the teeth and supporting tissues. The hollowing is done during
packing the acrylic resin, by placing a sand bag between the acrylic resin in the middle of
the defect. After currying a small hole is made on the fitting surface to empty the
obturator from the sand. Then the hole is closed with self cure acrylic resin.
The construction of the definitive obturator will vary with the type of resection
and the presence or absence of teeth. Techniques for both edentulous and dentulous
patients with total or partial maxillactomy defects will be described
The superior surface may be closed to avoid accumulation of the nasal secretions
leading to odor and added weight, or left open to decrease the weight and is easier to
adjust. In the open type if secretions do tend to accumulate, a small diagonal opening
may be made between the inferior-lateral floors of the obturator through to the cheek
surface for drainage. If the skin graft lining the cheek surface has no secretory potential,
an opentop is acceptable.
6- The presence of teeth: As with all maxillofacial prostheses the presence of teeth
enhances the prosthetic prognosis. The teeth will assist retention, stability, and support
for the prosthesis.
7- Covering prostheses: The obturators are basically covering prostheses serving
primarily to reestablish the oral-nasal partition.
1- Edentulous patient with total maxillectomy defects
With any palatal perforation, retention in the classical sense of complete denture is
impossible, so that the residual palatal structures and the defect must be used more
extensively to improve retention, stability and support. In most cases acceptable retention
can be gained from:
1-Remaining palatal structures: The arch form and the amount of palatal shelf
remaining influence the stability and support. A square or ovoid arch will exhibit
relatively more palatal shelf area following a total maxillectomy.
Mostafa Fayad 48
The surgeon should be encouraged to resect only enough hard- palate to allow adequate
tumor margins. Especially important is ipsi-lateral palate preservation, which will allow
a tripoding effect. If the anterior alveolus can be maintained, the patient will have better
facial and less contracture postoperatively.
2-Engagement of the skin graft superiolaterally above the skin graft mucosal scar
band. The thick squamous epithelium of a split-thickness skin graft will resist the wear
and tear applied by the obturator. Engagement of the skin graft and the scar band formed
at the skin graft-mucosal junction will significantly improve retention. The scar band is
flexible and will permit the prosthesis to be inserted but will tend to resist dislodging
forces.
3-Extending the prosthesis along the oral surface of the soft palate
J unction of oral mucosa and skin graft lining.
4- Additional retention may be gained by extending the obturator along the nasal
surface of the soft palate and or anteriorly into the nasal aperture. If the vomer was
surgically removed, an undercut may exist superiorly along the medial margin. However,
this is a bony undercut lined with respiratory mucose. Therefore, this area is limited for
use unless a resilint material is used to engage the undercuts.
The support and stability can be improved by engagement of key portions of the
defect. Stability is enhanced by engaging the superuolateral portion of the defect and the
medial margin of the defect when it is lined with keratinized epithelium.
Some support can be obtained from the oral side of the skin graft-mucosal junction and
from the oral surface of the soft palate.
Technique of construction
Impression technique:
The skin graft-
mucosal junction
Nasa
Oral
Mostafa Fayad 49
An edentulous soft metal tray is selected and ultered according to the
configuration of the remaining maxilla. The medial and anterior undercuts are blocked
out with vaselineated gauze.
Adhesive is applied to the tray and alginate is mixed and loaded in the tray. Prior
to seating the tray, impression material is wiped or injected into posterior and lateral
undercuts. Cast is poured, and the undesirable undercuts are blocked out with wax.
shim is provided and a special tray are made from acrylic resin. Extension of the
tray are verified in the mouth. Several perforations are made for escape of the
impression material with at least three perforations being along the medial palatal margin.
Border molding using modeling plastic is carried out initially on the unresected side to
stabilize and orient the tray to the defect. The modeling plastic is relieved approximately
1 mm in all the areas. The tray and modeling plastic are painted with adhesive. Saline
irrigation is performed to remove excess nasal secretions .
Elastomaric impression material is prepared and injected into desirable undercut
areas and the loaded tray is seated into position. The lips and cheek are manipulated and
the patient is instructed to perform eccentric mandibular movements to account for the
movement of the anterior border of the ramus and the coronoid process of the mandible.
After the material has set, the impression is removed with a gentle teasing action.
Obturaror should maintain contact with soft palate during elevation
otherwise fluid leakage may occur.
If the anterior margin of the soft palate exhibits marked elevation during
swallowing and speech, the portion of the impression that engages the superior and
inferior part of the soft palate is cut away with a scalpel and a functional impression is
advocated using thermoplastic wax. To reinsert the impression, it may be necessary to
trim some of the impression material that has engaged undesirable undercuts.
If the patient exhibits extreme trismus, an alternative impression techniques is
suggested by using the surgical obturator after making necessary adjustment. A new
application of tissue conditioning material (or impression material ) is used for tacking
final impression.
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Recording of jaw relationship
Two methods are suggested for construction of record bases.
1- If the defect is large and stability and support are difficult to obtain with a
conventional record base, the definitive base is fabricatedfrom the master cast. This base
is used in recording jaw relation and at a later time the denture teeth are added with self
curing acrylic resin.
2- If stability and support are adequate, a conventional self curing acrylic base is
constructed after blocking of all undercuts and the rugae area to protect the master cast.
The vertical dimension of occlusion is determined in the usual manner using wax
rims on the record bases. An arbitrary face bow transfer is obtained and centric relation is
recorded.
Trismus is common in patients received radiation therapy. If trismus is extreme,
the vertical dimension of occlusion is reduced to allow passage of the food between the
denture teeth.
Care must be taken to prevent displacement of the maxillary record base during
the registration. Even in acceptable stable maxillary base, pressure on the defect side will
result in superior displacement into the defect. Soft wax, zinc oxide or plaster are the
material of choice for recording jaw relation.
The use of tracing devices to record centric relation are contraindicated.
Nonanatomic posterior teeth are preferred and adjusted to eliminate lateral
deflective occlusal contact. The trial denture are tried in the mouth and changes are made
to accommodate the esthetic desires of the patient and the prosthodontist.
Processing, delivery and follow up:
The obturator with the denture are processed in heat-cured acrylic resin. On
delivery, the resin extensions into undercut areas may require considerable relief to
permit seating of the parosthesis.
The superior surface of the obturator should be slightly convex and well polished.
Any sharp projection on the lateral surface of the obturatot should be rounded and
polished with pumice. Polishing improve cleansibility and reduce the friction between the
prosthesis and soft tissue during functional movements.
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If more retention in necessary, soft silicon material is used for the obturator
segment to engage undercuts more profoundly.
Home care instructions are reviewed and recall appointments are arranged. Most
maxillary obturator will require rebasing within the first year because of dimentional
changes of the defect.
Modifications over the next years are often performed if the prosthesis becomes
intolerable to the patient or a warning signsare encountered. The warning signs that the
obturator is no longer functioning are, liquid reflux into the nasal cavity, change in the
quality or nasality of the voice.
To obtain hollow bulb: During backing of acrylic
resin a small cellophane bag filled with sand is backed
within the bulb. After processing, a hole is drilled
throughout the bulb and sand drained away. The opening is
then closed with self-curing resin.
Superior surface of the obturator should be slightly
convex and well polished to decrease friction during
functional movement.
To gain better retention, soft material allows the obturator to engage the undercut
in the defect more aggressively.
2- Edentulous patient with partial maxillectomy defects:
In this defects, more of the hard palate remains and thus the stability and support
are increased. However, retention may be reduced. Soft silicone materials may be used to
improve retention by engage bony undercuts .
Fabrication of definitive obturator for partial resections of the edentulous maxilla
are similar to the prosthesis for total maxillectomy resection. However , rebasing is not
necessary as frequently.
3- Dentulous patients with maxillectomy defects:
Mostafa Fayad 52
The presence of teeth assist retention, stability and support of the removable prosthesis.
Treatment Concepts:
1- Location of the defect. The distal portion of the maxilla are usually included
in the surgical resection andthe distal abutment is rarely remain. Therefore for
most patients, a Kennedy class II partial denture with extensive lever arm is
required.
2- Movement of the prosthesis: The defect must be used to minimize the
movement of the prosthesis to reduce thestress on the abutment teeth.
3- Length of the lever arm. Considerably longer lever arms are encountered in
patients with intraoral surgical defects.
4- Arch form: Square or ovoid arch forms provides more bearing surface
perpendicular to occlusal stress resulting in more stabe prosthesis during
function. Tapering arch form gives less palatal shelf area and therefore support
iscompromised.
5- Teeth: Preservation of the remaining teeth is important for retention and
esthetics. The partial denture design must prevent the natural teeth from any
pathologic stresses during functional. Maximum retention, stability and support
should beobtained from the defect.
Aramanys classification of maxillary defects:
Maxillary defects have been classified according to the defect location and its
relation to the remaining teeth.
Class I: lateral defect with anterior margin approaching the midline.
Class II: Lateral defect with anterior margin away from the midline.
Class III: Middle defects surrounded by remaining dentition.
Class IV: Lateral defect with anterior margin crossing the midline.
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Class V: Defect with anterior teeth remaining.
Class VI: Defect with posterior teeth remaining.
Partial denture design:
Diagnostic casts are surveyed carefully to locate the undercuts, the contour of
guide planes, and selection of the path of insertion. Often a compound path of insertion
must be employed to use the undercut in the defect. For example, if lateral and posterior
undercuts will be used, the obturator is inserted into the defect first and then rotated into
position onto the teeth.
The basic principals of partial denturedesign should be followed :
-Major connectors should be rigid,
- Occlusal rests should direct occlusal forces along the bony axis of the teeth,
- Guide planes should be designed to facilitate stability and bracing,
- Retention should be within the physiologic limits of the periodontal ligaments. The
clasp arms should be passive when not functionally stressed and provide minimal
retention needed to resist displacement.
- Maximum support should be gained from the residual soft tissues.
- Indirect retainer should be distributed as even as possible.
Aramany classes 1, II & IV
These defects are considered together because they share the same cantilever stress
patterns. A Kennedy class II partial denture with an extensive lever arm is required for these
patients.
Defferent partial denture designs were suggested to achieve adequate retention
and to ensure proper orientation of the prosthesis. A rest and retainer should be placed on
Mostafa Fayad 54
the tooth closely adjacent to the anterior margin of the defect. If this concept is not
employed, the prosthesis will tend to rotate out of retentive areas posteriorly.
Often the bony support for the tooth adjacent to the defect is compromised and
does not permit its use as abutment. Other adjacent tooth should be used for this purpose.
This compromised abutment can be treated endodontically with amputation of the crown
and the root serves as an overdenture abutment.
Different suggested partial denture designs. Note fulcrum line in relation to defects.
Multiple occlusal rests may be used to improve stability and support. The fulcrum
line is determined by the position of the occlusal, incisal or cingulum rests.
Sometimes lingual retentive clasp arms with buccal reciprocating arms are used
depending on the angulation of the abutment teeth.
Since there is no cross-arch reciprocation of either buccal or lingual retention, this
partial denture must be viewed as a unilateral partial denture and both buccal and lingual
retentive arms may be considered to obtain cross-tooth retention and reciprocation.
Dentulous patients with partial maxillectomy defects Aramany class II
In Aramany class II the prosthodontic consideration are similar to the total
maxillectomy except that the prosthetic prognosis improves as the margin of the resection
moves posteriorly.
If the maxillary cuspid of the defect side remains. The prosthetic prognosis
improves dramatically. Even the presence of a central or lateral incisor on the defect side
will enhance the stability and support of the prosthesis. The fulcrum line is dependent on
the placement of occlusal rest. As more teeth are retained on the defect side, the fulcrum
line shifts posteriorly. If bicuspid teeth remain the fulcrum line will be similar to a
conventional Kennedy class II partial denture .
Mostafa Fayad 55
Indirect retainers should be placed as far anterior as possible from the fulcrum
line. If adequate retention, stability, and support can be
obtained from the residual dentition and soft tissues, no need
to engage the defect aggressively.
The partial denture designs of Aramany Class II defect is similar to
Kennedy Class II partial denture.
Class I design: The design can be either tripodal or linear.
Tripodal design: Two or three anterior teeth are splinted. Retention and bracing
(labial and buccal retention and palatal bracing) and support are derived from the central
incisor and the most posterior abutment tooth. Indirect retention is utilized by the location
of a rest on the canine, or on the distal surface of the first premolar.
The linear design: If the anterior teeth are not included in the design, a linear
design is recommended. Where the unilateral design requires bilateral retention and
stabilization (diagonally placed on the posterior teeth).

Class I. Left; tripodal design. Right; linear design.
Class II design
The triangle formed by the fulcrum and lines through the anterior and posterior
teeth with the canine as an apex serves as a reference. As this triangle flattens and
diminishes in area, the stresses on the posterior teeth increase,
leading to more difficult considerations of retention and stress
Mostafa Fayad 56
distribution. Based on this principle class IV is the most critical, followed by class I and
finally class II is the least.
canine (apex, A), the distal abutment B and anterior abutment (C, or D, or E).
In Class II design, the teeth next to the defect are splinted. Retention is placed
buccally on all abutment teeth, and indirect retention is located on the opposite side of the
defect. Guiding planes are on the proximal surfaces of the second molar and the tooth
next to the defect.
Class IV design:
Cross tooth reciprocating retention (lingual retention on the molars and buccal
retention on the premolars) are used. Guiding planes are placed on proximal surface of
the tooth next to the defect and the posterior terminal tooth. It is indicated to use only
light wires in an acrylic resin base for class IV definitive obturation if the remaining
dentition is not optimal.
linear design for metal frameworks for a Class IV maxillectomy is indicated. Retention and
bracing are diagonally opposed
Prosthetic procedures:
The mouth preparation is completed as outlined and master impression is
performed to construct the partial denture framework. The master cast is made and the
framework is designed and fabricated. The frame work is adjusted to the abutment teeth
in the patient s mouth using disclosing medium. The undercuts within the defect are
Mostafa Fayad 57
blocked out on the cast and relief is placed over the scar band and lateral wall of the
defect . Acrylic resin is molded to the framework and the defect in preparation for the
altered cast impression.
The extension of the prosthesis is adjusted using modeling plastics. The extension
is relieved and holes are made along the finish line to escape excess material. Adhesive is
applied and an elastic impression material is used to complete the altered cast
impression. While the impression is tacking the patient is directed to make eccentric
mandibular movements. After setting , the impression is removed and examined. The
master cast is segmented , the framework and altered cast impression are seated on the
tooth segment, and the impression is boxed and poured in dental stone. Conventional
methods are followed to complete the prosthesis.
The obturator portion is made hollow and constructed from acrylic resin to allow
for adjustment and rebasing. Slight pressure against the cheek is desirable to ensure
maximum retention, stability and support.
Dentulous patients with partial maxillectomy defects which not involve the
alveolar ridge and teeth .Aramany class III
This is essentially a tooth supported partial denture with central obturator
extension. Conventional clasping elements are selected according to the position and
conditionof remaining dentition.
The partial denture design of Aramany Class III is essentially a tooth- supported partial denture
with central obturator extention.
The Class III defect can be treated by tooth supported partial denture with central
obturator extension.
Mostafa Fayad 58
Class III: retention, bracing and support are derived from four widely separated abutment teeth.
It is unreasonable to make any support from extension into the defect space,
although soft liner extensions above the lateral palatal shelves may be useful. If the
junction of the hard and soft palates is involved, construction of an obturator for this type
of defect is more difficult than it appears, as the obturator must maintain contact
posteriorly and laterally during soft palate elevation.
Thermoplastic is used to record thefunctional impressions of the tissue bordering
the defect. Speech is usually normal after delivery of the prosthesis. However the patient
will note excessive fluid leakage when swallowing . To alleviate this problem 5-10 mm
extension is placed across the intact soft palate. During function the soft palate will lift
from this extension, but this shield will serve to direct food and liquids into the oral
pharynx. Extension into the defect with contact with the nasal side of the soft palate
during elevation also is suggested.
Patients with bilateral total maxillectomy defects Aramany class V
Class V design:
The design for Class V maxillary defect. Splinting of the anterior teeth is
recommended. Tripodal design calls for buccal retention and palatal bracing. Support is
derived from the splinted components, and indirect retention is located on the central
incisors.
When both maxillae have been excised, the prosthetic prognosis is quite guarded.
Prostheses constructed for these patients are primarily for speech and esthetics. However,
without bony support the prosthesis will exhibit considerable movement during
mastication and swallowing and placed tremendous stress on the remaining anterior
Mostafa Fayad 59
teeth. When retention is compromised, consideration must be given for creating
undercuts surgically. Silicon or two-piece prosthesis may be used to increase retention.
Splinting the anterior teeth and the use of gate or swing lock prosthesis will distribute
stresses to anterior abutment teeth and may provide favorable
situation for support in this case.
Swing lock prostheses may provide favorable situation for
support in class V defect patient.
If a large portion of the orbital floor is surgically removed, the incidence of
diplopia is increased. In these cases prosthesis are often useful to support the orbital
contents. The prosthesis may be fabricated as a one-pice in which the antral extension is
attached directly to the obturator or in two section in which the superior orbital extension
is connected to the obturator section via an attachment. The antral section may be flexible
or rigid. The advantages of flexible apparatus are that, it is light in weight and it minimize
the movement generated by the obturator during function.
patient with surgical resection of premaxilla Aramany class VI .
This defect will usually be smaller in area then the class V defect, so the
gravitational movement will be less important and conventional clasping may be used to
support this extension.. However, resection of this type can leave the upper lip totally
unsupported or missing. The acrylic resin extension will be designed to position and hold
the lip in an esthetic position . If the lip or nose is resected, the obturator may be designed
to hold a facial prosthesis. If the remaining teeth can tolerate full coverage, a cross arch
bar splint can dissipate rotational stress to the anterior abutments and also give additional
retention to the prosthesis .
Partial denture design with conventional clasps for Class VI defect.
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Double swing-lock partial denture with acrylic esthetic overlay engaging remaining teeth.
Defect is usually less stressful to remaining posterior teeth. Full palatal coverage and
conventional clasping are effective to retain and support the prosthesis.
Class VI defect, conventional clasping may be used to support this extension.
Technique of Construction of Definitive Obturator:
The same procedures of making the conventional partial denture are followed with
attention is focused during impression to record the defective area.
4- Patient with total soft palate defect
Patient exhibiting considerable movement of the residual palatopharyngeal
complex during function have excellent prosthetic prognosis for achieving normal
speech.
Patient with little or no movement of the remaining palatopharyngeal mechanism
makes it difficult to achieve normal speech with either surgical or prosthetic
reconstruction. The obturator is attached to a conventional prosthesis. For dentulous
patient, the obturator is constructed from acrylic resin and retained to the metal
framework of the denture. The obturator should contact the remaining musculature of the
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palatopharyngeal mechanism during function. The optimal level of the obturator in the
nasopharynx is determined by the position of movement of the residual palatopharyngeal
mechanism. Passavants pad and the anterior tubercle of the atlas bone can vary in
location in relation to normal palatopharyngeal closure. Therefore, it is difficult to define
a definite land marks for placement of the obturator.
As a general rule the following guide lines should be consider for location of the
obturator for adults:
1- The obturator should be located in the nasopharynx at the level of normal palatal
closure.
2- The inferior margin of the obturator should be placed at the level of greatest
muscular activity exhibited by the residual palatopharyngeal complex.
3- The inferior extension of the obturator will usually be an extension of the palatal
plane as extended to the posterior pharyngeal wall.
Methods of construction:
The conventional prosthesis should be fabricated first. In obtaining impressions
for diagnostic casts, the palatal portion of the tray should be extended with wax to record
the defect. Partial denture designs should consider the long lever arm created by the
extension for the obturator. Multiple occlusal rests on either sides of the fulcrum line will
increase stability and resist the downward displacement of the obturator. Multiple
retainers should be used with the retentive arms engaging distal undercuts.
If the patients has an anterior edentulous area, crown should be placed on the
adjacent abutment teeth with the attachment of an anterior bar. The base will act as an
indirect retainers and give excellent stability for the obturator extension .
If the defect is too large, acrylic tray is added to the retentive meshwork or wire
loop to approximate the area of the defect. The acrylic tray is adjusted and checked with
disclosing wax to ensure that contact does not occur with the lateral and posterior walls
when the patient says ah.
Warm modeling plastic is added to the tray and placed in the mouth. The modeling
plastic should be as worm as the patient can tolerate because the pharyngeal tissues dont
contract forcefully except in swallowing. The patient is instructed to move his head in a
circular manner from side to side, to extend his head as far forward and back as possible,
and to speak and swallow. These movements activate the remaining palatopharyngeal
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musculature and shape the modeling plastic. Since swallowing makes a more forceful
closure, it should be performed at the end of the sequence to avoid underextension of the
obturator. When the modeling process is completed, the patient is asked to speak, to
swallow and to breath through the nostrile to test the effectiveness of the formed
obturator. Then, all extensions are reduced 1 mm with a sharp scalpel, a mouth
temprature thermoplastic wax is added to the obturator, flamed, tempered, and placedin
the mouth for approximately 5 minutes. The previously described functions are repeated
several times.
The prosthesis is removed, chilled with cold water and examined. Excesses wax
are trimmed and additional wax are applied to the deficient areas. Thewax is flamed and
tempered, the prosthesis is reinserted, and functional movements are repeated. When the
obturator appears adequate, the prosthesis is tempered in water bath and replaced in the
mouth for 1 to 3 hours. The patient is instructed to wear the prosthesis without removal
and to speak, swallow and perform the previously described movements. Before removal
of the prosthesis, the patient is instructed to gargle with cold water to chill the wax.
The obturator is converted into acrylic resin in a customary manner. If the
obturator is extensive hollowing is usually indicated. The oral surface of the obturator
should be concave to provide adequate space for the tongue. The superior surface should
be convex to deflect the nasal secretions into the oropharynx. The final contour of the
obturator are determined with the prosthesis in the mouth using pressure-indicator paste.
Following obturation the movement of the palatopharyngeal complex may be increased
and the obturator may require reduction after delivery.
Size and position of obturator:
The lateral dimensions are determined by lateral and posterior pharyngeal wall
movement. As the position and length of the superior extension are controlled by the
prosthodontist, too extensive superior extension should be avoided (approximately 10mm
is adequate).
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Methods to Improve Retention of Acquired Obturators
Securing retention of a prosthesis is a vital factor in its efficiency and in patient's
comfort. Acquired palatal defects usually present problem in prosthesis retention,
especially in edentulous patients. This can be overcomed by:
1- Engagement of the scar band formed at the skin-graft mucosal junction. As this area
contracts during healing it does so like a purse string creating a lateral undercut superior
to the scar band. Engagement of the scar band superiorly, and inferiorly improves
retention of the prosthesis.
2- Extension of the obturator against the lateral wall of the defect . In patients with
lateral maxillectomy defect, the axis of rotation is located along the medial margin of
the defect (class I,II,IV), the lateral portion of the prosthesis will exhibit the greatest
degree of movement.Extension of the prosthesis, and tissue contact superolaterally will
minimize vertical displacement of the prosthesis .
3- Resilient lining material; the use of resilient lining material may be indicated to
engage more undercuts in the defect. Definitive prosthesis with flexible obturator (soft
silicone material) will permit the engagement of bony undercuts more aggressively, thus
improving retention of the appliance .
4- Hollowing the obturator portion; large extensions of the prosthesis into the defect
should be made hollow to reduce the weight and vertical downward displacement of the
appliance.
5- Refitting the base; changes in the tissues supporting a maxillofacial prosthesis may be
rapid than those supporting a complete denture thus ,base adaptation must be re-evaluated
frequently and corrected by relining or rebasing to compensate for tissue changes .
6- Osseointegrted dental implants Recently, excellent retention and stability can be
provided by the placement of osseointegrated dental implants in residual alveolar ridges
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and within bony regions of the defect. This improves the retention of the prosthesis
significantly.
The osseointegrated implants, placed into multiple regions of bone within the defect
provide a rigid, immobile base which can be used to retain the prosthesis using suitable
attachment system (magnets or clip bar attachment). The prognosis of osseointegrated
implants for irridated patients is less favorable because of changes in the supporting
structures .Successful osseointegration can be achieved by the use of hyperbaric oxygen
therapy, this improves hypoxia , hypocellularity and hypovascularity in irradiated
patients.
7- Two piece obturator, sectional obturator : It is used for edentulous patients with
acquired palatal defect involving large area of the palate. This usually presents a problem
in prosthesis retention. To ensure effective retention, the prosthesis must be extended
sufficiently to engage more undercut within the defect, with the result than that path of
insertion may present a great problem. Two piece obturator (sectional obturator) with
different paths of insertion will solve this problem, and increases retention. This also is
valuable for patients with bulky prosthesis and small mouth opening. The path of
insertion of the two pieces should be different to help in retention. The obturator portion
is constructed with two projections parallel to each other. The obturator portion is
inserted to engage undercuts in the defect, an overall impression is made, and the denture
base is constructed on a cast obtained from this impression. The two parts and related
together by attachment, hook or magnets.
8- Magnets: Magnetic retention is an effective method for retaining maxillofacial
prostheses. Most of the prostheses incorporating magnets are sectional prosthesis, in
which each section of the prosthesis contain a magnet. When the sections are properly
oriented, the magnets attract each other so retaining the sections.
9- Clasping: For partially edentoulous patients, the presence of teeth will enhance
retention of the prosthesis. Clasp placement should be broadly distributedthroughout the
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remaining dentition. Clasps should be placed on abutments teeth adjacent to and distal to
the defect. Auxiliary clasps can be used.
"cross tooth" retention and reciprocation should be considered for cases with
lateral defects. Lingual retention with buccal reciprocation clasp is indicated for the tooth
away from the defect. This clasp design will disengage from the tooth during occlusal
movement of the prosthesis, reducing the rotational stresses transmitted to the posterior
abutment.
Means of retention for acquired defects obturators
1-Clasps in dentulous patients.
2-Undecuts in the defective area, especially when soft liner is used.
3- Buccal flanges engaging undercuts in teeth and ridge.
4-Maximum coverage to the remaining tissues.
5-Theuse of implants with attachments in the unresected side .
6-The use of two parts obturator; the first in the defective side engaging undercuts and
the second covering the palate.
7- The swing-lock partial dentures.
8-Bar attachment andclip.
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Labial flange made from flexible acrylic engage undercut.
Implant placed in the unresected side.
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Swing lock type prosthesis for class V defect patient.
Left; bar soldered to crowns on cast. Right, fitting surface of partial denture obturator (for anterior
defect) with clips.
Mandibular defects
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Rehabilitation of mandibular defects
Causes of Bony defects of the mandible
-Trauma.
- Tumor resection
-Inflammatory disease
-Radio necrosis
Disabilities of mandibulectomy patients
Deviation of the mandible toward the resected site.
Scarring on the remnant mandible.
Limited range of motion.
Occlusion discrepancy.
Problems associated with discontinuity of the mandible in swallowing, speech,
respiration and control of saliva.
Disturbance of appearance.
Classification of mandibular defects:
a) Marginal Resection ( Continuity defects):
Superior resection of the alveolar bone leaving the inferior border intact.
1- Anterior marginal resection:
May include part of the tongue and floor of the mouth if the arch isn't
restored in a short time remaining teeth will be no longer in the neutral zone
and the buccal musculature will cause severe lingual tilt of remaining teeth
so, selective extraction and use of labial bar major connector design will
improve the condition.
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- After resection an interim prosthesis must be fabricated and inserted
during healing period to prevent collapse of mandibular segment.
- R.P.D. design will be typical to class IV design.
2- Lateral marginal resection:
- Definitive prosthesis is constructed after sufficient healing period has passed.
- The most important considerations:
a) Firm and non movable tissues.
b) With normal buccal and lingual vestibular depth is favourable.
- R.P.D. framework design will be typical to class II design.
b) Segmental Resection ( Discontinuity defects):
Complete resection of a segment of the mandible from the alveolar crest to
the inferior border of the mandible.
- Resection often in the region of 2
nd
premolar and 1
st
molar.
- Resection should be through the alveolus of an extracted tooth
rather than interdental bone to:
1- Preserve supporting bone distal to the last tooth.
2- Used as 1ry R.P.D. abutments.
- Increase the size of the resected mandible increase degree of
severity.
A] Treatment of mandibular defects
a) Surgical reconstruction using a bone graft
It is the best approach that a surgeon can take to correct defects of the mandible.
The bone graft restores continuity to the mandible and provides a prosthesis-bearing area.
However, surgical reconstruction may be contraindicated in patients receiving radiation
therapy or in individuals with residual tumors.
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Optimal treatment involves placement of endosseous implants in the bone graft,
which help to anchor removable or fixed prostheses. The implants also minimize bone
resorption and add to patient comfort.
In marginal mandibulectomy (the mandible remained continuous), the patient can
be restored with an implant-supported prosthesis for the lower jaw.
Prostheses for segmental resection of partially Dentulous mandible
Snap-on prostheses can be designed and serve as a final removable partial denture can
be designed in the form of snap-on prostheses. The selected abutment teeth are crowned,
splinted and cemented in place. Bilateral bracing is important to minimize stress on any
one tooth and to offset the lateral forces exerted by the slight jaw deviation which still
persists.
A Dolder, Andrews, or Baker bar is splinted to crown and clip attachment is embedded in
the denture base . the final partial denture with the clip snape onto the bar(fig 3).
Fig 3A, Baker bar splinted to crowns. B, the clip is embedded to the fitting surface of the
denture base C, snap-on prosthesis in place.
Prostheses for segmental resection of fully Dentulous mandible
In such case the multiple abutments should be crowned and splinted before the final
removable partial denture is constructed. This resection prostheses provides acceptable
occlusion
Prostheses for anterior marginal excision of edentulous mandible.
The construction of prostheses for anterior marginal excision of the edentulous mandible
require additional care. The huge intraoral vertical dimension must be restored, and a
heavier denture is often constructed, sometimes unconventional prostheses with springs
may be constructed to bring the teeth to acceptable occlusion and the lip to normal
alignment.
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Prostheses for partially resected edentulous mandible
The prostheses in such case are constructed manually for esthetics. The denture
base usually need plumping to improve the facial appearance. This plumping is done by
adding more wax during the try-in phase to open the patient's facial symmetry. These
plumping should be passive to avoid unset of the denture by muscles impingiment. The
acrylic teeth may need reshaping by grinding the buccal of the upper and the lingual of
the lower to stabilize indirectly the denture during various mandibular excursions.
B] Treatment of mandibular deviation
The most serious sequel of acquired mandibular discontinuity is deviation. The
mandible deviates towards the affected side.
The dentulous mandibular discontinuity patient is at a more advantage over their
edentulous counterpart in the correction of deviation.
Frontal plane rotation. A, As the force of mandibular closure increases, the mandible rotates around
occlusal contacts on the unresected side, and (B) the remaining teeth on the resected side drop further
out of occlusion.
1-Immediate post surgical intertmaxillary fixation. Maintaining this fixation for
several weeks and reapplying elastic for several hours daily to preserve the occlusal
relationship.
2-Palatal acrylic resin ramp (deviation appliance); It is easiest and most practical
device, it is consists of acrylic resin ramp on the palatal incline of the non-affected side.
This is a functionally generated platform that slopes occlusally away from the maxillary
dentition and engage the remaining mandibular teeth as closure begins.
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- Acrylic Ramp Vs Metal Ramps: Acrylic ramps are advantageous because:
1) Periodic revisions and adjustments of the ramp are possible.
2) The final desired position doesn't have to be achieved with the 1st application of
acrylic resin.
3.Physical manipulation: The most effective treatment is by early physical manipulation
of the proximal fragment towards the unoperated side. This is done as soon as healing
permits (within 2 weeks). It will be most effective in preventing scar contracture and
breaking up tissue adhesion.
4-Training flange ( Guiding flange prosthesis): is used to train the masticatory muscles
to close in normal occlusal relation. It is a flat cast or acrylic resin vertical extension
from mandibular partial denture, or cap metal splint. It should be long enough vertically
to engage the buccal surface of maxillary teeth on maximum function opening.
Patient with a lateral tongue mandibular discontinuity defect. The left lateral tongue was reconstructed
with a myocutaneous flap. A, Mandibular prosthesis in position. B, Maxillary prosthesis in position.
Note the functionally generated occlusal platform or palatal ramp, (arrows). C and D, Note the angular
path of closure.
The partial denture framework designs should positively engage most of the
remaining dentition, to prevent movement of individual teeth. The training flange is
usually designed to extend vertically from a continuous clasp along the buccal surfaces
of the maxillary bicuspids and molars.
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The flange may be constructed to extend from maxillary palatal plate and lies in
the lower lingual sulcus in contact with the lower lingual surface of the lower molar and
gingiva on the sound side.
This flange is constructed from Victoria metal, German silver or brass sheet 0.7 to 1
mm thick and recurred metal; cap splint at the opposite side of the defect.
When the patient open his mouth for enough the flange looses contact with the
upper teeth and the mandible displace toward the resected side, with the result that the
patient is unable to close again as the flange comes into contact with the palatal mucousa
giving pain with the occlusal surface of the upper teeth. To close the mouth the patient
should push the mandible towards the sound side by hand, or later the masticatory
muscles can pull the flange to clear the upper teeth and help it to lie again in the upper
buccal sulcus. This necessity of pulling the mandible into normal position every time the
mouth is closed trains the muscles. At first a voluntary effort was needed by the patient's
hand but in a short time it becomes involuntary ( by the muscles of masticartion).
Mandibular guidance prosthesis
with jaws opened.
Acrylic mandibular guidance
prosthesis with jaws closed.
Metallic mandibular guidance
prosthesis with jaws closed.
Another design include a split splint with a buccal superior flange that attached to
the lower teeth. In 3 weeks this " training splint" resulted in unilateral muscle
development that compensated for the loss of bone in the other side, so that on opening
and closing the mouth, the teeth met in normal occlusion.
After treatment if there is still slight mandibular deviation two rows of back teeth
might be used on a the upper denture to get occlusion in two positions or imprints in the
acrylic base palatal to t he upper posterior teeth are made to occlude with the lower
posterior teeth.
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5- Maxillary guidance ramp:
- Preferred for patients with severe mandibular deviation.
- Constructed of acrylic resin or cast or wrought wire retainers.
- It serves as interim prosthesis until acceptable occlusion is established.
- Technique:
1
st
Visit:
1) Full palatal coverage prosthesis is constructed following conventional prosthetic
guidelines and then fitted and adjusted in the mouth.
2) Mandible is guided until proper occlusion occlusal contact with palatal
prosthesis is noted.
3) Prosthesis is removed and a mix of autopolymerized acrylic resin is prepared and
added to the palatal prosthesis along lateral and anterior borders of non defect side.
4) The prosthesis replaced in the mouth and mandible is moved to desired position
forming a palatal index lingual to maxillary teeth.
5) The prosthesis is then removed to allow for completion of polymerization.
6) Smoothing, finishing and polishing patient instructed to wear the prosthesis
continually.
7) The index shouldn't extend below level of maxillary teeth, because:
a) Interfere with speech.
b) Interfere with deglutition.
c) Interfere with other oral functions requiring tongue manipulation.
2
nd
Visit:
1) The mandible will usually exhibit more movement laterally toward non surgical
side.
2) Adjustment of palatal ramp is done to enable the mandible to assume proper
maxillo-mandibular relationship.
3) When intercuspal position is achieved Mandibular guidance prosthesis is
required.
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Success of mandibular guidance therapy varies and depends on:
1) Nature of surgical defect.
2) Early initiation of guidance therapy.
3) Patient cooperation.
4) Radiation therapy.
5) Amount of soft tissue dissection
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C]- Lip and check support prosthesis.
In patients had mandibular resection and reconstruction; initially lip prosthesis can
be constructed to support the patients lower lip and cheek to improve the external
cosmetics. Final mandibular resection prosthesis with teeth and pink acrylic support the
lower lip.
Intra-oral view of lower jaw surgery
and reconstruction.
Lip support prosthesis. Final mandibular resection
prosthesis with teeth.
The lips play an important role in the articulation of speech. An intact lower lip is
more important for speech than the upper lip because of its greater potential for
movement.
The prosthetic replacement for the lower lip and the retention of this prosthesis is
difficult because of movements of the mandible and the presence of saliva. Usually the
surgical reconstruction of the lower lip is the treatment of choice whereas prostheses for
replacement of a resected lower lip will aid speech and saliva control.
Facial paralysis may be resulted from trauma, infection, Cerebravascular accident,
or bell's palsy. Because the facial nerve supplies the motor and sensory innervation for
the buccinator and circum oral musculature, the loss of innervation of these muscles will
result in sagging of the affected side of the face. Drooping of the eyebrow, cheek, corner
of the mouth and lip lack of tonus and drooping of the corner of the mouth with
Mandibular defects
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compromised saliva control are also associated with facial paralysis. On unilateral
paralysis, the muscles of the unaffected side of the face exert an abnormal pull on the
paralyzed side leading to chronic spasticity of the uninvolved muscles. The articulation
of speech may be affected with varying degrees.
To test the function of the facial nerve, instruct the patient to alternate between
"oo" and "ee" sounds normally semishencteric posture is assumed during the production
of the "oo" sound and a tense and spread posture for the "ee" sound.
Lip support prostheses may be beneficial to patients with facial nerve paralysis.
These prosthetic aids can be constructed with maxillary removable partial denture. Open
wire loop of 8-guage half-round wire is attached to the upper denture in the first premolar
area. The loop should be adjusted to protrude from the from the mouth to be used as hook
to elevate and support the upper lip and the corner of the mouth.
The partial denture framework is adjusted, and the loop is covered with baseplate
wax. The wax is adjusted to achieve the desired support for the corner of the mouth then
the wax is replaced by clear acrylic resin .
Although this loop is strengthened the lip line, it is unesthetic and does not
improve facial sag and still permitted drooling and may cause distortion of bilateral (P
and B) and labiodental (F and V) speech phonemes.
Another technique
A maxillary removable partial denture framework with a retentive meshwork in
the biscuspid areais constructed. Modeling plastic is added gradually to the meshwork to
elevate the vestibular fornix and cheek while speech and esthetic changes are evaluated
until the desired contours are achieved. The modeling plastic are substituted by
autopolymerized acrylic resin.
Mandibular defects
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D] Laryngectomy aids
Most tumors of the larynx are squamous cell cercinoms. After surgical removal of
the larynx an alternative airway is required. A tracheostomy is performed creating notch
area of the neck to provide air exchange while bypassing the nasopharygeal airway.
Large number of patients with larygectomies may be required top wear a prosthesis to
prevent stenosis of the stone.
The use of metal tracheostomytube (silver alloy) may cause many problems, such
as tarnish, irritation, infection, difficulty in cleaning and to achieve proper angulation,
erasion of the trachea and formation of tracheasophageal fistulas.
A custom-made silicone rubber tracheostomy tube can be used to prevent stenosis
of the stoma with comfort and minimal complication. It is flexible, inert, adjustable and
can be molded to reproduce anatomic detail.
Technique of fabrication
Baseplate wax is adapted to the superior portion of the tube to serve as a tray for
makiking an impression of the tracheostoma and the surrounding structures. The tray
suction is used to clear the trachea of secretion. The tracheostomy tube should not be
obstructed to ensure an adequate airway during the impression procedures. The tray is
coated with adhesive and a fast- setting algenate is used to make an impression of the
anatomic contours of the depression and the stoned opening.
The impression is removed and poured with dental stone is stage to create a three-
piece mold. A copper tube of a guage similar to the material diameter of the standard
tracheostomy tube is incorporated into the mold to maintain an adequate airway in the
prosthesis the mold should be modified to incorporate a deflection in the finished
prosthesis to direct air and tracheobronchial secretions away from the patient's face.
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Inert earth segments may be used to blend the silicone rubber to reproduce the
basic skin shade before the silicone is packed into the mold. Nylon mesh may be used to
add edge strength to the prosthesis. To facilitate retention of the prostheses, fabric tape
ties can be embedded within the silicone before closing the mold.
Duplicate prostheses should be made for each patient and it is advisable to save
the mold for feuture use. The patient is instructed to clean the prostheses with soaped
water, and to wear the prostheses constantly for 3 weeks or more to prevent stenosis.
When the stoma opening has stabilized the prostheses need only be worn at night.
E] Trachestomy obturator
When breathing is compromised by infection or trauma a patient airway is
provided by tracheostomy. After improvement of patient condition the tracheostomy tube
is removed and the opening heals primarily or is closed surgically.
Occasionally it is desirable to maintain the patency of the tracheal stoma. However
the speech will be affected unless the tracheostomy is obturated. Obturation is
occomplished by patient finger or by wearing a prosthesis.
Method of fabrication
A thin mix of alginate is used to tick the impression with spatual precautions for
protection of the airway. The impression is poured in stone and the mold is scrapedto
develop a retentive flange. The obturator may be made of acrylic resin or silicone rubber
and tented to blend with the patient's skin tones. The prosthesis may be retained by cloth
tape or tissue adhesive. The patient is instructed to clean the obturator with water and
soap and to wear it continuously.
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F] Tongue prosthesis
The large oral cavity created by the loss of the tongue and some related structures,
as floor of mouth, teeth and alveolar ridges makes great difficulty in the control of saliva
and liquid fluids tend to pool in the altered floor of the mouth and to seep around the
epiglottis thus stimulating the cough reflex and/or leading to aspiration. If the tongue is
only removed, the use of tongue prosthesis with the compensatory movement of the
mandible and cheeks may permit some articulation.
Technique of construction
A maxillary stock tray is modified by adding a wax to make alginate impression of
the mandible and the floor of mouth. If the mandible is partally edentulous, the tongue
prosthesis is incorporated into a removable partial denture.
The retentive meshwork of the framework is extended into the floor of the mouth
to provide support for the resin tongue prosthesis.
The denture base should extend into the oral pharynx and overlay the epiglottis.
The prosthesis is contoured with wax and tried in the patient mouth to ensure freedom in
lateral and protrusive movements, and to check for adequate palatal contact during
speech and deglutition and the epiglottis are not imbedded in its activity. The denture
base should extend over the epiglottis and larynx to provide a protective cover for the
airway. The dorsal surface of the tongue prosthesis is contoured to allow food and fluide
to be directed into the oral pharynx by the action of the cheek muscles.
After processing the denture base should be reevaluated with pressure indicating
paste to eliminate interferences with the floor of the mouth during muscular activity.
Speech may be improved by attaching a flexible tongue of silicone rubber to Mandibular
prosthesis. The tongue prosthesis is held in place by making a snap-ring and undercut
design in the Mandibular denture base at the level of occlusal table.
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The tip of the tongue is flexible and elevated 2-3 mm above the denture base. This
position permits a positive contact with the palate during the formation of linguoalveolar
sounds (this mandible should be slightly protrusive during formation of this speech
sound. During closure the rubber tip of the tongue prosthesis depression. Allowing
contact of the posterior teeth.
In edentulous patient with little alveolar ridge remaining it is better to suspend a
tongue prosthesis for maxillary complete denture. Mouth sagerature wax is added to the
palate of a maxillary denture and modified.
Intraorally until maximum contact is developed with the floor of the mouth during
swallowing. Then the wax pattern is processed into acrylic resin. This prosthesis assist
swallowing but speech and salivary control are rarely improved .
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Speech aid appliances:
- Factors that predispose to misarticulation of speech sounds:
1) Following mandibular resection oral cavity decrease in size and portion
of the tongue is excised or used for wound closure.
2) The sensory and motor innervations of the tongue may be compromised.
3) The sensory and motor innervations of the lips and cheeks are
compromised by 1ry mandibular resection and radial neck dissection.
4) Varying amounts of mandible and number of teeth are removed.
5) Mandibular movements are altered.
6) Radiation therapy Xerostomia.
Types of speech aid appliances:
I Palatal speech aid:
- Constant sounds as "g & k" required valving by posterior surface of the tongue
with posterior part of hard palate and anterior surface of soft palate very
difficult for mandiblectomy patient.
- If the palatal vault was lowered prosthetically into the space to accommodate for
restricted tongue movements speech improvements might be noted.
- Restriction of tongue movement is divided to:
a) Extreme restriction: inability to contact either palate or maxillary
teeth with tongue.
b) Moderate restriction: partial tongue contact with palate or maxillary
teeth during speech.
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- The palate is lowered by means of retainer for dentulous patient and palatal acrylic
resin extension onto the upper complete denture for edentulous patient.
- Functional impression of the dorsal surface of the tongue is done with hollow
palatal speech prosthesis.
- After 2 weeks a test should be done with 10 words contains "k & g".
II Tongue prosthesis:
- Articulation is compromised in patients requiring total glossectomy.
- Silicone rubber tongue prosthesis placed following surgery improving quality
of speech and help deglutition.
Maxillofacial Splints
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Jaw fracture
A fracture is the breaking of a bone or a bend in a bone and always has associated damage
to the soft tissue around the broken bone. Falls, sporting accidents and motor vehicle accidents
account for themajority of broken bones. There are 206 different bones in the body that hold us
up and produce blood and blood cells essential for life.
A fractured lower jaw may be life threatening as it may cause an obstructed airway
particularly if the patient becomes unconscious. Thetreatment of jaw fracture requires reduction
of the fractured segments in the proper position, immobilization till bony union occurs and
rehabilitation to restore normal functions.
Types of fractures
Closed-Simple The bone is fractured but the skin is still intact
Open- Compound The bone is fractured and protrudes through the skin.
Complicated This is a major fracture involving damage to vital organs or many
bloodvessels damaged
A greenstick fracture is one in which the bone is not broken completely through.
Because the bones of young children are relatively soft and pliable, it is in this age
group that such fractures are generally encountered.
Comminuted fractures: These arefractures that exhibit multiple fragmentation of
the bone at one fracturesite.
Telescoped or impacted fracture: This type of injury is rarely seen in the
mandible, but it implies that one bonyfragment is forcibly driven into theother.
Pathologic fracture: A pathologic fractureis said to occur when a fractureresults
from normal function or minimal trauma in a bone weakened bypathology.
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A blow to the chin can cause a fracture at the parasymphyseal region (so-called "direct
fracture") and the fracturing force may be transmitted to the opposite condylar area, causing a
subcondylar fracture (so-called "indirect fracture").
mandibular fracturesare frequently influenced by muscular displacing forces. Whether or
not the fragments become displaced by the muscular forces depends on the direction of the
fracture plane. Whenit is parallel to the muscular pull, the fracture plane allows displacement of
the fragments (unfavorable fracture). When the fracture plane is in the opposite direction, the
muscle pull is advantageous (favorable fracture)
Common Sites of mandibular Fracture
_ Condyle36% _ Body 21%
_ Angle 20% _ Parasymphysis 14%
_ Coronoid, ramus, alveolus, symphysis 3%
_ Weak areas include 3rd molar and caninefossa
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for the middle facial third, the most common is a fracture of the zygomatico-maxillary
complex (53%)
luxation or subluxation affects mostly the teeth of the upper jaw (72%)
soft tissues of the chin and cheeks get injured most often, followed by tissues of the upper
lip and nose.
Radiological examination
At least two views are usually neededto demonstrate afracture adequately.
Teeth. Periapical view is supplemented by another intra-oral view from an oblique angle, e.g.
obliqueocclusal or bisecting-angle periapical.
Dento-alveolar fracture. Periapical(s) and obliqueocclusal views.
Mandible. Panoramic film and postero-anterior (PA) of mandible are the basic views. A reverse
Towne's (modified PA) is useful for suspected condylar fractures. True occlusal views of a
fracture in the body or symphysisare helpful.
Zygoma (or malar) fractures. Occipitomental (OM) andOM30 views are required.
Maxillary fractures. OM, OM30 views of true lateral facial bones and computed tomographic
scans are helpful for complicated fractures.
Nasal fractures. True lateral nasal bones, sometimes with the addition of superoinferior nasal
bones: both aretaken using occlusal films.
Nasoethmoidal fractures. Views are as for maxillaryfractures.
If moreaccurate information of the involvement of the temporomandibular joint isrequired, axial
and coronal computedtomography (CT) scans offer an excellent opportunity to study the fracture
details.
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Goals of Therapy
1. Obtain stable occlusion.
2. Restore interincisal opening andmandibular excursive movements.
3. Establish a full range of mandibular excursive movements.
4. Minimize deviation of the mandible.
5. Produce a pain-free articular apparatusat rest and during function.
6. Avoid internal derangement of the temporomandibular joint on the injured or the
contralateral side.
7. Avoid the long-term complication of growth disturbance.
Treatment of jaw fracture:
Reduction: placing the fragments in their normal anatomical relation.
Immobilization: fixing the fragments in position by various means until healing and union is
completed.
Rehabilitation: restoration of normal function after complete healing.
Methods of immobilization:
Wiring: indicated when all or most of the natural teeth are present.
Arch bar: indicated when there is no enough number of natural teeth to enable effective
wiring.
Splints
Rigid osteosynthesis is the most modem development in maxillofacial trauma surgery.
Titanium plates and screws have superseded the stainless steel variants, and many patterns and
sizes are now available.
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Wiring
1. Direct wiring: It is the method of choice in the earlier stages of treatment. Where
an opposing two natural teeth are wired to reduce the fracture displacement by bringing
the jaws into occlusion.
2. Eyelet wiring: Used when the patient has a complete or almost sufficient pairs or
set of opposing teeth.
3. Inter-dental wiring: Used in single jaw fixation. In this method a single wire is
passed around two or more teeth on each side of the fractured segments and tightened
together. This method brings the fractured fragments into good position
4. Inter-osseous wiring: Used for fractured edentulous body of the mandible with
displacement or fixation of un controllable edentulous post fragment.
5. Trans-osseous wiring: This is especially useful in the treatment of edentulous
mandibular fractures or for control of the edentulous posterior fragment. It can be
carried out at the lower border of the mandible through an extra-oral surgical approach
or at the upper border from intra-oral incision.
6. Circumferential wiring.
7. External pin fixation.
Arch bar: Used when the patient has an insufficient number of suitably shaped teeth to enable
effective inter-dental eyelet wiring to be carried out.
Hammond Splint double arch bar:
It is used when displacement of the fractured segments
exists.
It is adapted to the neck of the teeth on both buccal and
lingual surface and fixed to them by wiring. Arch bar applications.
Impressions of the dental arches are made to obtain models onto which the bars are adapted.
The wire is then transferred and fitted to the teeth in the patient's mouth, and fixed in place
using stainless steel wire.
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Splints
Definition: a rigid or flexible device that maintains in positiona displaced or movable part; also
used to keep in place andprotect an injured part. GPT
it is an applianceused for immobilization of displaced or movable parts of jaw into their
original positionafter jawfracture or re-constructive surgeryuntil repair occurs.
Uses:
In the treatment of fractured jaws: immobilize fractured segment till healing occurs.
In surgical orthodontics of malposed jaws: ex: mandibular prognathism after segmental
osteotomy to splint bone segments together.
In conjunction with bone graft.
In treatment of periodontally mobile teeth (periodontal splint).
To support resected mandible in its new position.
In holding another appliance e.g. training flange.
Advantages:
Provide good fixation of fractured segments for long period of time.
Allow early movement of the mandible so decrease trismus.
Not harmful to teeth and supporting structures as intermaxillary fixation.
Withstand strong inter-maxillary traction without extruding the teeth.
The problem of fragment rotation due to muscle pull and inter-maxillary elastics is eliminated.
Require little post operative attention.
May extend to restore edentulous fragment.
Serve as an excellent medium for applying traction to displaced bones. Especially the maxilla.
Disadvantages:
Some types of splints require accurate impression techniques and a skilled technician, which
becomes costly and time consuming.
Splints that cover the lingual or palatal surfaces tend to accumulate debris.
Metal splints require good standing teeth.
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Requirements
Should be rigid and not allow mobility of the fractured segment.
Simple in construction with the least amount of pain or discomfort to the patient.
Made from radiolucent material to show fracture line in the x-ray.
Not affect function or interfere with occlusion with opposing teeth.
Comfortable to the patient and decrease patient injury.
Minimum injury to the standing teeth, bone or soft tissues.
Minimum disturbance to normal function.
Ease of construction.
Low in cost.
Impression of fractured jaw
Adequate light and suction should be present.
Use:
hydrogen peroxide to dissolve blood and remove food debris.
Sodium bicarbonate to dissolve mucous and control excessive salivation.
Flavored mouth wash.
Control trismus and pain by local anesthesia.
According to the presence or absenceof displacement:
If there is no displacement of the jaws at line of fracture: make alginate impression and
poured to produce casts which mounted on simple hinge articulator.
If displacement occurs: use sectional impression to the fractured jaw with shallow stock
tray is made and another impression to the opposing jaw is taken and the impressions are
poured, the cast with fractured jaw is segmented with a saw at line of displacement and the
2 segments are reassembled into their original position guided by the occlusion of the
opposing arch and the 2 segments attached with plaster base on the articulator.
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Types of splints
a) For dentulous patient:
1) Metal cap splint
2) Labio-lingual splint
3) Fenestrated splint
4) Occlusal waver splint
5) Palatal occlusal splint
6) Bite plane occlusal splint
7) Mandibular Lingual splint
8) Cast labial splint:
9) Guide flange prosthesis
10)Arch bar
11)Wire splints
b) For edentulous patient:
Gunning splint
c) For both dentulous and edentulous patient:
Kingsley splint
1. Cast metal cap splint:
It is a cast metal that covers the buccal, lingual and occlusal aspect of teeth on either side of
the fracture and cemented to the teeth. It provides a rigid and efficient form of reduction and
immobilization.
Indications:
Permanent teeth with fully erupted crown and definite undercuts
Delayed fracture if displacement occurs and fibrous tissue formed at fracture line which need
excessive reduction force that cannot be applied by acrylic splints
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Long term immobilization in case of jaw resection and need of resection guiding flange
In TMJ exercise: by extra oral rode extend from upper and lower metal cap splint and elastic
bands in between the rods
In immobilization of bone segment in segmental osteotomy (ex: mandibular prognathism)
Types:
1. One piece cap splint (simple cap splint):
It is used when there is little displacement and position of the fractured segments canbe
determined by the occlusion of opposing teeth without displacement of the jaws.
2. Two piece cap splint (cap splint with screw connecting bar):
It is used when displacement occurs and fibrous tissue present between the fractured
segments as it needs high reduction force. The two parts of the splint are connected together
by localizing plates and screws
3- The Modified Cap Splint:
This type is exactly the same as the normal cast metal cap splint except that the occlusal
surfaces of the teeth are left free.
Advantages of cap splints:
1-Provides effective fixation of jaw fracture even in the presence of few teeth in each
segment.
2-Rigid without being bulky, smooth and easy to clean.
Disadvantages of cap splints:
1-It interfere with occlusion as the occlusal surface is covered.
2-Expensive and time-consuming procedure.
Construction:
Impression of both arches with alginate is made with short tray flange as occlusal surface of the
teeth is only needed.
If displacement occurs, cast sectioned at line of fracture, casts are hand articulated, reassembled
and mounted on simple hinge articulator guided by the occlusionof opposing teeth.
Cast is surveyed, path of insertion is selected, undercuts were blocked out.
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Sheet of wax is warmed and adapted on the occlusal surface of the teeth on the cast and the
articulator is closed to carry the imprints of opposing teeth. Wax should be thin and not
interfere with free way space and the periphery of the wax should be square (not knife edge).
Cusps of teeth may perforate the wax and project through the splint to decrease jaw separation
and help in escapement of the cement throughthe vents.
Tags (underplates) are embedded in the wax pattern which hold wire loop (overplates), it also
help in intermaxillary fixation.
a) Tags (underplates): it is the female element, waxed in the wax pattern or soldered later.
b) Wire loops (overplates): screwed to the tags with screw.
Wax pattern is invested and casted with direct or indirect casting system:
Direct system of casting: done directly over the cast, stone cast under cuts were blocked
out on the surveyor, then the cast is duplicated into refractory cast on which the wax
pattern is made
Indirect system of casting: wax pattern is removed from the cast (to verify that undercut
is blocked to avoid interference during insertion), invested and casted.
Cement the splints on the corresponding teeth, apply careful directed traction force to the bone
segments till assume proper reduction.
Wire loops screwed to the tags, use quick setting plaster to hold the position of the wire loop
in reduced state of fracture, after plaster setting wire loops unscrewed and removed while it is
attached to the plaster and the jaws are allowed to return temporarily to the displaced position.
Wire loops invested in the laboratory and connected together by soldering metal bar to them.
Reduce the fractured part again, the wire loops with connecting bar screwed to the tags.
Other method used to connect the 2 pieces metal cap splint using metal rode and metal tube:
the anterior portion contain metal rode (male part) and posterior portion have metal tube
(female part) that contain channel for rode and inserted before anterior portion, after reduction
the metal rode inserted into metal tube to immobilize fractured segments.
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2. Labiolingual splint (sectioned-hinged, stout sectional splint,divided plastic splint) :
It is an acrylic band fits around the bucco-labial surfaces of the teeth as well as the
lingual aspects, leaving the occlusal surfaces uncovered. It consists of three sections; a
lingual section fits around the lingual surface of the teeth
and two labial sectionsaround the facial surface of the teeth.
A stainless steel wire connects the two acrylic
portions posteriorly around the last remaining tooth. This
wire acts as a hinge.
A button divided into two halves in the midline is
used to secure the two labial sections by wiring.
Indications:
- Dentulous or partially edentulous patient.
- mixed dentition (children).
Construction:
Primary alginate impression is taken and poured to produce casts, if displacement of fracture
segment occurs, cast sectioned at line of fracture, casts are hand articulated, reassembled and
mounted on simple hinge articulator guided by the occlusion of opposing teeth.
A half round wire 0.9 mm is well adapted to the surface of the last standing tooth. The two
ends of the wire are bent to follow the contour of the buccal and lingual of the last tooth and
the tooth anterior to it. The wire is then bent at right angle to its length. This portion will help
to hold the wire in the flask.
Wax adapted on the labial, buccal and lingual surfaces and not cover occlusal surface of the
teeth (extend to survey line), wire embedded distal to the last molar tooth on each side to hold
buccal and lingual flange together, the wire form a hinge that allow open and close of splint
without fracture, wire hooks attached to the buccal surface of the appliance, blunt button
which have undercuts is made at midline.
A square wax button, 5 mm, is adapted in the midline of the facial surface. The model is
trimmed occlusally to the upper edge of the wax.
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Wax is processed into clear acrylic resin, the acrylic button is divided vertically at midline
with a fissure bur or with a saw.
The splint opened and placed on the teeth, reduce the fracture and immobilization made by
tighten wire ligature around the 2 halves of the acrylic button, and buccally placed wire hooks
are used for intermaxillary fixation and attachment to the facial bone.
Labiolingual splint is classified according to the material from which it is constructed into :
i. Acrylic labiolingual splint ii. Cast metal Labiolingual splint.
The cast metal splint is used when a long-term immobilization strength and rigidity are
required. Cast metal splint offers superior fit, rigidity without being bulky. It is also smooth,
easier to clean and more comfortable for the patient. The reassembled casts are duplicated into
investment cast , the splint is waxed up on the duplicate cast, and casting procedures are then
carried out.
Advantages:
Not need intermaxillary fixation.
Not interfere with opposing occlusion.
Clear resin allow observation of tissue under the splint.
Easily constructed, easily adjusted and easily repaired.
Provide good oral hygiene (removable).
Retention from proximal embrassres and not need fully erupted
crown.
Radiolucent: allow monitoring of fracture union by x-ray.
Removed easily to test union of the 2 fractured part.
Can incorporate undercut in soft and hard tissues.
It fixes the fracture firmly and is retained by the teeth
interproximaally without cement.
Disadvantages:
Easily fractured as it not resist force of muscles in case of displacement of fractured segments
leading to misalignment of fractured segments.
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3. Fenestrated splint:
It is a modified labiolingual splint (one-piece acrylic device or silicone). These splints are
used for short permanent clinical crowns, for deciduous teeth when no undercuts are available
for retention, and for badly decayed teeth. It is designed to fit a dentulous maxilla and mandible
through fenestrations created for the occlusal surfaces of the teeth
Indications:
Deciduous teeth with no clinical crown badly decayed teeth post radiation carries.
Construction:
Resemble labiolingual splint without button.
retention mechanically by friction into interproximal spaces.
fit the dentition of one arch through the fenestration of the
occlusal surfaces, wire tags or holes may be incorporated to
the buccal flange to facilitate immobilization.
4. Occlusal waver splint:
Indications:
This splint is used for intermaxillary fixation of fully dentulous
patients who have occlusion that is inadequate for a positive
index. (ex: unilateral open bite).
The occlusal and incisal surfaces of both arches are covered
with the splint. The immobilization is achieved with elstic bands on Ivy loops or arch bars This
splint is constructed of acrylic resin.
Construction:
May be made from acrylic or metal, occlusal surfaces of both arches covered with the
splint and immobilization done with elastic bands and arch bar. When thickness and strength
are critical, cast metal may be used.
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5. Palatal occlusal splint:
It is useful for fixation of maxillary segmental fracture. It covers the palate, the occlusal
surfaces & the incisal edges including the incisal third of the labial surfaces. It is fixed to
the maxilla with inter-dental wiring.
Indications:
Fixation of maxillary segmental osteotomy fracture of maxilla.
Construction
Covers the palate, occlusal surface and incisal third of labial surface of anterior teeth.
Fixation to maxilla by inter-dental wiring and intermaxillary fixation is not necessary.
Palatal Splint of Acrylic or Metal:
These clear acrylic splints can be constructed without covering the occlusal surfaces or the
incisal edges. The cast palatal splint is usually used in the treatment of a comminuted fracture of
the maxilla with collapsed arch.
6. Bite plane occlusal splint:
Indication
Bruxism trauma from occlusion tooth wear clicking pain tenderness premature
occlusal contact disc displacement.
Construction
If vertical dimension lost, squash bite wax is used to restore VD at correct centric relation or
centric occlusion, then processed into acrylic resin and retained by Adams wire clasp or wired
to the interproximal embrasures of the teeth.
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7. Mandibular Lingual splint:
This type of dental splint is conforming to the inner aspect of the dental arch. It is
considered as the most common surgical splint used today.
Used in para-symphyseal fracture of the mandible at midline to prevent collapse of
fractured segment lingually.
It is fixed with wire to the teeth or to buccaly placed arch bar(holes drilled for wire in the
acrylic at lingual embrasures).
Allow early movement of the mandible and prevent TMJ ankylosis as it not need
intermaxillary fixation.
The symphysis region is more difficult to reconstruct than the mandibular body due to the
abrupt curvature of the bone in this area.

8. Cast labial splint:
These splints are designed to withstand heavy traction forces as in cases in which
powerful forward traction is necessary. It is used in case of old, fused fracture of the
maxilla with displacement in which re-fracture and forward positioning are necessary.
9. Guide flange prosthesis
This is a training type of prosthesis. When the mandible is resected, a similar
situation occurs if continuity is lost at the midline. Lateral guide flange prostheses
are often used to control deviation of the residual mandibular segment after resection,
and as a re-training process of the neuromuscular system. Multiple retentive clasps in
widely distributed areas of the arch would be the best approach. Splinting of
weakened teeth should be seriously considered.
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10. Arch bar:
Used for single jaw fixation.
There are various methods of attachment of the elastic bands: archbars, buttons or hooks,
fixed to the dentition under local or general anaesthesia, silver cap splints or simply
orthodontic brackets bonded to the teeth have all beenused.
11. Wire splints:
a. Direct wiring: wiring of upper and lower teeth together.
b. Interden al wiring: wiring the adjacent teeth together
across the line of fracture.
c. Eyelet wiring: wire eyelet is made interproximally at the
line of fracture, each free wire end rotate around tooth,
enters the eyelet and tied.
d. Intra-osseous wiring: perforations around fracture line is made and the wire used through
it for reduction.
12. Vacuum-formed splints.
The management of fractures with occlusal disruption but without loss of vertical height is
simple, using elastic intermaxillary fixation attached
to Vacuum-formed splints 1 mm thick with bonded
wire cleats. Orthodontic elastics guide the patient into
centric occlusion
Advantages over other methods of fixation
include the fact that clinical work is completed
entirely at the chairside without the need for general
anaesthesia, the patients discomfort is minimal, laboratory time is reduced, the materials are
cheap and themagnitude and direction of intermaxillary fixation canbe modified easily.
This method of treatment should be particularly useful in the management of mandibular
condylar neck fractures in children.
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13. Gunning splint: (for edentulous patient)
It is made as a one piece for the two arches or two separate pieces (fig. 4-8). The two
pieces is easier to manipulate and to be wired to the jawbones. The splint can be made in
conjunction with elastic chin bandage to reduce pain and discomfort
Indications:
It is used for the fixation of mandibular or maxillary fractures in completely edentulous
patients. It is indicated when there is little displacement and there is no infection.
Types:
A. One piece gunning splint:
Upper and lower impression is made, if fractured segment displaced the cast is
sectioned on the fracture line and reassembled by plaster base.
Two shellac record bases and two wax rims are made on the casts.
Casts with record blocks are mounted on the articulator at proper vertical dimension
and horizontal relation.
Space created in the wax rim anteriorly from canine to canine for breathing, feeding
and to decrease postoperative vomiting.
Wax rims are sealed together and processed as one unit into acrylic resin.
After reduction of the fractured segments, the splint is immobilized extraorally with
elastic chin bandage (Barton bandage).
B. Two pieces gunning splint:
Allow early mobility of the mandible after removal of intermaxillary fixation as
separate maxillary and mandibular stents are made:
Two shellac record bases and two wax rims are made on the casts.
Casts with record blocks are mounted on the articulator at proper vertical dimension
and horizontal relation.
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Space in the wax wade anteriorly at mid line, wire hooks embedded in the buccal
flange and used for intermaxillary fixation.
Holes in the buccal flange are made for wiring the upper splint to the facial bones,
root of zygoma, infra-orbital bone, lateral orbital rim, nasal spine, malar bone and
for circumferential wiring of the lower splint in the area of first molar.
Male projections (buttons) about 3mm are made on the occlusal surface of one wax
rim for anchorage by self cure to the grooves (female) on the other wax rim during
fixation (used as an index to maintain centric position).
C. Modified gunning splint:
It is made by modifying existing complete denture as
follows: repair the fractured denture, remove upper and
lower incisors, and fix upper and lower denture together
by asking the patient to bite on a piece of compound
which may be left or processed into acrylic resin to
obtain one piece gunning splint.
Faulty occlusion and reduced vertical dimension is corrected by adding colored
self-curing resin to the occlusal surface of the denture.
Hooks or arch bars are fixed to the facial surface for intertmaxillary fixation.
Holes are drilled on the upper denture flange for wiring the upper denture to the
facial bone to obtain two pieces gunning splint.
If existing denture lost fitness or develop occlusal discrepancies, use soft liner or
tissue conditioner, it also act as a cushion between hard acrylic resin and traumatized
tissues.
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D.Gunning splint with training flange:
It is a 2 piece gunning splint.
Prevent deviation of the mandible to defect side after mandibular resection or
after irradiation due to fibrous tissue formation.
metal plate extend from the upper splint to the lingual surface pf the lower
splint, so the patient can't close except in correct relation.
at first, patient may use hand to guide the mandibleto correct position then it
becomes involuntary by training of muscles.
E. Sectional Gunning splint
This splint is designed for immediate immobilization of the resected mandible to minimize
postsurgical deviation. It is the same as two-piece Gunning splint with indices designed for
possible use as a flange prosthesis and a locking mechanism for immobilization
14. kingsley splint: (for both edentulous and non edentulous patients)
Indication
Fixation of fractured maxilla both in dentulous and edentulous patient.
It is indicated for fracture of edentulous mandible as an alternate to gunning splint.
As an emergency treatment for depressed maxillary fracture where traction is required.
Construction
Acrylic or cast metal base plate which covers the ridge, palate and the teeth is made.
Metal rod is extended from the anterior part of the base plate, emerged through oral
commissar bilaterally and attached to vertical rod by universal joint.
Extra-oral immobilization of fractured maxilla is made by elastic or plaster head gear.
Modified kingsley splint:
o Used in emergency to prevent fall of maxilla on the dorsum of the tongue to avoid
suffocation.
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o The upper tray filled with compound and attached to maxilla, metal rods soldered to the
tray are protruded from the lip to join to the vertical rode by universal joint.
o The vertical rode terminate in flat plate embedded in plaster head gear.
o An intraoral tray may befitted to the teeth or edentulous ridge by compoundimpression
material. The tray has stout wires attacked and projecting between the lips around the
sides of the face. The wires provide attachment for bandage over the head in case of
maxillary fracture and below the chin in mandibular fracture.
Stents
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Maxillofacial Stents
Stents are removable appliances constructed to cover the tissues and/or the teeth
for their protection, to carry medicaments, radium material or to control bleeding. They
were named after the dentist who first described their use Charles R. Stent.
Function:
Control bleeding.
Protect the tissue from radiation, maintain tissue in position, carry radium in the
treatment of malignancy.
Carry medications.
Promote healing and decrease wound infection.
Protect teeth.
Protect skin graft andpreserve the depth of vestibule after vestibuloplasty.
Materials:
1. Hard acrylic materials: heat cure, self cure acrylic resin, may be lined with soft
liner or tissue conditioner.
2. Soft materials: Soft rubber or soft resins are used for special purposes. It can also
be fabricated from silicone vinyl rubber - poly vinyl vaccuform. but an additional
reinforcement of resin is usually required.
3. Modeling plastic, black gutta percha and silicone: In emergency cases where there
is no time to construct a stent, these materials may be used directly in the oral
cavity on the bleeding area.
Stents
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Types:
A. Intra-oral stents:
1. Anti-hemorrhagic stent.
2. Medication carrier.
3. Fluoride carrier.
4. Radiation stents (prosthesis for
radiotherapy):
a. Radium applicator (carrier).
b. Positioning peri-oral cone
(Docking device).
c. Displacement (positional) stent.
d. Intra oral radiation protective stent
( tongue protector).
e. Positioning dosemetric device
stent.
f. Stent for recontouring tissue to
simplify dosemetery.
g. Positioning radioactive source.
h. Positioning radioactive source
after loading.
i. Stent used in direct implantation.
j. Stent used to prevent tongue and
check biting.
5. Pedodontic stent.
6. Periodontic stent (labio-lingual stent-
cosmetic stent).
7. Paraplegic stent.
8. Drainage stent.
9. Cyst plug.
10. Occlusal stent.
11. Mouth guard.
12. Oral screen.
13. Trismus stents:
a. T.M.J exerciser (dynamic bite
opener).
b. Inflatable bite opener.
c. Intra oral prosthesis with inter arch
spring.
14. Stent for vestibuloplasty.
15. Palatal stent.
16. Stent for epulis fissuratum.
17. Stent for resected maxilla.
18. Stent for lip and check support.
19. Stents for implants:
a. Stent for surgical implant
placement.
b. Stent for implant imaging.
20. Speech rehabilitation aid.
B. Extra-oral stents:
1. Extra oral radiation protective
stent.
2. Stent for neck scar (burn stent).
3. Stent for nasal defect ( temporary
nasal prosthesis).
4. Nasal stent.
5. Auditory stent.
6. Oro-facial plug.
Stents
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A. Intra-oral stents
1. Anti-haemorrhagic stent:
Indication:
It is used in patients with tendency to severe bleeding following extraction
or hemophilic patients to arrest bleeding.
It may be constructed in the form of a partial plate (acrylic) to control
bleeding by applying gentle pressure to the extraction wound.
Such stents can be constructed in clear methacrylate with suitable relief to
accommodate the hemostatic agent.
Construction:
Upper and lower impressions are made and the casts are poured and mounted
on a simple articulator. The tooth to be extracted is removed from the stone
cast.
A layer of molding wax is adapted on the cast to cover the buccal and lingual
surfaces and the top of the ridge. The articulator is then closed to allow the
opposing teeth to touch the top of the wax. The wax is processed in clear heat
or chemical cure resin lining with soft resin, is advised.
The stent is inserted immediately after extraction. Bleeding is controlled as the
patient closes and applies gentle pressure over the extraction site.
In patients with clotting problems as in hemophilia a stent could be of great
help in the arrest of bleeding. But here no pressure should be applied. They are
designed only to protect the socket and blood clot from the tongue and to hold
a haemostatic dressing in place. It can be left in the mouth for a week or even
more if needed.
The use of such stents is not considered essential in the management of
hemophilic patients by many other oral surgeons, as it is believed that it may act as a
source of irritation and possible infection.
So EL-ASSAL incorporates different ratios (5%) of well proved anti-
inflammatory agent (Ketoprofen) in the Acrylic resin to decrease postoperative irritation
or inflammatory reaction.[ JKAU: Eng. Sci., vol. 15 no. 2, pp. 33-43 (2004 A.D./1425 A.H.)]
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2. Medication carrier:
Indication:
It is used carry medical paste (palliative paste) to contact oral mucosa as in
case of chemotherapy and osteoradionecrosis.
Construction:
Acrylic base plate made on the diagnostic caste with relief space in the area of
the lesion in which palliative paste will be applied.
3. Fluoride carrier:
Indication:
Used in fluoride gel application to the teeth to protect it from carries (ex:
osteoradionecrosis after mouth preparation for RPD)
Construction:
Made of resilient material (vaccum machine) on the occlusal, buccal and
lingual surfaces of the teeth after covering these surfaces with tin foil to allow
a space (reservoir) for fluoride
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4. Pedodontic stent:
Indication: This type of stent may be used for young children when there is
delayed eruption of teeth. The unerupted tooth surgically uncovered to
stimulate eruption to prevent closure of uncovered tissue over the tooth.
Construction: Make impression of the surgical site, poured, wax adapted over
the cast and extend to the surgical site to prevent its closure.
Disadvantages: Sudden fall or accident which may lead to sub-luxation or
damage to the tooth.
5. Periodontic stent (labiolingual cosmetic stent):
Indication:
It is used after gingivectomy to cover the exposed root surfaces and
to disguise the elongate crown-root appearance seen in wide smile.
The periodontal stent serves both the cosmetic and protective
functions.
- It hold periodontal dressing in place after periodontal surgery.
- Used as cosmetic stent or protective prosthesis to cover exposed
root surface especially in anterior teeth.
Construction:
1) The stent (labio-lingual design) is fabricated pre-operatively on the
diagnostic casts in the area of the contemplated surgery.
2) An accurate alginate impression is made and poured into dental stone.
3) Two layers of modeling wax are adapted over the buccal and lingual
surfaces covering the area from the right to the left 2
nd
bicuspids. The
wax extends above the survey line occlusally and extends to the labial
and buccal vestibules.
4) Then the stent is processed in clear or pink acrylic
5) The retention of the stent depends upon its extension in the teeth
undercuts , wiring of the anterior buttons if necessary, friction with
interdental undercut or by wrought wire clasp if needed.
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6. Paraplegic stent:
Indication:
Used as a mouth controlled device for handicapped patient in: feeding
holding things dial telephone tying painting pushing buttons).
Construction:
Upper and lower primary impression alginate is taken and the upper cast
mounted with face bow transfer and the lower cast mounted with centric
inter occlusal record at proper vertical dimension of occlusion (VDO).
Wax protrusive record is build up between opposing teeth to increase
VDO by 2mm and poly ethylene tube (10-12 inch) is waxed in a hole
between 2 central incisors and the wax is processed into acrylic resin,
tested intra-orally and adjusted to harmonize condylar guidance of the
patient.
Entire thickness of intraoral prosthesis should not exceed 3mm to avoid
interference of free way space.
Arch shape metal frame may be embedded in the resin of theoral part to
hold extra oral aluminum tube. Active friction grip connector that accepts
various attachments may be attached to the stent. These attachments held
in various devises which patient needs thus the patient can change these
devices himself.
To decrease lever forces on the stent: the stent should have maximum
teeth coverage (extend 2mm into the labial surface) to maximize
distribution of forces over large number of teeth.
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7. Drainage stent:
Indication: It is used to allow the escape of blood or other tissue fluids from
chronic periapical lesions with a fistula, for drainage of infection.
Construction:
1)An impression is made and the fistula is reproduced on the stone cast.
2)A 15-gauge polyethylene tube is inserted in the hole and the labial aspect of
the cast is covered with two layers of base plate wax.
3)The waxed stent is processed with clear acrylic resin around the tube
4)If the patient has denture, the stent can be attached to it.
8. Cyst plug:
Indication: In large marsuplized cyst to prevent closure of its opening. i.e. it
maintains the potency of the cyst orifice.
Construction:
The cyst is plugged with gauze or wet cotton wool leaving the neck
part of the cavity free. Impressions are made and a cast is poured with a
small depressionis cut representing the cyst neck.
The plug should have a labial and buccal flange, to prevent falling of
the plug deep into the cavity. Acrylic buccal flange extend into cyst
cavity but not reach full depth to not interfere with cyst wall as cyst
decreases in size. Buccal flange extend to buccal sulcus to prevent
falling of the plug deep into cyst cavity. Buccal flange also help the
patient to remove the plug.
Gradually reduce the depth of acrylic plug as cyst decrease in size until
complete filling of the cyst cavity.
If the patient has a denture, the plug will attached to it.
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9. Mouth Guard Or Mouth Protector For Contact Sports:
Indication:
Protect teeth and jaws from injury in boxing contact sports.
Protect fixed restoration when surgery will be made under general
anesthesia.
Construction:
Upper and lower primary alginate impression is made and the casts
mounted on the articulator.
3-4 mm thickness of resilient material as (plastic sheets of vacuum
machine- silicone polyvinyl rubber) adapted to the upper cast (to be
stable, retentive and not interfere with tongue) and cover labial and
occlusal surface, border trimmed, finished and smoothed.
The material covering the occlusal surface should be about 3-4 mm to be able to absorb
the impact. A wide variety of materials can be used; soft cured material that is applied
by a brush in layers or silicone sheets that are adapted to the cast by using a vacuum
machine and the excess is trimmed by sharp scissors.
10. Oral screen:
It is an intra-oral acrylic resin stent that is worn usually at night and is
bounded by the lip and cheek laterally and by the teeth medially
Indication:
Stimulate nasal breathing.
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It may also be considered as an orthodontic appliance for protruded
upper incisor teeth through the pressure applied.
Prevent thumb sucking-prevent lip biting.
Construction:
Alginate impression including the reflection of the buccal sulcus of
both jaws are made, casts are mounted on the articulator at correct centric
occlusion or centric relation.
2 layers of wax are adapted to the labial surface upper and lower
teeth and extended to the depth of the sulcus , processed into clear acrylic
resin, it should not interfere with labial frenum or muscle attachment and
all pressure areas on attached gingival and movable tissues are relieved.
11. Stent for vestibuloplasty (Stents For Plastic Surgery Of Alveolar Ridge):
Indication:
Used in conjunction with surgical deepening of the mucobuccal vestibule and
for holding mucous membrane and skin graft (Vestibulo-plasty).
Reposition the muscle attachment and prevent its reattachment at higher level
near the crest of the ridge during healing period after sulcus deepening.
Protect and immobilize the graft, prevent hematoma formation, decrease
ischemia of the graft, helpthe graft to takes, carry medications, make the patient
more comfortable.
Construction:
Modification of the ridge and sulcus depth is made on the cast after consultation
with the surgeon, modified cast is waxed, flasked and processed into clear
acrylic resin (to permit seeing of the pressure area in the mucosa) which is
overextended to the new sulcus depth.
If the graft is used it is placed on the stent with its raw surface facing upward.
The stent may be lined with the soft liner, immediately fitted after surgery, may
be wired to the ridge if required ( circumferential wiring) and kept in mouth
for few weeks till complete healing.
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A similar stent may be designed to facilitate healing after removal of exostosis,
palatine and mandibular tori and enlarged median palatine raphe.
Old denture may be modified by extending its border with self cure acrylic resin
on the modified cast and used as a stent for vestibuloplasty.
12. Palatal stent:
Indication:
Cover the palate after palatal surgery as (palatal mucosal
graft- removal of papillary hyperplasia - torus platinus) to
protect the healing surface and apply medications.
It is used to apply pressure to soft tissue after surgery to
facilitate haemostasis, healing, prevent collapse and protects
the healing of raw surface of the palate.
Construction:
Primary maxillary alginate impressions used to make diagnostic cast before
surgery, remove torus platinus or palatal hyperplasia from the cast.
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Acrylic plate is made on the modified cast to cover the palate and wrought
wire clasps are made on the teeth for retention.
After surgery, the stent is lined with tissue conditioner and placed on the
palate , left in mouth till healing occurs.
If upper complete denture is present it is used as a palatal stent.
13. Stent for Epulis fissuratum:
Indication:
Maintain sulcus depth and prevent obliteration of the sulcus due to fibrous
tissue formation after removal of epulis fissuratum.
Construction:
Primary maxillary alginate impression used to make diagnostic cast before
surgery, remove the epulis fissuratum from the cast and acrylic plate is made
on the modified cast to the proper sulcus depth.
After surgery, tissue conditioner applied to the stent till healing occurs.
If the old denture present it may be used as a stent after modification of its
border.
14. Stent for resected maxilla: (Immediate surgical obturator)
Indication:
Carry medications and dressing to the surgical site to improve healing and
decrease wound contamination (act as a matrix).
Carry skin graft to the surgical site to improve support, stability and
retention of the obturator (compound used on the stent to support the skin
graft).
Restore normal palatal contour and allow the patient to speak and swallow
normally after awaking from anesthesia.
Allow early removal of nasogastric tube.
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Improve patient psychology: restore patient self image and allow the patient
to function normal with society.
Construction:
Look in immediate surgical obturator.
15. Stent for lip and check support:
Indication: Support lip and check in
Facial nerve paralysis (Bells pulsy)-
Mid facial defects (resected anterior maxilla and upper lip and nose)
Thesediseases affect speech by decrease valve seal mechanism of articulation of
orbicularis oris muscle and buccinator muscles which lead to sagging of muscles
of check, lip and corner of the mouth on the affected side and abnormal pull of
muscles toward intact side and difficulty to control saliva (saliva dribbling).
Construction:
Open looped half rounded wire (hook) attached to the buccal surface of
maxillary RPD at premolar area and covered with acrylic resin to support upper
lip and the corner of the mouth.
After frame work of RPD casted, the wire loop covered with wax to
produce the desired lip support, then thewax replaced with acrylic resin.
Retentive mesh work instead of wire loop may be used in the area of
premolars, modeling compound used to produce desired lip support then replaced
with acrylic resin (advantages: improve facial sagging, more esthetic, improve
labiodental sound more than wire loop).
16. Stents for implants:
a. Stent for surgical implant placement:
Indication:
It is used during the first stage surgery to aid in properly positioning and
angulating the guide drill, so that the fixture can be placed to insure optimum
esthetics for the prosthesis.:
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It determine site of implant placement and implant angulations especially in
the anterior maxillary region.
Construction:
RPD:
A) clear acrylic resin stent perforated at implant site.
B) Vacuum formed stent with holes prepared at implant site and it
should have positive tissue stops to be firm, stable during surgery.
CD: old denture may be used as surgical stent with holes prepared at proposed
implant sites.
b. Stent for implant imaging: ( radiographic stent, radiographic measurement
template , diagnostic Stent)
Indication:
The use of pre-surgical measurement splints has been an accurate
cost-effective means of determining various bone dimensions. It is used
in detection of bone quantity and bone quality at site of implant
placement.
Construction:
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Study casts should be mounted on a semi-adjustable articulator. A
clear acrylic splint is fabricated to extend over the edentulous areas of
the arch where implant placement is anticipated.
The intended implant site should be marked on the cast. A
compatible bur is used to create a slight depression in the acrylic splint.
A 5-mm precision stainless steel ball bearing is placed mesial and
distal to the intended implant site. The ball bearing is secured with one
drop of super glue. Once the ball bearing is secured, the entire splint is
placed in the oral cavity and a panoramic radiograph is obtained.
The ball bearing image on the radiograph is measured with a
millimeter gauge to determine the distortion factor of bone in a vertical
fashion. If the 5-mm ball bearing now measures 6 mm on the radiograph,
a 20% distortion factor is present. Therefore, for each multiple of 6 mm,
or fraction thereof, three is only 5 mm of available bone for placement of
an implant.
In a similar fashion the splint can be maintained in the oral cavity
and an occlusal film may be exposed to obtain a guide as to the
buccolingual or horizontal dimension of bone in the area of the intended
implant site.
In the totally edentulous mandible a straight lateral radiograph will
also provide knowledge of bony dimension at the midsymphyseal area.
(a) Poly vinyl stent: modified by filling the teeth at implant site with
radio-opaque material as barium sulfate ball bearing metal cylinders
(tubes).
(b) Processed clear acrylic resin: holes drilled in teeth and filled with
gutta-percha.
(c) Acrylic stent contain radio-opaque teeth.
17. Occlusal stent see later
18. Radiation stents: (prosthesis for radiotherapy)
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19. Trismus stents:
20. Speech rehabilitation aid.
21. Snoring
B. Extra-oral stents:
1. Extra oral radiation protective stent:
Function
Protect extra-oral organs from effect of radiation ex; basal cell
carcinoma of eye lid- seqamous cell carcinoma of lip.
Construction:
Lead mask cover most of the face, fenestrated for passage of
radiation beam. At least 3-4mm thickness lead covered with acrylic to prevent scattered
radiation which is harm full to adjacent tissue.
2. Stent for neck scar: (burn stent)
Function:
Neck burn cause extensive scar formation after healing leading to disfigurement so
surgery needed to release scar band and place split thickness skin graft that should be
closely attached to the tissues by custom made stent in order to takes and decrease
formation of hypertrophic scar again.
Construction:
Primary alginate impression is taken to the burned neck which should extend
beyond the margin of the graft, if the burn extended to the nares oral tube is
used to maintain air way.
Impression is casted and 2 layer wax spacer are applied on the cast to provide a
space for the soft liner to be applied inside the stent. Wire hooks are made and
self cure acryl is applied on the wax spacer to produce the stent.
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Holes drilled in the stent to make mechanical retention of the soft liner which
support the skin graft.
Stent secured in place with loop tape attached to the wire hooks, worn 24
hours/day and removed only to exchange the soft liner till complete healing
occurs.
Electrical burns to the oral commissures are the most common type in children.
Contraction of wound margins does not usually begin until about 5 days after injury. The
use of stent or splint therapy before the start of wound contraction minimizes post burn
scaring and the development of micro-stomia.
3. Stent for nasal defect: (temporary nasal prosthesis)
Function:
Worn 3-4 weeks after surgery to improve patient appearance till complete healing of the
surgical defect then definitive nasal prosthesis made.
Construction:
It is made of heat cure acrylic resin and lined with tissue conditioner and its
retention with medical grade skin adhesive.
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Impression to the defect is made with thin alginate (by adding water) with
patient in upright position to avoid distortion of the tissue bed, block nasal
cavity with gauze to prevent entrance of impression material, impression
poured to produce the cast.
Wax pattern is made and processed into heat cure acrylic resin of suitable
color with smooth transition between stent margin and adjacent tissues, the
inner surface should be hollowed to decrease the weight.
4. Nasal stent:
Function:
Support nasal cartilage transplant during healing of normal nasal deformity in
cleft lip.
Decrease scar contraction following skin graft to the nostril.
Widen nostril in burned patient prior to graft procedure.
Restore nasal air way passage if obstruction occurs.
Construction:
Impression with green stick compound is taken to the nostril and poured to
produce a cast, wax pattern is made then processed into clear acrylic resin.
The acrylic resin stent is hollowed to maintain air way and tinted with intrinsic
stain as skin color to be less noted by eye.
In case of enlarging nasal air way use series of stents of increasing size or use
expandable nasal stent (have orthodontic expansion screw in the lumen of
sectioned stent).
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Modeling plastic is used to gradually develop the desired contours of nares.
5. Auditory stent:
Indications:
In surgical reconstruction of external auditory meatus.
mastoid surgery in patients wearing hearing aids.
protect swimmer from chronic ear infections.
Allow anasethiologist to prolong monitor the patient during
extensive surgery.
Construction:
It is made from acrylic resin, polyvinyl-silicone.
Cotton wrapped around dental floss and inserted in external auditory meatus
leaving 3mm of floss exposed.
Free flowing alginate impression is loaded into a syringe and injected into the
meatus and ear pinna. The impression is poured, floss removed.
Mold splitted into 2 halves, lubricated with petroleum jelly and filled with acryl or
silicone, extend beyond ear pinna to facilitate orientation and tinted with the color
of skin.
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6. Oro-facial plug:
Indication:
To plug skin fistula resulted from infection or done dehiscence which lead to opening on
the outer akin and dribbling of saliva.
Construction:
Impression alginate is taken to the opening, cast is scrapped at the site of the fistula, wax
applied to the defect and flanges made for retention, wax processed into silicone rubber,
tinted, flushed with adjacent tissues for esthetics until corrective surgery is made.
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Occlusal Splint or Stent (bite plate, bite guard, bite splint)
A bite splint (also called bite plane, deprogrammer, intraoral orthotic, night
guard, occlusal splint) is a removable appliance, usually fabricated of acrylic or
composite, most often designed to cover all the occlusal and incisal surfaces of
the teeth in the upper or lower jaw.
Objective
1- Protect the TMJ disks from dysfunctional forces that may lead to
perforations or permanent displacements.
2- Improve jaw-muscle function and to relieve associated pain by
creating a stable balanced occlusion.
Indication:
1) It is a diagnostic appliance e.g. for evaluation of the required increase of
vertical dimension in case of severe attrition of the teeth.
2) As night guard in patients with parafunctional habits e.g. bruxism and
clenching. For Prevention of tooth surface loss. Patients who are prone to
nocturnal bruxism should routinely wear occlusal splints at night.
3) Pre-restorative stabilization
4) Creating space to restore worn anterior teeth
5) Protection of new restorations from parafunctionhabits
6) For the treatment of temporomandibular joint pain dysfunction syndrome
- It may have smooth flat occlusal surface for relaxation (muscle relaxant splint).
- It may provide relief of acute symptoms by repositioning the condylar head within
the glenoid fossa (anterior repositioning splint).
The effect can be direct by changing the relations between the intracapsular
TMJ elements or indirect by affecting themuscles workingconditions.
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Types of stent: Bite splints can be classified according to:
Material used for fabrication.
Location of placement.
Design of area for contact with opposing teeth.
Effects on condylar position at clenching.
Specific purposes.
Smooth flat occlusal surface for relaxation by allowing contact of all
opposing teeth.
Indentation and / or ramps for mandibular reposition device.
Soft device is more comfortable to patient with bruxism or clenching to
distribute the pressure equally.
Design of area for contact with opposing teeth.
Splints may for instance be classified as follows:
A) Splints which make balanced contacts with all opposing teeth at jaw
closure
a) Causing a minimal increase of vertical allowing the patient to close
with a hinge axis movement. That is the rotation centers of the
condyles are not changed.
b) causing a more than minimal increase of the vertical but still
without changing the condyles rotation centers.
c) Increase the vertical and causing a translatory movement of the
condyles at the final part of closure (thus changing the rotation
centers).
B) Splints that make contact only with parts of the opposing arch at jaw
closure.
a) Contacts only with the anterior teeth in the opposing arch.
b) Contacts only with the molar and premolar teeth in the opposing
arch.
Splints in groups A.a, b have a minimal risk of causing permanent changes in
occlusion. Splints in groups A.c and B can cause such changes if used for
longer than a few (4-6) weeks. Examples of Group A.c splints for instance, are
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the so-called repositioning splints. Long term use of splints that make contact
only with some of the opposing teeth may cause serious irreversible changes
in the occlusion. Splints where the only contacts are with the incisors may
cause an anterior open bite. Splints with contacts only in the molar regions
may cause intrusion of the teeththere.
a- Splint Material
In the past several metal materials were used to fabricate bite splints
including gold, silver, - even lead.
Most splints are now made using heat cured acrylic. Splints can also be
made in soft acrylic , vacuum-formed soft vinyl or using light cured
composite.
a) heat cured acrylic
The material of choice is laboratory-processed acrylic resin. It is a
reasonably hard material which may be easily adjusted and is
durable enough to serve as a protective night-guard.
b) Soft acrylic splints
They are usually made for thelower jaw, can be made quickly by
thedentist
indicated for short time use in patients with acute pain and/or
dysfunction symptoms caused by muscular hyperactivity or acute
trauma. This type is also indicated in children with deciduous
teeth if they have signs and symptoms of severe bruxism.
Soft acrylic splint for daytime use are indicated in patients when
night time use of a hard splint is not sufficient to relieve the
symptoms or break the habit during daytime. A soft splint can be
used during daytime to help in breaking theparafunctional habit,
either alone or used in one jaw with aconventional hard splint in
the other.
b) Resilient vacuum-formed vinyl splints
they are of limited use. Although quick and economic to make
they are soon destroyed by determined bruxers.
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Their resilient surface is not amenable to the production and
maintenance of the stable occlusion necessary to achieve muscle
relaxation.
c) Hard metal alloys:
The use of hard metal alloys such as cobalt/chrome to cover
occlusal surfaces is highly inadvisable as it will result in increased
wear of the opposing teeth.
b- Location
Maxillary or mandibular splints?
Providing the requirements of full occlusal coverage, posterior stability,
anterior guidance and use of an appropriate material are met, it matters little
whether a splint is made on the maxillary or mandibular arch.
In Class I and II incisor relationships it is easier to produce an ideal occlusion
on a maxillary appliance while the converse is true in Class III situations.
Maxillary splints.
Without specific reasons for a mandibular placement, a splint
should be made for the upper jaw.
Many clinicians find it easier to make a stable splint with good
retention andadequate cuspid guidance in the upper jaw.
A maxillary splint can be made invisible in most cases if
extension onto the facial surfaces is avoided.
Extension onto the facial surfaces of the incisors should be avoided.
Besides not being esthetic it may prevent adequate lipseal.
Breakage of lipseal may lead to mouthbreathing during sleep with harmful
side effects. Extension onto the incisal facial surfaces is not needed for
retention which can as well be obtained by extension onto the buccal surfaces
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of molars and premolars. Such coverage is not visible and does not prevent
lipseal.
If not enough retentioncan be obtained that way a couple of simple clasps
may be added.
Mandibular splints
Indeep curve of Spee or substantial loss of mandibular teethit may
be preferred, to make a mandibular splint .
If the splint is to be used during daytime it may be preferred, for
esthetic reasons, to make a mandibular splint which may be less
visible.
However it encroaches more on the space normally occupied by the
tongue.
In patients with horizontal overjet, a mandibular splint has to be
extended in the anterior direction to obtain anterior support. Such
abuttress may interfere with normal lipseal and irritate the lower
lip thereby triggering parafunctional activity in the orbicularis oris.
Anterior contact may not be possible in all cases with large
horizontal overjet.
If teeth are missing the splint should be made for the jaw with thefewest
teeth (in the jaw where most teeth are lost) . If molars and premolars are
missing in both jaws, it may be advisable to make both an upper and a lower
splint or to first restore occlusion in at least one jaw with prosthodontic
reconstruction.
c- Usage
There are no fixed rules for how long patients should continue to use splints.
However, with few exceptions, non-conservative splints that often have to be worn 24
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hours a day should not be used for more than 4 to 6 weeks to avoid the risk of irreversible
occlusal changes.
Bite splints should be looked on as temporary solutions to be used only until a
final diagnosis has been made and a curative treatment has been successfully performed.
Unfortunately, it is some-times not possible to reach those goals; in those occasions only
should, a dentist can encourage a patient to use a splint indefinitely.
Patients who have conservative bite splints prescribed because of parafunctional
motor activities like bruxing, clenching, and tongue pressure mainly use their splints only
during sleep. However, those who cannot control such habits when awake might need to
use the splint during the day also.
Construction:
Upper and lower impressions are made. Stone casts are poured and mounted in
centric relation. The articulator is opened slightly for the required thickness of
the splint.
The upper cast is usually used for waxing the splint. A base plate is adapted to
cover the incisal and occlusal surface surfaces of the teeth till the middle of the
second molars distally. The splint extends 1-2 mm on the facial surface and
covers the whole palatal surface of the teeth and 1-2 mm above the gingival
margin.
The splint is processed in clear acrylic resin.
Soft rubber material may be used in splint construction. A rubber sheet is
adapted over the cast by vacuum machine.
Most used types of splints.
A Michigan (MI) type splint ( plane splint with cuspid guidance) is usually placed in the
upper jaw covering all the maxillary teeth, giving the opposing mandibular teeth
balanced, even contacts at habitual closure.
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In a MI splint all mandibular teeth, except the cuspids, are discluded at protrusive
and lateral movements. Thistype is recommended in patients with signs and symptoms of
jaw muscle hyperactivity (bruxism, clenching). If teeth are missing, the splint is usually
made in the jaw where most teeth are lost. If molar support is lost in onejaw only, the
splint should most often be made in that jaw with a saddle extended where teeth are
missing.
Some patients may feel that a mandibular splint is uncomfortable and a maxillary
splint may then be tried in spiteof lost mandibular occlusal support.
Cuspid Guidance. A cuspid guidance is created to provide a rise in lateral and protrusive
movements, so that the only contacts are between the mandibular cuspid apex and the
cuspid guidance.
The mandibular cuspid should slide on a flat area inclined only in the sagittal
planeduring protrusiveand in the coronal (frontal) plane during lateral movements.
Ideally cuspid guidance should be on the apex of the mandibular cuspid. It may be
onthe mesial cusp ridge of the mandibular cuspid during protrusive movement or on the
distal cusp ridgeof the mandibular cuspid during lateral movement. No guidance should
be on the axial surface of themandibular cuspid! There should be no posterior contacts in
protrusive and balancing and no incisal contacts in protrusive.
In the natural dentition a slide from CR to CO takes place mostly with a vertical
and sometimes also with a lateral shift in the mandibles position. One important goal in
the fabrication of a planesplint is to create an area around the contacts at habitual closing
which makes it possible for the mandibular teeth to move from CR to a CO position
without such vertical or lateral shifts. It is consideredby many clinicians that part of the
beneficial effect of the plane bite splint is because of the eliminationof such shifts.
Plane splints without cuspid guidance. For esthetic reasons some patients may prefer to
havesplints without cuspid guidance. It is easier to make a plane splint invisible if that
feature is excluded.
A common feature to the above two types is that balanced contacts with all
opposing supportingcusps and the incisal anterior teeth edges should be achieved. There
are, however, some clinicians with longtime experience from treating TMD patients who
claim that better results are achieved if the anterior contacts (incisal areas) are very light
or removed.
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Bite splint according to Shore. This splint has a design similar to the plane splint but
does not extend onto the facial or buccal surfaces of the teeth, and covers the entire
palatal area. It may bepreferred by some patients who need to use the splint also during
daytime, for esthetic reasons, becauseit can be made less visible. In some patients with
parafunctional tongue activities, such a palatal extensionmay be felt more comfortable. A
Michigan splint can easily be changed into this type by removing facial and buccal
extensions, adding palatal cover and, if needed, securing adequate retention with
clasps.
Relaxation plate (Sved plate). Only the opposing anterior teeth make contact with this
splint.
It is not recommended if the patient has acute pain in the TMJ or feels pain or soreness at
palpation of those areas. It is easy to change a plane splint into a relaxation plate or vice
versa. It is recommendedthat the relaxation type is tried in patients with acute or chronic
muscle pain if the plane splint is without effect. It is usually placed on the upper teeth
with an incline in the anterior part giving contact only with opposing cuspids and
incisors. It should be used only during nighttime and not more than 10- 12 hours/day.
There is a risk for intrusion of teeth, which has to be explained to the patient before splint
delivery. Regular checkups are, as always, important.
Mandibular splint with lingual bar. Unlike the Sved plate, this type is supposed to be
used during daytime. Its primary purpose is to help patients who can not control oral
parafunctional activities when awake and do not feel comfortable with a splint of the
Shore-type. The splint does not cover the cuspids or the incisors and should have
balanced contacts in the premolar and molar areas both in CO and in CR. It is most often
adjusted to achieve group contact on the working side at lateral movements. Precautions
are the same asfor the relaxation type splint.
Repositioning splints. Plane bite splints increase the vertical but should not in any other
way affect the position of the mandible when habitual clenching occurs on the splint.
Repositioning splints guide the mandible into a different position at closing, which is
supposed to facilitate repositioning of the disk and reduce the load on retrodiscal pain
sensitive areas. These splints are sometimes indicated for short-term use to keep a
recaptured disk in a normal superior position for instance when a displaced disk has been
recaptured bymanipulation.
Bite splint with a pivot. This type was introduced by Krogh-Poulsen about 40years ago
and wassupposed to be helpful in patients with disk displacement. The proposed effect is
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that the condyles are pulled downwards upon clenching on the pivot, thereby relieving
traumatic load and giving the disk freedom to reassume a normal position. Today it is
seldom used because most patients find it uncomfortable.
Cap splints. A cap splint can be described as an intermediary between a splint and a
bridge. It is useful for temporary reconstruction before final decision about design,
vertical dimension, etc. It is often madein metal with the occlusal surface in hard acrylic.
Combination splint/partial denture and splint/orthodontic appliance. Missing teeth
caneasily be replaced by adding artificial teeth to the splint. A Shore splint may function
as a temporary partial denture by adding artificial teeth. Another fringe area exists
between occlusion and orthodontics.
There are numerous combinations of splint and orthodontic appliances. An invisible
retainer maysimultaneously function as a soft acrylic splint.
Sved plate. Only the opposing anterior teeth make contact with this splint. It is
recommended for patients with acute or chronic muscle pain if the plane splint is
ineffective. The Sved plate is usually placed on the upper teeth. It is mostly used only at
night and not more than 10 to 12 hours a day. There is a risk for intrusion of teeth, which
has to be explained to the patient before delivery. As always, regular checkups are
important.
Gelb splint. The Gelb appliance is made in the lower jaw, covering only the premolar and
molar teeth. It is used to correct mandibular displacement, reduce TMJ dysfunction and
oral/facial pain, and to provide occlusal stability with the patient's natural dentition
serving as the anterior guid-ance. Some dentists fear that thissplint can cause intrusion of
the posterior teeth. The originator claims that what seems to be an intrusion is actually a
postural change because of a corrected jaw imbalance.
Distraction splints. The pivot splint was introduced by Krogh-Poulsen about 40 years
ago and was supposed to be helpful in patients with disk displacement. The proposed
effect is that the con-dyles are pulled downward upon clenching on the pivot, thereby
relieving traumatic load and giv-ing the disk freedom to reassume a normal position
15
. It
is seldom used today because most pa-tients find it uncomfortable. The distraction splint,
used by Pedersen et al to achieve a similar ef-fect, has been tried successfully to reduce
the destructive effect of juvenile rheumatoid arthritis on internal TMJ structures.
Splints for protection of oral tissues. The most common reason for making a splint is to
protect the teeth from excessive abrasion in bruxers. Several variations of splints are
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designed to protect cheeks and the tongue in patients with oral parafunctions (such as
cheek biting or tongue thrust). These patients may benefit from a splint with extensions
or enlargements designed in a way that keeps the cheeks from being pinched or the
tongue from pressing against the lingual surfaces of the teeth.
Combination splints. Missing teeth can easily be replaced by adding artificial teeth to the
splint. A Shore splint can function as a temporary partial denture by adding artificial
teeth. There are nu-merous combinations of splint and orthodontic appliances. A
removable bionator appliance can act both as an orthodontic and as a repositioning
appliance. An invisible retainer can simultane-ously function as a soft acrylic splint.
Others. Patients with oral parafunctions like cheek biting, tongue thrust, large
diastemata, etc. may benefit from a splint with extensions or enlargements designed in a
way that will keep the cheeks from beingpinched or the tongue from pressing against the
lingual surfaces of the teeth.
Bruxism
Signs of bruxism
Masseter hypertrophy
Non-functional wear facets
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A maxillary MI Occlusal Splint is the type most often used
Mandibular advancement splints to be used for repositioning a disk and keep it in
a normalized position
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Holder for the articulating paper.
Use a horse shoe formed holder for the articulating paper. If you do not have
that type - use type B not type A.
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Radiation Therapy
The common treatment of neoplasm is surgery and/or radiation. A tumor can be
destroyed by radiation if the dose is sufficient and is within the tolerance level of the
adjacent normal tissues. Post radiation sequels are significant and may result in total
morbidity.
Irradiation may be delivered to diseased tissue with internal or external madea or
both, depending on location, sensitivity of the tumer being treated, type or internal
sources include intracavitary cones or cylinders positioned by a carrier appliance.
Interstitial tubes, needles, seeds or threads that contain radiation sources may be
implanted. The use of colloidal suspensions, solutions, intra-vascular injections and intra
cavity instillations are less commonly. External radiation sources are more widely used.
Definition of some basic terms
Roentgen: the unit of exposure
The rad: the unit of absorbed dose or energy absorbed in the depth of the material.
Since it is difficult to meassure rads directly, exposure is measured in roentgen, and
by means of conversion factor the number of rads is calculated using the following
equation:
rads per minute (absorbed dose rate = roentgens per minute (output) X depth dose in
roentgens X conversion factor (F)
KV : Operating kilovoltage of the machine.
HVL: Half-value layer; the filtration needed to reduce the beam to one half of its
original value.
TSD : Target-to-skin distance: distance from the radiating source to the patients
skin.
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SSD : Source -to- surface distance, distance from radiating source to the patients
skin.
STD : Source -to- tumor distance; distance from the radiating source to the tumor
Wedge filter: Filter used to modify the treated beam to produce more homogeneity,
specially on curved surface.
- Gy = Gray (standard unit of measure)
- CGy = Centi-gray (1/100 of a Gray)
- 1 cGy = 1 rad (old terminology for dosage)
Types of Radiation
1- Waves:
a) Short waves deep penetration more damage.
b) Long waves less penetration less damage.
2- Beams.
3- X-rays.
4- Implants (Radiation Implant seeds).
Types of Radiation Therapy Techniques
- External Beam therapy: X-rays (photons) and electrons (particles)
- Interstitial therapy: Radioactive needles and seeds
- Intra-cavitary therapy: Radioactive needles, seeds, wires, etc.
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Effects of radiation :
Although this treatment modality is effective in the management of selected
patients and disease entities. Its curative dose of whatever type is often associated with
unwanted destruction of normal tissue, and this risk must be accepted by the patient if his
life is to be saved.
The primary effects of radiation occurs within the nucleus which is extremely
more sensitive than the cytoplasm. The complication of radiotherapy are not limited to
the immediate postoperative period; in fact the more seious complication occur 12
months or more after therapy. The hazered of the radiation may affect the offspring,
perhaps for several generation.
There is a direct proportion between radiation absorption and the density of the
tissue being irradiated. The density of the bone is 1.8 times that of the soft tissue. Thus it
would absorb more of the delivered dose than would soft tissue.
However, the ways in which energy is dissipated along the path of an exciting
photon or gamma ray is important for the biologic effect produced in the irradiated
tissues and for control of such irradiation, its direction, definition and manipulation by
the radiotherapist , the number of fractions, interval of delivery, and total dosage
administrated must be taken into account.
The biologic effectiveness of supervoltage therapy is somewhat less than that of
the orthovoltage range. When supervoltage radiation is used, the course of therapy is
commonly split into two halves, with approximately a one-month interval between. This
approach enables the normal tissues to recover from the effects of the first half before the
second phase is begin, which is then better tolerated.
Cobalt-60 is a satisfactory radiation source for therapy. The radiation has a skinsparing
effect and decreased absorption in bone, in comparison with conventional units. The
treatment fields can be well defined, and scatter of rays is in a forward direction instead
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of laterally. Late atrophy is rare with Cobalt-60 therapy. The linear acceleration radiation
up to 10 Mev. (million eletron volts) has decreased absorption in bone, but above to Mev.
Absorption increases. So the electronvoltage (in Mev) can be selected according to the
depth of the lesion.
Under 3,000 cGy
Mucositis, candidiasis, xerostomia & dysgeusia begin
Over 3,000 cGy
Xerostomia (permanent) and taste dysgeusia
Altered saliva (thick, more acid, changed flora)
Over 5,000 cGy
Trismus
Concerns for osteoradionecrosis
Over 6,000-6,500 cGy
Significant concerns for osteoradionecrosis
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Factors affecting the rate of damage:
1- Radiation dose :The higher the dose the higher the damage.
2- Energy source : Radiation by external source may cross normal structure before
reaching the tumor, thus affecting theses structures. While, if radiation is implanted,
the radiation is more confined to the area.
a) External source ( Increase damage to adjacent structure ).
b) Interstitial radiation therapy ( e.g. needles tubes wires small seeds ).
3- Type and sensitivity of tissues to radiation: Embryonic, immature or poorly
differentiated cells are more easily affected than differentiated cells of the same
type.
4- If radiation is in fractions, recovery may occur, when the rate of delivery is small.
5- The greater the mass of irradiated tissue, the greater the damage.
6- Radical neck dissection before radiation reduces blood supplies and increases the
damage.
7- Pretreatment performance status,
8- Pretreatment periodontal condition.
9- Mass of irradiated tissue: increase the mass exposed to radiation increase damage
of tissue.
10- Obesity: increase the obesity increase the damage.
11- Age of the patient: increase the age increase the damage.
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Effect of radiation on different tissues:
The primary effects of radiation occur within the nucleus since it is 100 to 1000
times more sensitive to radiation than the cytoplasm.
A- oral mucosa
Immediate Effects: Buccal mucosa shows initial erythema, reduced
keratinization, vascular dilatation and inflammation of the submucosa. It
appears 2 to 3 weeks after the start of therapy and reaches its peak towards
the end of therapy.
Erythema of the oral mucosa is usually begin 10-14 days from the beginning
of the treatment and subside shortly after therapy has been completed. The
capillaries become congested and may obstructed later by thrombasis. The
oropharyngeal mucosa may be covered with whitish painful membrane.
Changes in the oral flora with overgrowth of candida albicans may occur.
White patches appear on the lips, cheeks and tongue and overgrowth of
Candida albicans is a common complication, which may be due to the
imbalance in oral flora. Healing is usually rapid and is within 2 to 3 weeks
after completion of therapy.
Delayed effects: Severe mucositis in the soft palate, mucosa of the
hypopharynex, floor of the mouth, buccal mucosa, and base and dorsum of
the tongue.
B- Skin:
Immediate effects on skin are mainly erythema; redness and swelling that
resemble thermal burns.
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The skin becomes erythemature, edematuse and dry- Desquamation of
epithelial. Denudation of the surface and epilation is usually noted. These
changes may lead to necrosis of the soft tissue
Delayed effects on skin Changes may go on from erythema to ulceration
and necrosis. The epithelium becomes thin atrophic and superficial blood
vessels become telangiectatic or occluded.
Ulceration on the corner of the mouth may occur (angular cheilitis).
C- Tongue
Immediate effects on tongue The tongue becomes more sensitive to spicy,
hot and cold foods.
Delayed effects on tongue: Taste buds show signs of degeneration, atrophy
and the patient experiences partial or complete loss of taste that is
accentuated by reduced salivary outflow.
D- Eyes
Immediate effects on eyes : Eyes if left unshielded, irritation conjunctivitis
may occur.
Delayed effects on eyes: Eye effects include damage to eye lens and
development of cataract.
E- Salivary glands
The amount of saliva is decreased and became thickened due to interstitial
edema and duct obstruction. Loss of appetite may result due xerostomia and
falling of pain during swallowing. Also reduction in the pH of saliva (3.5)
occurs.
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Prosthetic effects: the patient can't tolerate his prosthesis due to more
friction during function as saliva acts as an effective lubricant. Retention is
compromised, as the peripheral seal may be difficult to obtain.
F- Taste
Alteration of the taste sensation may occur in the first days of irradiation
therapy due to congestive changes of the taste buds accompanied by
modifications in the quality and quantity of saliva. These alteration are
usually not permanent unless doses of 6.000 rads or more are used.
G- Neuromuscular function
Temporomandibular joint and masticatory muscles are allover affected by
radiation. Trismus ma be occured especially after 4-6 months.Regyular
mandibular exercises before and after therapy reduces the incidence of
trssmus.
H- Teeth and periodontium
Radiation cases often occurs at the cervical area of teeth. This finding may
be due to decalcification of teeth of teeth. and changes in the quality
(increase acidity) and decreased quantity of salivary secretion associated
with radiation. The teeth became hypersensitive to temperature change and
sweets. Changes in periodontal ligament and feeling elongation of the teeth.
In growing teeth the development may be partially or entirely inhibited by
irradiation. In children partial anodontia or dwarfing teeth may be noted
due to injury to the tooth germ.
Decalcification of teeth due to radiation (radiation caries). The vascularity
of the pulp tissue is reduced leading to fibrosis and atrophy.
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Fibers of the periodontal ligaments are disoriented, thickened, decreased
vascularity and are more prone to infection, which may be associated with
bone resorption and eventual loss of teeth.
I- Osseous Tissue
maxillary bone effects is more than the mandibular due to more radiation
absorption osteoradionecrosis.
Bone is relatively resistant to radiation, but a heavy dosage can upset the
normal balance between bone formation and resorption, and cause
limitation or obstruction of the blood supply. These disturbance reduces the
ability of the tissues to withstand trauma and infection and thus increases
the opportunity for osteomyeltis and necrosis. Bone growth may be limited
or stopped due to destroying of osteoblasts and osteoclastes.
Osteoradionecrosis may be develop due to loss of bone vitabity caused by
sclerosis of the periosteal and associated vessels. The pathogenesis is not
known, but three factors are invloved: radiation, trauma and infection.
Osteoradionecrosis is the major complication of irradiation to the head and
neck. Osteoradionecrosis is more common in mandible than maxilla due to
a diminished in frequently unpaired mandibular blood supply.
The effect of irradiation on bone is often become manifest for years after
treatment.
Bone absorbs radiation 1.8 times than does a comparable volume of soft
tissue. The more the bone density the more is the absorption of radiation.
This explains why the mandible absorbs more radiation than the maxilla.
More absorption of radiation coupled with reduced blood supply in the
mandible than the maxilla makes it more susceptible to osteoradionecrosis.
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J- Trismus:
Radiation in the temporomandibular joint area and muscles of mastication may
lead to fibrosis 3 to 6 months after the completion of therapy leading to trismus
which result in impaired mastication and limited mandibular movements 10 to
15 mm.
Treatment: includes exercising and the use of dynamic bite opener.
K- Diet:
As a result of reduced salivary output, mucositis, pain during swallowing and
loss of taste occurs. The patient experiences loss of appetite, nausea and
malaise
Weight loss and dyspnea: The treatment is supportive and symptomatic
saline rinses, systemic analgesics, Nystatin and local anesthesia.
Oral complications from radiation therapy
Radiation changes have a direct effect on rehabilitation of both intraoral and extraoral
defects found in the maxillofacial prosthetic patient. Radiation changes include:
Erythema and tissue sensitivity (mucositis),
Ulcers in the mouth and on the lips,
Fungal infections,
Dryness (xerostomia) of the mouth from salivary gland destruction,
Dental decay from decreased salivary flow and pH changes,
Possibility of infections in the jaws or the potential for osteoradionecrosis from
infection or trauma to irradiated bone.
Hypersensitivity of the teeth,
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Dental pulp changes,
Taste loss,
Oral bacterial shift,
Periodontal breakdown
The morbidity of head and neck irradiation, for instance, include xerostomia,
laryngeal edema, trismus, hearing loss, facial hair loss, and loss of taste.
Dental management of irradiated patients
The main objective of dental management for irradiated patients is to preserve the
tissues in the field of radiation. A lot of controversy has existed concerning the
preradiation and post radiation dental treatment alternative.
1- Preradiation treatment
Before the onset of irradiation the patients will require a thorough visual and
digital oral examination and a radiographic ( periapical, penoramic or both) survey of the
teeth and jaws.
It is recommended by the consensus that any malposed, non restorable diseased
teeth.(affected be caries, periodontal disease, periopical pathology) or lie in the field of
radiation must be removed to reduce the possibility of osteoradioneocrosis. Some authers
prefer the prophylactic removal of all teeth, regardless of their condition or location
because patients who are edentulous before radiotherapy are less likely to acquire
osteoradionecrosis.
The surgical procedure must emphasize minimal trauma. A healing period 10-30
days is desirable before beginning of irradiation, depending on the case.
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The following must be removed:
1- Teeth in the field of radiation to avoid osteoradionecrosis.
2- Periodontal involved, badly decayed should be removed before therapy.
3- Sharp bony specules.
The following must not be removed:
Teeth within tumor to avoid dissemination of tumor cells.
The following could be left:
Teeth of unaffected side if radiotherapist allow that.
II- Post radiation treatment
1- The patients must be seen at frequent regular intervals for examination as early
diagnosis minimizes patient morbidity and entances the effectiveness of treatment.
2- Strict oral hygiene include rinsing and cleaning of the mouth are essential. Trauma
caused by tooth brush should be avoided.
3- The daily use of topically applied 1% sodium fluoride gel is specially made carrier
may reduce the incidence of caries by 30% - 40%. The tooth sensitively may also be
reduced by fluoride .
4- To reduce the pain in swallowing, topical anesthetic solution can be used before
mealtime.
5- In case of xerostomia, the patient is advised to carry a small spray bottle of water all
times to wet the mouth.
6- All patients undergoing postirradiation extraction or surgery should receive prophylactic
antibiotic- at least 1 gram of penicillin daily- for 2-4 weeks postoperatively.
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7- Unsloughed bony sequestra should be surgically removed and rough bone is smoothed
with debridement.
1- Conservative, strict oral hygiene rinses with H2O2 or warm saline.
2- Antibiotics and analgesics in case of infection or pain.
3- Any surgical intervention is contraindicated massive tissue loss.
4- Prophylaxis against tooth decay (treatment by 10% stannous fluoride application ).
Prosthetic construction for irradiated patient:
Some authors suggesting that removable prosthesis should not be used for
irradiated tissues. Others, however have proposed that after careful evaluation denture
prosthesis can be constructed 6-24 months postradiation.
The period of waiting before construction depends on the site of the lesion, the
radiation dosage and the condition of the mucous membrane and the patient comfort.
Irradiated patients who required obturators began immediately after removal of the
surgical pack. If more conventional types of removable prosthesis are indicated, it can be
constructed after several months to allow for adequate improvement of the oral hygiene.
A symptomatic denuded bone can be covered with a prosthesis. The irradiated
tissues are fragile so the finished prosthesis should be well adapted, stable and retentive.
Trauma caused by ill - fitting denture specially the lower should be avoided.
The use of resilient nonirritating impression materials, stress limiting occlusal
schemes and tooth material are important to reduce tissue trauma.
The patient is instructed to leave the denture out of the mouth at night and for
frequent and longer periods during the day to rest the tissue.
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The patient is advised for soft diet and to use more liquids with meals sticky, hot and
spicy foods as well as alcohol and tobacco should be avoided.
a) Prosthodontic treatment:
- Placement of Dentures (Timing):
Denture construction for irradiated patients should made if 12 14 months had elapsed
for mucosal healing. Some patient may wait 2 3 years before mucosa has recovered
sufficiently to tolerated denture.
- Two groups to consider:
1- Patients edentulous prior to radiation therapy and having denture
experience new denture can be made after mucositis has resolved.
Denture bearing area should be checked with PIP before insertion.
2- Patients undergoing pre-radiation or post-radiation extraction with
denture after completion of radiation denture bearing should be
examined contour, irregularity and scar before denture fabrication.
- Success of prosthodontic treatment depends on:
1- Pre-operative data.
2- Through oral examination.
3- Prosthodontic treatment (Non traumatic and non irritating denture).
4- Effective follow up system.
[ I ] Preoperative data:
1- Type and size of tumor. 2- Mode of therapy.
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3- Total dose.
4- Data of treatment.
5- Radiation fields.
6- Tumor response.
7- Prognosis of tumor.
[ II ] Oral examination:
1- Routine examination for denture:
- Entire oral cavity should be
examined visually and palpated
for any soreness.
- Appearance of oral mucosa.
- Scarring and fibrosis at tumor site.
- Degree of trismus.
- Salivary function.
- Tori.
- High tissue attachments.
- Enlarged maxillary tuberosity.
- Flabby tissue.
- Abnormal jaw relation.
2- Undercuts are undesirable to engaged, if they are present in field of radiation.
3- Surgery is contraindicated.
4- Post-irradiation symptoms. e.g. pain, Xerostomia and trismus.
5- Patient warned of possibility of osteoradionecrosis.
[ III ] Prosthodontic procedures:
1- Impression:
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- 1ry impression: should be made with alginate and not compound.
- Xerostomia: should be treated by using petroleum jelly.
- Border molding: Done by using low fusing wax or heavy rubber base. The lingual
flange shouldn't used to gain more retention and only for stability.
- 2ry impression: should be made with rubber base.
2- Jaw relation:
- Low vertical dimension of occlusion offers low forces and less trismus.
- Centric relation record should be achieved with no trauma.
3- Try-in:
- Modified anatomical or flat teeth should be used to decrease the horizontal forces.
- Denture base should cut away to minimize irritation.
4- Insertion:
- Any roughness or sharp angles should be removed.
- Silicone soft liners may be used to minimize mucosal trauma.
[ IV ] Follow-up:
- The patient follow-up performed daily for about 2 weeks.
- Then patient follow-up performed once every 3 months.
Radiotherapy prostheses
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Radiotherapy prostheses are stents used to help the radiotherapist in treatment of oral
malignancies by radiation.
Objective of radiotherapy prosthesis:-
1-It reduces the side effects of the treatment.
2-It protects tissues that are not meant to receive radiation.
3- It increases the accuracy of radiation source and assures that the area of treatment is
the same every time the patient is irradiated.
4-It results in a more cooperative patient since discomfort and injuries are reduced.
5- Enable lowering the field of radiation (protect the parotid gland).
6- Safer for radiotherapist in treatment.
Indication:
Protect or displace vital structures.
Locate diseased tissues in repeatable position during treatment.
Carry radio-active material to turner site.
Recontour tissue to simplify dosimetry.
Positioning of beam.
Requirements:-
1-Comfort: - The patient should be able to wear his prosthesis comfortably while
receiving radiation and allows the patient to breathe easily. All surfaces must be smooth;
a tissue conditioning material may be used to line the prosthesis in contact with sensitive
areas.
2. Minimal weight: The lighter the prosthesis, the better it will be tolerated by the patient.
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3. Retention and Stability: The prosthesis must remain in a definite position throughout
the treatment.
4- Suitable strength:The material used should be of suitable strength that resists
breakage; acrylic resin is a suitable material.
5- Easy to repair and clean.
6- Allows visualization of tissues; clear acrylic resin is the material of choice.
7- Easy to be inserted and removed by patient.
8- permitting easy breath
Types:
1- Carrier applicator.
2- Director appliance.
3- Maintaining the structure of the tissues to be treated.
4- Tongue protector (shielding).
5- Prevention of tongue and cheek biting.
6- Positioning of the radioactive source (Dosimentric device).
7- Recontouring tissues to simplify dosimetry.
Types:
a) Radium applicator (carrier):
Use:
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Allow administration of pre-calculated dose to inaccessible area.
direct radiation to exact location in treatment of malignancy
Construction:
Primary alginate impression casts the area involved is out lined by
radio therapist base plate (heat self cure) clear acrylic resin to allow
pressure area to be seen.
Types:
a) Wire carry radium capsule: fixed at 2ends e set cure to plate clone, wire adjusted
so that radiation directed to exact location.
b) Radiation material embedded in play-ethylene tubes: at fitting surface of base and
covered with self cure acryl. Rubber gloves impregnated with lead, protective
shield must be used during radium manipulation for self protection.
c) Soft irradiation applicator (lithium fluoride carrier):
Advantages:
Simple, economic, efficient in irradiation of persistent superficial carcinoma.
Easy to control dose to various parts of lesion, if large does required, simply
remove some seeds
Construction:
Primary alginate impression cast outline surface to be irradiated with a
pencil adapt layer of base plate wax to outline. A line is drawn 1 cm beyond
periphery lesion, strip of beading wax attached to cast at this line, self lure acrylic
resin extend 1cm beyond periphery lesion in all directions. While the wax is soft
hooks attached to it for retention of prosthesis.
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Grooves placed along inner surface of prosthesis in which nylon tubes embedded
to average depth 5 mm from inner surface in depth of each groove, tubes are
parallel to each other at interval of 1cm, extend 3-5mm out of the prosthesis.
Nylon ribbon contains radioactive seeds fit within hollow tube, prosthesis attached
by hooks (3 wire hooks) to modified orthodontic head gear maintained
in stable position to deliver desired amount of radiation.
b) Positioning peri-oral cone (Docking device):
Function
Positioning perioral cone and direct beam of radiation in exact
position in repeated exposure (beam director)
Deviate mandible, salivary glands and tongue from source of
radiation (in treatment of the lesions on anterior mandible -
anterior floor of mouth - anterior hard palate).
Construction:
Edentulous: sheet of wax or tin foil applied to cone of radiation unit, cone
attached to upper and lower denture base of one piece gunning splint while mouth
is opened, if dorsum of tongue is elevated above cane wax extension used to
deviate tongue.
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Dentulous patient: cone attached with self cure to maxillary and mandibular
occlusal index.
c) Displacement (positional) stent:
Function:
Recontour or reposition tissues (in or out of) radiation field for exposure or
protection ex: tongue.
Deviate tongue toward radiation source (extraoral) and avoid radiation of salivary
gland which causes xerostomia.
Construction:
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Dentulous patient:
2 sheets of base plate wax extended in flat plane to 2
nd
molar area, depress base of tongue
to lingual border of the mandible, prevent tongue from extend above occlusal plane, hole
is made in anterior portion, in which tongue tip rest reproducible position.
Edentulous patient:
Impression jaw relation: interim record (conventional steps of complete denture
until JR record) casts mounted on articulator, 2sheets of base plate wax
attached to mandibular record base to from stent that will depress tongue.
Also acrylic duplicate of old denture may be used and lined with tissue
conditioner.
Direct tech: Sheet of softened base plate wax formed in patient mouth to desired
position over existing dentition invested, processed in acrylic resin.
d) Intra oral radiation protective stent:
Function: Remove structures from radiation field.
Types:
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A. Stent used to protect the maxilla, parotid gland (to avoid Xerostomia): by
maximum opening of the mandible (large one piece stent), if it is difficult to insert
especially with trismus use 2 piece stent.
B. Stent used to protect the tongue (tongue protector): in treatment of buccal mucosa,
posterolateral border of tongue, alveolar ridge protect tongue and opposite side
of mandible.
Construction:
Patient is asked to bite on soft compound ball push check, tongue aside (made
during impression of mandible).
Mandibular and maxillary cast mounted on articulator at centric occlusion with
incisal pin opened 2-3mm 3-4 sheets of wax softened, placed between teeth
form occlusal index. Wax strip fit into lingual surface (concavity) created by
compound lingual wax extension is covered to create 1cm concavity then
packed into acrylic resin.
Low fusing metal (lead-cerrobend) is melted and poured in cavity of acrylic resin
prosthesis, covered by acrylic resin or wax to decrease scattered radiation (2-3min
thickness lead if low voltage radiation, 5mm thickness lead if high voltage
radiation used).
If patient is edentulous it is made on duplicate upper, lower denture.
Needle invested in acrylic resin of affected side to irradiate ridge growth.
Radiation
Mostafa Fayad
e) Positioning dosemetric device stent:
Function
Measure exact amount of radiation (of lithium fluoride capsule).
Construction
Capsule wrapped by tin foil for separation. Self cure acryl wrapped around it
(carrier).
Stent is stabilized by maxillary and mandibular record bases or interocclusal wax
waver. Hole placed in one end of stent, orthodontic wire used to push capsule
out of resin.
Acrylic resin carrier attached to stent in appropriate position (made with
compound to detect good position).
f) Stent for recontouring tissue to simplify dosemetery:
This stent used in radiation of skin of upper and lower lip, as in this site
radiation at corner of mouth is less than mid line of lip due to curvature of lip
stent is used to flatten lip, corner of mouth entire lip at the same plane.
Made from modeling plastic, processed to acrylic resin.
Radiation
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g) Positioning radioactive source:
Carry source of radiation near lesion in treatment of lesions of (palate- buccal
mucosa - small superficial lesion at any area of mouth).
Source incorporated in denture base ex: maxillary denture base in treatment
of recurrent carcinoma of posterior wall of maxillary sinus.
h) Positioning radioactive source by after loading:
As positioning radioactive source except radioactive source placed in stent
after stent secured into position, placed in poly ethylene lube.
Radiation
Mostafa Fayad
Used in: accessible superficial area to avoid exposure of the technician to
radiation-
After treatment source removed, placed, in container.
i) Stent used in direct implantation:
Some lesions as (tongue - anterior floor mouth) treated with direct implantation
of radioactive source in the tumor.
Prosthesis with tissue conditioner is used to secure position of radioactive
source during treatment and to achieve patient comfort.
j) Stent used to prevent tongue and check biting:
Irradiation of tongue and check lesions leads to edema, mucostis, check biting
stent used to displace tongue, checks, placed over teeth as mouth guard or
fluoride carrier.
Radiation
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Trismus
Mostafa Fayad
TRISMUS
Limited mandibular movement
A Maximum mandibular opening may be reduced to 10-15 mm, impairing, speech and
deglutition, and limits access for dental treatment.
In the past, this word was often used to describe the effects of tetanus, also called 'lock-
jaw'. More recently, the term 'trismus' has been used to describe any restriction to mouth
opening, including restrictions caused by trauma, surgery or radiation.
Etiology:
I. Acute factors:
1. Local trauma can occur during an inferior alveolar block injection which can result
in muscle inflammation that limits movement and causes pain.
2. Infection of the pterygomandibular space can limit mandibular movement also
infection can occur as a sequela to pericoronitis or oral surgery.
3. Psychological and emotional stress.
II. Chronic factors:
1. TMJ dysfunction is the most common chronic cause of trismus.
2. Poor joint architecture and malposition of the disk.
3. Rheumatoid arthritis can also be a cause of TMJ pain and restrict mandibular
movement.
4. Pathological processes as osteoma of the mandibular condyle or the zygoma,
cysts, and overgrowth of the condyle or coronoid process of the mandible.
5. Intraor extracapsular ankylosis of the TMJ can restrict mandibular motion.
III. Treatment related factors:
1. Radiation therapy may limit mandibular movement if the muscles of mastication
or TMJ are included in the treatment fields. It is most noticeable following
nasopharyngeal, palatal and nasal sinus tumors.
2. Trismus is caused by surgical resection of the maxilla and mandible.
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Factors external to the joint include neoplasms, acute infection, myositis, systemic
diseases (lupus, scleroderma, and others) pseudoankylosis, burn injuries or other
trauma to the musculature surrounding the joint.
Factors internal to the joint include bony ankylosis (bony in growth within the
joint), fibrous ankylosis, arthritis, infections, trauma and (perhaps) micro-trauma that
may include brusixm.
Central Nervous System disorders can also cause limitations to mouth opening.
Tetanus, lesions that affect the trigeminal nerve and drug toxicity may all be suspects
in this condition.
iatrogenic causes, such as third molar extraction (in which the muscles of mastication
may be torn, or the joint hyperextended) hematomas secondary to dental injection and
late effects of intermaxillary fixation after mandibular fracture or other trauma.
Signs of trismus
The most obvious effect of trismus is difficulty in opening the mouth.
A simple test for trismus
Trismus tends to develop slowly. In some patients, it progresses so slowly that they may
not notice it until they can only open their mouth to 20mm or less. Treatment that begins
early in the progression of the condition is likely to be more effective, and easier on the
patient. Because of this, it is important to be proactive in looking for early signs of
trismus.
Mouth opening varies from person to person. It is usually 35-55
millimeters. This distance is usually equal to the width of three
fingers. One simple test is the 'three finger test'. Ask the patient to
insert three fingers into the mouth. If all three fingers fit between the central incisors,
mouth opening is considered functional. If less than three fingers can be inserted,
restriction is likely.
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Treatment:
The treatment modalities for trismus or limited mandibular movement include
medical, surgical and physical therapy. Each mode may be used alone or in combination
with other modes of treatment.
I. Medical treatment:
When infection is the cause of trismus, antibiotics are the treatment of choice.
Arthritis, inflammation of the joint can be treated with anti-inflammatory agents which
relief pain and result in some improvement in motion. Muscle relaxants may help in
acute cases of limited mandibular movement.
II. Surgical Treatment:
Surgery is the treatment of choice for removal of tumour ,cysts or foreign bodies.
Surgery may also be indicated in TMJ ankylosis and scleroderma after more conservative
therapy has failed.
III. Physical Treatment:
Several methods have been utilized to counteract trismus and increase inter-arch space
including exercise and the use of mechanical devices, and aids to improve circulation.
A. Exercise:
Exercise is helpful during radiation therapy, following orthognathic
surgery and for scleroderma patients.
These include opening the mouth as wide as possible 20 times at
least three to four times per day.
In addition 8 to 10 actively assisted lateral excursions should be
done to exercise the pterygoid muscles.
downward pressure on the mandible (8-10 times for 10 second).
For scleroderma patients, manually assisted exercise may also be
used.
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B. Mechanical devices:
a) Simple devices:
1.Tapered threaded acrylic screw:
A tapered threaded acrylic screw can be used,
placed and turned between the teeth to apply an
opening force to themandible.
base plate wax is twisted to form a screw with
desired taper, then processed into acrylic resin.
2. Tongue depressors
It can be lubricated with petroleum jelly or glycerin
and placed between the arches for one minute to
increase opening. Additional depressors can be added
one at a time to increase opening.
3. Woodenclothespin
It can be inserted between arches while the patient applies
gradual pressure.
4. Flex jaw exercisers
b) Dynamic bite opener (T.M.J. exerciser):
Dynamic bite opener is a modified kingsley splint, which is a combination
of maxillary and mandibular stents, with metal rods extending through the
commissures of the mouth to permit the use of elastic bands to apply an
opening force.
Dynamic bite opener
Trismus
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Construction:
Upper and lower alginate impression is taken in shallow stock tray (as
trismus present) after coating the tray with adhesive and the casts are
mounted on the articulator.
2 horse shoe shape stainless steel perforated metal plates adapted between
occlusal surface of upper and lower teeth to receive acrylic resin maxillary
and mandibular occlusal stents (3 mm thickness). The acrylic occlusal stents
have mechanical retention from the perforation of the plates. Teeth are
lubricated and mix of self cure acrylic resin is applied over the upper and
lower plates and the patient bite in centric occlusion to form upper and lower
occlusal stents.
2 metal rods are welded to the buccal flange of upper and lower metal plates
and extending backward from the commisure of the mouth extra-orally.
Maxillary rod extend back ward in the temporal region where it bend down
ward to form a U-shaped crimps in the area of premolars, mandibular rod
bent upward to form a U-shaped crimps in reverse direction to the maxillary
crimps.
Mandibular rod is parallel to the occlusal plane and maxillary rod is place 10-
15 mm buccal to mandibular rod. Elastic bands stretched between upper and
lower crimps which exert bilateral positive seating forces on the upper and
lower occlusal stents and opening force on the mandible.
If the patient was edentulous, the metal rods attached to the buccal surface of
the denture base but detection of the fulcrum exerted by the rods is very
important to decrease tipping of the denture base.
Trismus
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The Dynasplint Trismus System
The device is based on low-load, prolonged-duration stretch
(LLPS) technology. It is spring loaded for simple, adjustable,
reproducible tension at each therapy session. This correct
biological stimulus has been proven to permanently lengthen
shortened connective tissue.
The device is worn inside the middle of the mouth while the
patient is relaxed. Proper placement is essential for the ideal
stretch of the masticatory muscles. The patient can hold the
device with their hand or attach the counterbalance bars for
hands-free therapy.
c) The Inflatable bite opener:
It is consists of maxillary and mandibular stents, an inflatable pediatric blood
pressure bag, rubber bulb and tubing.
The stents are inserted and the inflatable bag is placed between the stents.
The bag is inflated by squeezing the rubber bulb, forcing the stents apart.
The pressure is maintained for 10 seconds followed by 1 minutes of rest. The
procedure is followed for 10 minutes three times a day.
Four basic parts of appliance acrylic maxillary plate, acrylic mandibular
plate, inflatable rubber pediatric blood pressure bag, and rubber blood
pressure handbulb with lock-nut attachment and connecting tubing.
d) An intraoral prosthesis with interarch spring:
It can be used for dentulous and edentulous patients. The spring
clips are attached to mandibular stent and the free end of the
clip locks into a latch on the maxillary stent. The springs
provide a constant force bilaterally which is controlled by
adjusting the size of loop.
Trismus
Mostafa Fayad
Microstomia Orthoses J ournal of Prosthodontics 19 (2010) 161165
It is dynamic opening devicesused in treatment of Microstomiawhich is is defined as
an abnormally small oral orifice.
A limited oral opening can be caused by
surgical treatment of orofacial cancers,
head and neck radiation,
reconstructive lipsurgery,
burns,
trauma,
microinvasion of muscles of mastication,
temporomandibular joint (TMJ ) dysfunction syndrome,
and genetic disorders.
Scleroderma is a connective tissue disease of the skin, joints, and sometimes
internal organs. Facial skin and oral mucosa become thin and taut, and wrinkles
disappear, resulting in amask-like appearance and a reduced oral opening.
Immediate Dentures
Mostafa Fayad
Immediate Dentures
An Immediate Denture: is a complete or removable partial denture constructed
before the teeth are extracted and inserted immediately after the extraction of the
natural teeth.
Advantages
1- Preservation of healthy oral environment
Prevent migration and overeruption of remaining natural teeth.
Control alveolar ridge resorption.
Abnormal chewing habits are avoided.
Little or no disturbance of T.M.J.
Prevent the change in the tongue size.
The facial muscles will function at their natural length avoiding the
creasing of the soft tissues of the cheeks resulting, in extreme cases, in
angular cheilitis.
2- Preservation of appearance:
The patient never appears edentulous. maintaining of a pleasing
appearance
Lip and cheek support is maintained.
Unless pre-extraction models are made the selection of the mould and
the arrangement of the upper anterior teeth can be a problem for the
clinician when providing first time complete dentures. When
immediate dentures are provided this problem is simplified.
Natural facial expression and appearance is maintained because the
facial muscles are maintained in their correct position and the
appearance of the natural dentition can be copied.
3- Jaw relations are maintained:
The reproduction of the vertical jaw relationship is much easier to
achieve and more likely to be correct. If only two opposing natural teeth
are present they will act as occlusal stops.
Immediate Dentures
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Centric relation is easier to record: When a patient has been rendered
completely edentulous, the edentulous ridges can only be brought
together close enough to masticate food by an extreme protrusion of the
mandible. This is a habit that can be very difficult to break during the
registration of the horizontal jaw relationship. This problem does not
arise during the construction of immediate dentures.
4- Neutral zone maintained:
During a prolonged edentulous period, because of the absence of the
teeth, the relationship of the cheeks , lips and the tongue change .This
results in a change of the denture space or neutral zone, which, in turn,
can create problems in obtaining a stable lower denture.
The immediate replacement of the extracted teeth with a denture
preserves the neutral zone.
Because the artificial teeth are arranged in a similar manner to their
natural predecessors, chewing will be carried out more easily or even
better than after a period of edentulousness without dentures.
5- Minimal speech impairment:
When dentures are first fitted there is often a problem with speech, not
only because of the position of the teeth, but also because of the bulk of
the denture base. This problem is made worse if the patient has been
without teeth for an extended period, which is necessary after total tooth
extraction, to allow the soft tissues to heal and the initial resorption of
the alveolar bone.
When an immediate denture is fitted adaptation is made very much
easier, the musculature does not have to learn new patterns of behaviour
because tooth position and neutral zone is not changed.
6- Minimal loss of masticatory efficiency:
There is minimal loss of masticatory efficiency because at no time is the
patient without teeth.
7. The patient becomes adjusted to the immediate denture more quickly than with
conventional one.
Immediate Dentures
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8. Healing period is faster and less painful.
9. Protection of the tooth sockets
The trauma of eating may cause haemorrhage and infection in unprotected
tooth sockets. When immediate dentures are provided the sockets are
protected and the blood clots stabilized immediately after extraction.
With haemophiliacs and patients with related blood disorders immediate
dentures provide a form of splinting.
10.Prevent interruption of the digestive function, because the artificial teeth are
arranged in a similar manner to their natural predecessors, chewing will be carried out
more easily
Disadvantages of Immediate Dentures:
1) The immediate denture cannot be evaluated until the insertion appointment.
the patient may well be disappointed or even disapprove of the "new" appearance,
as Patients who have history of difficult extraction may require surgical extraction
that could result in much mutilation and destruction of the alveolar bone.
2) When the dentures are fitted large areas of spacing between dentures and tissues
can compromise the fit as well as the patients appearance. This can undermine
the confidence of the already apprehensive patient and can only be corrected by the
use of a temporary reline material followed by an early permanent hard reline.
3) Relining or remaking is required during the period of alveolar resorption.
The immediate denture should be relined or remade in six months to a year
following insertion.
4) It can be prone to fracture. If the anterior teeth are gum-fitted and the denture is
open faced It is more costly.
5) Increase denture maintenance and patient visits.
6) Increase patient discomfort by combination of post extraction pain and denture-
related trauma.
Immediate Dentures
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Indication
Patient is in good general health
Patient is co-operative
Patient can understand scope, demands and limitations attached to this
treatment option
Patient cannot go without teeth during the healing period
(aesthetic/psychosocial issues)
Patient can afford time and extra cost involved with this procedure.
Contraindications for immediate dentures
1) Previous history of difficult extraction.
The extraction of the teeth must be a traumatic.
A radiograph revealing dense bone, long or irregularly shaped roots or
hypercementosis should warn of possible problems.
The presences of un-erupted teeth or cysts are a positive contra-
indication.
2) Patients who present with gross oral sepsis
If sepsis follows tooth extraction the patient may well refuse to
wear the denture due to pain. With these patients it is
advisable to construct complete dentures only after an
edentulous period when all inflammation has fully resolved.
The success of an immediate denture depends on it being worn continuously for some
days after the extractions so that the healing tissues and blood clots adapt to the shape
of the fit surface of the denture.
Post operative oral and denture hygiene are therefore very important.
3) Patients with neglected oral hygiene.
4) Non co-operative Patients with regard to oral or denture hygiene.
5) Mentally impaired Patients, or the indifferent and unreliable patients.
6) Severe uncontrolled epileptics.
7) Radiation therapy, soft tissue infection, ulcerative gingivitis, sinus infection and
candidiasis are contra indications until resolved.
Immediate Dentures
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8) Aged or medically compromised patients who cannot tolerate multiple
extractions.
Systemic medical conditions such as diabetes, haemophilia, and cardiac disease are
not contra-indications for the provision of immediate dentures if carried out with l
co-operation and approval of patients Consultant or General Medical Practitioner.
Treatment Planning For Immediate Dentures
The patients medical and dental history should be reviewed.
A clinical examination of hard and soft tissues is performed, with a full- mouth
radiographs and mounted diagnostic casts.
A thorough scaling of the teeth should be carried out before the extractions. This
is necessary to reduce the possibility of calculus being dislodged into the socket
during extraction causing sepsis and delayed healing.
The dentist should discuss the following with the patient::
Limitations of service must be carefully explained.
Notify patient of possible difficulties involved with procedure.
Clinician must understand the patients needs.
Immediate dentures dont fit as well as complete dentures.
They may need temporary linings with tissue conditioners requiring the use of
denture adhesives.
They will cause discomfort (pain of extraction as well as sore spots).
Patient will experience initial difficulty speaking and eating.
Aesthetics may be unpredictable (no trial try-in).
Other unpredictable denture factors such as the gagging tendency, increased
salivation, different chewing sounds and facial contour.
Immediate dentures must be worn for the first 24 hours without removal. If they
are removed, they may not be able to be reinserted for 3 to 4 days.
Because supporting tissue changes are unpredictable, immediate dentures may
loosen up during the first 1 to 2 months.
The patient is responsible for all fees involved in refitting or relining the dentures.
Immediate Dentures
Mostafa Fayad
Types of Immediat e Dent ur e
I. According to the stages of teeth extraction its classified into:
There are two main methods with regards to the use of immediate dentures in the
ultimate treatment for the patient.
A. Interim (Transitional/ TID) One stage technique
Complete clearance :All the remaining teeth are extracted and the denture
fitted at one session. Advantage to some patients, particularly the
dentalphobic, there is just one surgical, anesthetic and prosthetic procedure.
Probably best done under general anesthesia.
Once the immediate denture is inserted and healing of the extraction socket
is complete, a new complete denture is fabricated.
Retention and stability can be improved by subsequent relines due to initial
rapid resorption of the alveolus post extraction.
Advantages
Vertical dimension preserved as extraction of posterior teeth occurs at the
surgical appointment of the insert.
Indicated when multiple anterior and posterior teeth remain and patient
cannot go without posterior teeth to allow the bone to heal.
Disadvantages,
o Usually very rapid resorption of all alveolar bone resulting in
dentures becoming ill fitting very rapidly.
o If a large number of teeth are involved some practitioners are
reluctant to fit complete immediate dentures questioning the
ethics of such blood-letting surgery.
Immediate Dentures
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B. Conventional (Classic/CID) Two-stage extraction technique
There are two versions of this technique:
a- All of the posterior teeth are extracted, preferably retaining the first premolars.
Two extraction visits required
Remove all posterior teeth about 3 months before making immediate denture
Allows for posterior segment to heal and stabilize
Maintains anterior teeth for appearance, some function
Immediate denture inserted at the second surgical appointment.
Once this immediate denture is inserted and healing of the extraction socket is
complete, the denture is refitted or relined for long-term use.
Advantages
Good retention and stability than transitional immediate denture.
The immediate dentures will be better supported because initial
posterior bone resorption has taken place.
The possible disadvantages of this technique are:
If there is gross periodontal disease of the anterior teeth then during the
posterior healing period periodontal abscesses may form and there may
be movement of the teeth.
There is also the possibility that the patient will develop a habitual
mandibular posture in order to masticate the food. This may create
problems during the CJR stage as discussed under advantages to the
clinician.
b- Interim partial denture construction : A modification of the previous technique
is to make an immediate partial denture to the stabilized bony base. After the patient
has learnt to control it the remaining anterior teeth are added as immediate additions.
Advantage:
1-It prepares the patient for complete dentures by first learning how to control
the partial denture.
2-The denture provides posterior support reducing the possibility of the
development of a habitual posturing of the mandible.
Immediate Dentures
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Immediate Dentures
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II. According to Surgical Procedure its classified into
A. Immediate Denture without alveoloplasty
Extraction of anterior teeth with no Surgery
Teeth are simply extracted with no surgery performed, the denture is
constructed either with or without labial flanges
B. Immediate Denture with alveoloplasty
Teeth are extracted and followed by a surgical contouring of the alveolar
ridge. Especially patients who has maxillary protrusion and to eliminate
undercuts.
III. According to presence or absence of labial flange
A-The flanged denture
The flange in the anterior region may be either complete or part. The flanged denture
may be either without alveoloplasty or with alveoloplasty.
a) The flanged denture without alveoloplasty
The complete flange
The pressure of a complete flange gives better retention and
protection to the sockets and thus assists more rapid healing.
The part flange:
It is indicated when the undercuts are greater than 2 mm and
in particular when they are diametrically opposed by
undercuts in the posterior region.
The part flange is extended just beyond the maximum contour
of the alveolar process, to a point where the undercut engaged
can be accepted by compression of the overlaying soft tissues,
this type of flange gives some retention to the denture and
avoids the gap between a complete flange and the tissue which
is inevitable where a large bony undercut exists.
Immediate Dentures
Mostafa Fayad
b) The flanged denture with alveoloplasty
There is a small proportion of cases where reshaping of the alveolar
process is indicated. Where there is marked protrusion of the upper
alveolar process and when the patient has a short upper lip, both
appearance and denture function can be improved by alveoloplasty.
Alveoloplasty may be performed by either septal or radial alveolectomy..
B-The open face denture
In this type, the artificial teeth are set (either in or close to the sockets of
their natural predecessors) and labial flange isnt made.
The open face immediate denture is only indicated in the upper jaw
when sufficient retention can be obtained from the rest of the denture
bearing area.
It may be
Socketted immediate denture
gum fitted immediate denture
Immediate Dentures
Mostafa Fayad
Immediate Dentures
Mostafa Fayad
Cl inical Pr ocedur es f or CICD Const r uct ion:
1- Examination and Mouth Preparation:
Proper intra and extra oral examination should be carried out.
Good scaling to remove plaque to obtain accurate impressions and reduce
post-operative edema. Impressions and
Inter-occlusal records are made to obtain mounted diagnostic casts as a
diagnosis, Treatment planning and reference.
2- Posterior Teeth Extraction:
While leaving bilateral centric Stops (bilateral opposing premolars or molars as
guide to jaw relationship). Then 6 weeks of healing than next appointment.
An alternative is to make an immediate partial denture replacing all of the
posterior teeth and inserted immediately after posterior teeth extraction.
3- Preliminary Impressions:
The removal of the teeth should be 4 to 6 weeks prior to preliminary
impression.
Using a proper stock tray and alginate impression to make a study cast. Then a
special tray is constructed.
If the teeth are very mobile, the undercuts and interproximal areas should be
blocked out with soft wax and lightly coating the teeth with petrolatum, to avoid
extracting the teeth with the impression.
4- Final Impressions: either by:
a- Single Final Impression Procedure:
Alginate impression in a boarder molded, perforated acrylic special tray.
b- Two Stage Final Impression Procedure sectional Impression:
Used in case of deep anterior undercuts. The impression is first made for
the posterior edentulous using Zinc Oxide and eugenol in an acrylic resin
Immediate Dentures
Mostafa Fayad
tray confined to the posterior only extending only till the positive stop on
the lingual side of the anterior teeth.
Then another impression using alginate on a perforated stock tray is used
while the first impression is still in place, they are removed together as
one.
Campagna technique describes when posterior teeth have been extracted, a custom
tray is border molded with impression compound and a rubber base impression
material impression is taken of the anterior vestibule and edentulous area, reinserted,
and then captured in an alginate wash impression.
Light-bodied rubber is the material of choice for the final impression. In sever
mobile teeth alginate impression is the material of choice due to low tear strength
which allow easier removal of impression.
5- Jaw relation registration and posterior teeth try-in:
The final impression is boxed poured master Cast. Then well adopted occlusion
blocks are made and placed on it,
The lower teeth can help guide its occlusal plane height. The vertical stops can
preserve the vertical dimension. Also the centric occluding relation is recorded.
Teeth selection: is carried out in relation to the remaining teeth.
Arrangement of Posterior teeth: The posterior teeth are arranged on the
recording base. The teeth are set so as to provide multiple bilateral posterior
contacts in centric relation, with bilateral balanced occlusion.
The partial denture is tried in the patients mouth to ensure correct Centric
occluding relation.
Then one of two treatment plane is chosen
o 1
st
technique: The transitional partial denture is finished and
polished. The denture is delivered to the patient. The patient is
dismissed for a period of a few weeks to become accustomed to the
Immediate Dentures
Mostafa Fayad
new dentures, and then cast modifications and the immediate
additions of the remaining teeth are carried out.
One advantage of this method is that it prepares the patient for complete dentures by
first learning how to control the partial denture. Another advantage is the denture
provides posterior support reducing the possibility of the development of an habitual
posturing of the mandible.
o An alternative technique: is to make cast modification and an
immediate addition of the remaining teeth are carried out to trial
denture base and an immediate complete denture is inserted
immediately after anterior teeth extraction. No transitional partial
denture is delivered to the patient
6- Modification of the Master Cast:
Mark the upper and lower casts in pencil to produce
guide lines:
Draw a line around each tooth at the level of the
gingival margin
Draw a line on the long axis of the tooth
Measure the length of the teeth with dividers and scribe these lines on the
cast
Removal of the tooth can be described as shown in the diagram (flanged
denture not socket-fit):
The usual method of gingival trimming is as follows
Cut off the plaster level with the gingival margin.
Hollow out the root to a depth of 2-3 mm.
Trim and round off the gingival margins to the above level.
Immediate Dentures
Mostafa Fayad
The mast cast is modified by
Removing all the stone anterior teeth, The stone teeth are cut from the
model and replaced by artificial teeth. This is best achieved by removing
and replacing one tooth at a time '' so that the form of the arch and the
position of each individual tooth can be more easily copied if desired''.
Contouring the residual ridge depending on the treatment plan
previously made during examination.
The cast is made to give the same shape to the post surgical contour previously
planned and that in which it will be carried out in the surgical appointment.
If alveoloplasty is planned to be done with exaction of anterior teeth :
The master cast is modified by cutting off the teeth and trimming of the
labial alveolar portion to eliminate the undercut or the protruded area.
a clear acrylic resin template was made previously on a duplicate
modified cast to determine the amount of bone to be contoured During
surgery
If no alveoloplasty is planned to be done with exaction of anterior teeth :
With Socketted immediate denture: The anterior teeth are extended a
few millimeters into the labial aspect of the sockets.
With Flanged Immediate Denture: removing all the stone anterior
teeth with no extension into the socket.
Immediate Dentures
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Root sockets are prepared in the stone model into which the necks of artificial teeth are
fitted. So that when the complete denture is inserted in the mouth after the extraction
of the natural teeth, these necks just enter the natural socket.
The direction of the socket should follow the long axis of the tooth.
1- The socket depth never more than 5 mm.
2- Dont carry the socket too far towards the palatal side.
7- Surgical Procedure and Extraction of Anterior teeth:
o Extraction of anterior teeth with no surgery: All remaining teeth are
extracted as planned before the cast modifications.
o Exaction of anterior teeth with alveoloplasty: During surgery the amount
of bone to be contoured is determined and guided by a clear acrylic resin
template previously made.
8- Denture Construction:
The trial denture base is extended to the anterior region and the selected
artificial teeth are placed in position with wax, flasked , processed ,
deflasked , finished , polished and ready for insertion.
8- Denture Insertion:
The use of a pressure paste to identify any pressure points on the fitting surface
then they are eliminated.
The patient should wear it for 24 hours continuously it shouldnt be removed
as the tissue will swell if removed making it impossible to reseat.
9- Post-Insertion care:
Scheduled visits should be made: the following day, 48, and 72 hours later.
The Patient should be recalled every 3 months to evaluate and check the
dentures: fit, retention and stability.
Immediate Dentures
Mostafa Fayad
In most cases of CICD rebasing will be required within 10-14 months after
insertion.
If the treatment plan involves making the upper and lower dentures separately, then the
lower denture should always be made first. In this way the height of the lower anterior
teeth and their relationship to the upper anteriors can be optimized.
Ant er ior t eet h Sel ect ion:
The existing dentition is utilized in selecting a shade and mold of artificial teeth
, or the natural teeth are duplicated as the following:-
1- An alginate impression for the upper and lower teeth is made.
2- Molten wax is poured into the alginate impressions. The teeth wax pattern is
removed after cooling.
3- The wax patterns of the upper and lower teeth are flasked. The wax is
eliminated , and the artificial teeth are packed by the autopolymerizing acrylic
resin of the same color of natural teeth. And then the teeth are processed
4- The teeth are removed from the mold as a block of teeth. a saw or disk is used
to separate them at the incisal edge and buccal surface while keeping the them
in contact at the cingulum area, Teeth are polished. attached to the modified
master cast (instead of the readymade artificial teeth)
Relation of the artificial teeth to the soft tissues:-
(1) Gum fitted, this is the first preference for this type of
denture,
(2) Socketed. Only used when the teeth have been extracted
because of periodontal disease resulting in alveolar bone
loss.
(3) A fully flanged denture.
(4) A part flanged denture (called half flanged denture).
Whenever possible a flanged denture should always be constructed.
Immediate Dentures
Mostafa Fayad
It is less destructive to the soft tissues.
The retention is greatly improved compared with an open faced one.
The appearance is much more acceptable.
An open-faced denture should very rarely, if ever, be used in the lower arch.
If there are gross bony undercuts present then it may be impossible to
provide a flanged denture without surgical reduction of the bone, but the long
term effects of alveolectomy should always be considered before resorting to
surgery as noted earlier when referring to alveolotomy.
The problem areas are commonly in the upper anterior region, particularly with
patients whose incisors were proclined that is Class II Div.1. malocclusion, and in the
tuberosity region.
Open face design is only suitable when the teeth have pocket depths of less than 3
mm. When pocketing is greater than 3 mm., a flange should always be used.
the anterior teeth are set up, prior to finishing, according to the choices referred to
above having been decided they can be gum fitted, that is, .the necks of the teeth
contoured to the alveolar ridge without intrusion into the future sockets or socketed
when the necks of the teeth are inserted into a depression carved out from the model to
represent the sockets.
The former method, gum fitted, is preferred. If the teeth are socketed the long-term
consequence could be the production of a scalloped, that is, undulating ridge.
Immediat e compl et e dent ur e wit hout al veol opl ast y
Replacement of the natural teeth by artificial teeth:
When it is decided to place the anterior teeth in their original position, the
following steps should be done:
Upper and lower impressions, with the dentures in position, are made and
poured with dental stone.
Cast modification:
One stone tooth by one is removed and replaced by artificial tooth in
the same position; the position of each individual tooth can be more
easily copied.
Immediate Dentures
Mostafa Fayad
Root sockets are prepared in the stone models into which necks of the
artificial teeth are fitted.
o The labial root portion of the teeth is excavated to
approximately I mm on the labial side and flash with the
gingival margin on the lingual or palatal side. The depth of the
socket should never exceed 5 mm (socketted denture)
The denture is waxed-up and processed in the usual manner.
After tooth extraction, the denture is checked for any pressure area by
pressure indicating paste. Then the denture is lined by tissue conditioning
material and inserted into the patients mouth.
Advantages of root socketing
It allows for initial alveolar resorption (no unpleasant gap appears between the
neck of tooth and alveolar ridges)
It provide anterior seal which assists retention of denture.
Gives natural appearance of the denture and protrusion of lip is avoided.
Difficulties in estimating the correct amount of trimming of the cast is avoided.
Disadvantages
1- Absence of labial flange leads to decrease in retension and atability
2- Labial flange help healing and conservation of ridge.
3- Not suitable for mouth need bone trimming as superior protrusioin.
The lower denture
Dont make socketing the anterior teeth because the stability of the lower denture is
much less than the upper, and the movement of the denture during mastication cause
pain as the artificial roots move in the sockets.
Greater stability will be obtaine and the pain is reduced if the lower denture is made
with normal labial flange.
Immediate Dentures
Mostafa Fayad
The Clinical Techniques
The depths of the periodontal pockets are assessed and recorded
The clinical procedures involved in the construction of immediate dentures follow
very closely those used for the construction of partial dentures.
Primary impressions are taken for study casts and the construction of special trays.
Secondary impressions are taken in the special trays for an accurate recording of
the denture bearing areas and the production of the working casts on which the
dentures are made.
Record rims made on the working casts, are used to register the centric occlusion at
the correct occlusal vertical dimension.
A face-bow record is taken at this appointment.
The working casts are mounted on an articulator (preferably a semi-adjustable one)
with the face-bow recording and using the split cast technique.
The wax trial denture, set up as a partial denture, is tried in the mouth and the
occlusion, vertical relationship and tooth shade and mould checked.
A post-dam is cut on the cast and an ante-dam just behind the teeth to be replaced.
The articulated casts and wax trials are returned to the laboratory for conversion to
immediate dentures, in wax, before processing
The working casts should be duplicated before modification.
The Laboratory Techniques
The teeth on the casts are cut off one by one to the height of the gingival
margins then, according to the type of denture decided upon, the cast is trimmed and
the artificial teeth are ground to fit the labial aspect of the prepared sockets.
Ideally the trimming of the casts should be done by the clinician as he will be
aware of the state of the tissues, the extent of damage by periodontally involved teeth
for example.
When the artificial teeth have replaced all the plaster teeth, the denture base is
laid down in wax and the wax denture flasked, packed and finished in acrylic resin. If
the split cast technique is used before flasking, the occlusion can be balanced to
eradicate any errors, which may have arisen during the processing. Less time will be
required when balancing the occlusion at the fit stage in the surgery.
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Fitting the Dentures in the Surgery.
Clear instructions should be given to the patient. This can take the form of verbal
instructions or better still, in a written form.
The patient should be instructed that for the next 24 hours the dentures should only
be removed briefly in order to clean them after meals then re-inserted as quickly as
possible.
They should be worn at night for at least five days after the fitting.
An appointment should be given for the following day for the first review to
examine the sockets and make any necessary adjustments to the dentures.
A further review appointment should be made for examination after one week.
Immediat e compl et e dent ur e wit h al veol opl ast y
Indications:
A prominent pre-maxilla as in Angle Class II, division 1.
Patients who have a short and thin upper lip and a prominent labial alveolar ridge.
A very close bite anteriorly.
In order to provide better retention and stability of the denture.
Technique of construction :
1- Upper and lower alginate impression with the dentures in position are made and
poured with dental stone.
2- The incisors and canine teeth are cut from the model and the stone representing the
alveolar ridge is trimmed to the desired shape.
3- The trimmed cast is duplicated, and a transparent acrylic resin template of 2 mm
thickness is fabricated on the duplicate cast.
4- Setting-up of anterior teeth is carried-out. The denture is waxed-up with labial
flange in position (flanged denture). Then the denture is processed.
5- Mucoperiosteal flap is reflected and all the remaining teeth are extracted.
Immediate Dentures
Mostafa Fayad
6- The bone and the soft tissue are trimmed until the template is securely seated
against the palate or on the mandibular residual ridge without any spots of pressure.
Then the wound is sutured.
7- The dentures are then placed in the mouth and the patient is asked to close for the
first check of occlusion. Pressure indicating paste is used to check for pressure
area, which is removed if present. The denture is relined by tissue conditioning
material and delivered to the patient.
8- Sutures are removed after 7 days. The occlusal correction should be postponed for
as long as 2 weeks.
Immediat e dent ur e wit hout pr ior ext r act ion of t he post er ior
t eet h:
Indication
1- When the anterior teeth are causing pain or excessively loose.
2- If the patient wishes to shorten the number of visits for extraction.
Technique:
This method is not suitable for general practice and should only be employed if the
patient can be treated in a hospital or nursing home.
Alginate impression are taken for both jaws.
The models cast from this impression are mounted on an articulator by means of
interocclusal wax record.
Duplicates of these models are made for reference when setting the teeth.
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Mostafa Fayad
The stone teeth removed from the cast and replaced by acrylic teeth. This is best
achieved by removing and replacing one tooth at a time until the all teeth are replaced.
The denture is then processed and finished as usual. The denture is cooled sterilized
and inserted into the mouth immediately after extraction. The post operative case and
instruction is as mensioned before.
The compl et e immediat e over dent ur e:
Complete immediate overdenture were evaluated by Jonkman et al 1995, they found
no differences in comfort, chewing ability, aesthetics and general satisfaction between
patients wearing immediate complete dentures and patients wearing immediate
overdentures.
Del ayed immediat e dent ur e
This denture is inserted within few days after extraction of the teeth
Clinical and technical procedures:
All the posterior teeth should be removed 4 to 6 weeks prior to impression making.
Alginate impression is performed for both jaws, and stone cast are poured. Jaw
relatioship are recorded in the usual manners of partially edentulous cases and the
models are mounted on the articulator. The posterior teeth are set up and the waxed
partial dentures tried in the patient mouth. The trial denture are returned to the
articulator, the front stone teeth are cut from the models and the gingival margins are
rounded. The base plate is extended to cover the ridge anteriorly and the artificial
anterior teeth are set up. Now we have complete waxed dentures.
The anterior teeth are extracted and the alveolar plate are squeezed. The patient is
asked to bite on cotton rolls for few minutes to stop the oozing blood. The waxed up
complete dentures are tried in the patients mouth and necessary adjustements may be
done. Zinc oxide eugenol impressions are made after extraction using the waxed up
dentures as trays.
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Mostafa Fayad
The impressions are poured, flasking, packing, finishing and polishing are carried out
in the usual manner.
Advantages of this technique
1- It has better initial fit and adaptation as the impression is taken after extraction of the
teeth.
2- The waxed up complete denture is tried in the patient mouth .
3- It gives a longer period of satisfactory service comparing to the conventional
immediate denture.
Immediat e par t ial dent ur es
These dentures may be construct to replace missing anterior or posterior teeth. due to
the stability of the partial denture which has natural teeth to support it, the results are
very satisfactory.
Permanent immediate partial dentures.
In these types the try-in of the metal framework is difficult and if the framework fails
to seat at the time at the time of insertion the patient will be left edentulous until
reconstruction of the denture.
There are two techniques that will permit try-in of the metal framework before
completing the prosthesis. The first technique used wrought wire projection to act as
the retention minor connector for the acrylic denture base. During the framework try-
in these wire can be bent backward so it will not interfere with the teeth that will be
extracted. After the try-in the wires may be adjusted to the cast for positioning of the
artificial teeth and waxing the denture base.
In the second technique the master cast is relieved, blocked out and duplicated in
refractory material. The teeth are to be extracted and replaced by the partial denture
are cut from both the duplicate refractory cast and the master cast. In the refractory
cast the framework is waxed with separate acrylic resin retention areas, then invested
and casted (Fig. 13-8). The framework is now tried in and fitted to the abutment teeth.
Immediate Dentures
Mostafa Fayad
The framework is then placed on the master cast and the acrylic resin retention minor
connectors placed in position and soldered to the framework (Fig.13-9). Space must be
provided between the minor connectors and the cast for the acrylic resin denture base.
Denture teeth are set and denture base is waxed to proper contour (Fig 13-10).
In both technique relining the denture base will be required as healing and resorption
of the edentulous areas take place.
Metal framework with separate acrylic resin retention minor connector.
Teeth to be extracted and replaced are cut from the cast and acrylic resin retention is
soldered to framework.
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Temporary immediate partial dentures
This type is constructed from acrylic resin and can be used successfully for a long time
to allow for complete healing before construction of the definitive prosthesis. It has the
advantage that changes in the denture base or teeth can be made easily. Impression
mounting the casts, and replacement of the teeth are the same as the definitive one but
the denture are constructed from acrylic resin.
relining of denture base will be necessary during the healing period.
Post oper at ive inst r uct ions
Clear and specific instructions be given to the patient
Advise patient not to remove the dentures to ensure minimal disturbance of blood
clot.
No vigorous mouth washing
Reduce possibility of post-extraction hemorrhage to avoid undue exercise, alcohol,
hot food and drink
Analgesic tablets given to reduce postoperative pain
Appointment should be arranged for next day.
Immediate Dentures
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Dietary advice:
Included upon the written instructions are instructions and advice about the diets that
they may expect to be able to manage with their immediate dentures.
It should be expected within the first 24 hours that they can manage only semi-
fluid foods.
Within the first week the patient should be encouraged to extend the range of
goods eaten, gradually eating harder foods.
After the first month, patient may eat a normal diet.
First 24 Hours:
Wear the immediate dentures continuously day and night and not to remove them.
Hot drinks avoided
Analgesic should be given
Dietary advice
Examination after 24Hrs
Surgical area irrigated with warm saline
Removal of denture with no alveoloplasty there should be firm healthy clots in the
sockets with no sign of continuing hemorrhage. Any oozing from sockets indicates
delayed clot formation due to trauma from denture or systemic causes
If alveoloplasty has been performed, sutured mucosal margins should be in close
contact. Rebasing is necessary if changes in shape of the ridge are greater then
planned on the cast.
Assess areas of inflammation, adjustment of fitting surface prevents progression to
ulceration.
Must inform patient to use immediate dentures for mastication; moderate
mastication increases blood supply and assists rapid healing.
Saline solution causes dehydration and shrinkage of the blood clot.
If surgical area is clean and adjustments are minimal, patient neednt be seen for
another 7 days. If friable blood clot or there is considerable denture adjustments
necessary, it is advisable to see patient 3 days after surgery
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Mostafa Fayad
One week:
Any sutures are removed
occlusion checked and corrected if necessary
continue wearing continuously and to remove the denture three times a day as he
did during the first week to clean it and carry out a similar routine of oral hygiene.
If healing uneventful, next visit may be a month after extraction
If there are changes to the alveolar ridge, possible requirement to rebase; patient
must understand the need for regular servicing of dentures.
One month:
- oral tissues examined
- occlusal imperfections and tissue damage should be noted
- advise patient to leave the dentures out at night
- chemically cleaning may be advisable
Three months:
- resorption of the alveolar bone should have occurred and the tissues should of
healed completely.
- Relining of the denture may be required.
Airway sleep disorders
Mostafa Fayad
Removable prostheses for airway sleeping disorders
Introduction:
Upper airway sleep disorders (UASD) are becoming commonly recognized by the
medical and dental communities, and patients are now being referred to dentists for
treatment of these conditions using removable oral devices.
Snoring is the mild form of these disorders, obstructive sleep apnea (OSA) is the
severe form, and upper airway resistance syndrome (UARS) falls some where
between the two.
Anatomy:
In the normal anatomy, the upper airway is a soft tissue tube,
maintained by muscle activity extending from the oral and nasal cavities to
the bronchial tubes.
The activity and timing of the tensor veli, elevator veli palatine,
genioglossus, and geniohyoid muscles maintain the position of the soft
palate, uvula, tongue, and hyoid bone in a position away fromthe posterior
wall of the pharynx.
The airway patent of snoring patients is partially obstructed. This
obstruction is very often caused by the tongue and /or hyoid bone and
overlying soft tissues dropping back toward the posterior wall of the pharynx. In attempting to
get sufficient oxygen to the lungs, there is an increase in velocity of air passing through the
reduced airway space. This increase in velocity may cause flabby tissue, often the soft palate and
/or uvula, to vibrate. This vibration is the sound of snoring.
Treatment Options
Once diagnosed with a UASD, the physician has five basic treatment options:
behavioral modification,
surgery,
continuous positive air pressure (CPAP),
oral devices,
Medication.
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upper airway muscle tone: mild OSA avoid alcohol and sedatives
upper airway lumen size:
o Mild to moderate OSA weight reduction, avoid supine position and
use oral prosthesis to keep airway patent
o Severe OSA: Uvulopalatopharyngoplasty
upper airway subathmospheric pressure:
o 1.mild to moderate OSA improve nasal patency;
o 2.severe OSA nasal CPAP
Bypass occlusion: severe OSA - tracheotomy
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Oral Devices
Types:
Oral devices are of two basic configurations,
Mandibular advancement device (MAD).
Tongue retaining device (TRD)
The TRD is laboratory fabricated; MADs may be stock devices or laboratory fabricated.
Mode of action:
Oral devices generally work by directly or indirectly preventing the tongue form
approaching the posterior wall of the pharynx.
The TRDs work through the use of a hollow bulb and sufficient vacuum to hold the
tongue forward.
The MADs work indirectly by holding the mandible and hence the tongue forward. These
devices also aid in preventing the hyoid bone form dropping posteriorly and its overlying
tissues from impinging on the upper airway.
All dental devices are obviously intraoral and therefore require a certain amount of space and
movement of the mandible or tongue.
Tongue size and the amount of space between the soft plate and tongue are objective evaluations
that may help identify a compromised upper airway or be useful in determining the type of
device most suitable for a patient.
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A] Mandibular advancement devices
MADs are either adjustable or single position devices.
Single-position MADs depend upon the clinician properly determining the desired protrusive
position that will eliminate the snoring and/or OSA.
Single-Position Stock Devices [single-piece single-position stock device].
These devices are generally fabricated from two rigid-plastic sheets in the shape
of impression trays joined into a single unit.
The trays fit over both the maxillary and mandibular teeth
simultaneously and receive retention from a thermoplastic
fill material.
The mandibular side of the device has a vertical arm
extending lingually below the plane of occlusion and behind the mandibular
anterior teeth.
Retention is not required on the mandibular arch because the lingual surfaces of
the mandibular anterior teeth are in direct contact with this lingual projection.
This flange will prevent the mandibular arch form moving posterior during sleep.
An interocclusal record is often made at approximately 70% to 75% of the
maximum protrusive movement.
A tongue blade is placed between the maxillary and mandibular incisors
with the patient in the normal retruded occlusal position.
A small mark is made on both the top and bottom of the tongue blade in
the midline and against the maxillary and mandibular incisors. The patient
is than asked to thrust the mandible as far forward as possible in a
protrusive movement with minimal lateral deviation, and a second mark is
made.
The distance between the two marks, multiplied by 0.7 is approximately
70% of the patients maximum protrusive movement.
An interocclusal record is made at this point. The tongue blade is also used
to determine the maximum vertical opening of the mandible.
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Adjustable Stock MADs
These devices are generally shaped like plastic impression
trays. The trays are filled with thermoplastic material for fitting
to the patient with some mechanism for adjusting the mandible
in a protrusive and retrusive direction. e.g Stock two piece
adjustable device with a screw mechanism.
A screw mechanism for positioning the mandible is commonly used. A potential

disadvantage of this device is that the patient must be very careful when adjusting the
screws.
The two-piece adjustable devices do not require as much interocclusal space as one piece
devices. The thermoplastic material allows multiple adjustments as necessary, and the
adjustability allows the mandible to be protruded the minimum distance necessary to
achieve satisfactory results.
Adjusting the screw mechanism either moves the mandible in an anterior direction and
indirectly moves the tongue away form the posterior wall of the pharynx or the mandible
is allowed to drop more posteriorly, reducing stresses on the TMJ .
The interocclusal records are made at approximately 50% of maximum protrusion and
with at least 5 mm of clearance between the anterior teeth.
If the device reduces snoring to an acceptable level or eliminates it following insertion and no
TMJ or tooth discomfort is reported, adjustment is not necessary and the device can be worn
withthe mandible in its initial position. However, if the snoring level is not acceptable, then the
mandible is slowly protruded 0.25 mm per night for no longer than 2 weeks, at which time the
patient is re-evaluated. This protrusion is resumed and continued until the desired snoring results
are achieved or TMJ discomfort begins.
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Tongue Retaining Device (TRD)
The TRD (e,g. Flexible tongue retaining device) is an
excellent device for edentulous patients or those who suffer
form TMJ sensitivity.
This is aone-piece device made of a non rigid vinyl material
without thermoplastic material to adapt to the teeth.
The effectiveness of these devices depends upon holding the tongue forward in a hollow
bulb away from the posterior wall of the pharynx.
Fabrication of this device requires a kit containing two hollow bulb templates. The
templates are basically hollow bulb devices on top of the tray of the device.
The templates is used to select the proper bulb size necessary to create a vacuum to
hold thetongue, to position the bulb to achieve the desired tongue protrusion, and as
tray to hold interocclusal recording material.
Once the proper bulb size is selected and the tongue is well retained in the hollow
bulb by the vacuum, the patient is asked to protrude the tongue the maximum
comfortable distance possible, and the incisors are closed onto the anterior part of the
template.
Air is squeezed out other bulb to achieve the vacuum, necessary to retain the tongue
in the hollow bulb.
Poly vinyl silaxance bite-recording material is placed on the sides of the template.
The template with recording material and diagnostic casts is used to fabricate the
actual TRD for the patient.
Patient instructions:
When initially inserting the device, the patient should be instructed to place the
device over both arches and push the tongue into the hollow bulb.
The patient is instructed to create a vacuum in the oral cavity, the bulb is squeezed
until as much air as possible is removed from the bulb and a significant vacuum is
created, especially around the tongue.
The patient is should be instructed to relax the lips and relapse the vacuum around
the maxillary and mandibular arches. The tongue must be well retained within the
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hollow bulb by the vacuum at this point and should be difficult to pull the device
off the tongue.
The patient is instructed to protrude the tongue into the hollow bulb and the
vacuum should hold it there for several hours per night a minimum of 6 hours of
sleep with the device inserted should bethe goal for the patient.
Total and Partial Glossectomy
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Prosthodontic Rehabilitation Following Total and Partial
Glossectomy
Tongue defects due to tumor removal can result in either total or partial glossectomy.
Effect of glossectomy:
a) Total glossectomy
When near total glossectomy is performed, the normal functions of speech
and swallowing are disrupted.
Role of tongue in speech production
The tongue shapes the oral and pharyngeal cavities for vowel
production. It restricts air flow in the oral cavity to produce
consonants linguovelar, linguopalatal K, linguoalveolar g,
linguodental T D and S Z.
The tongue is the major articulator during the production of all
phonemes, with the exception of the bilabial and labiodental sounds.
Compromise of the tongue secondary to surgical resection, resulting
in altered volume, limitedand restricted movement of the tongue.
Tongue segments, or flaps, can have an adverse affect upon the
quality of speech.
Limitation of surgical management
With the development of mycocutaneous flaps and free flaps, there
has been an increased frequency of surgical attempts to rehabilitate
the total glossectomy patient.
The major problems with these flaps are bulk, lack of voluntary
control with limited or no sensation.
When these flaps are used, consideration should be given to limiting bulk,
allowing room for future prosthodontic rehabilitation in the mandibular arch.
An awareness and use of the palatal speech and swallowing prosthesis should
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be stressed to the surgeons to assure them that excessive bulk may actually
hinder future rehabilitation.
b) partial glossectomy
In patients with partial glossectomy defect the status of the remaining
tongue is the most important prosthodontic prognostic indicator.
The motor and/or sensory control of the tongue has been
significantly compromised by the resection; the prosthetic prognosis
becomes extremely guarded.
The mobility and bulk of the tongue is also important. In stabilizing
the mandibular denture during function. Small amount of residual
tongue can move a large bulk of free flap if motor innervations are
intact.
The determination of whether a speech or deglutition aid prosthesis
should be placed in the maxillary or mandibular arch has been based on :
Volumeand mobility of residual tongue or reconstructed flaps.
presence and condition of teeth to help stabilize the prosthesis,
mandibular range of motion,
lip and cheek mobility,
tongue sensation and position,
commissure width.
Prosthodontic Treatment of Total Glossectomy
In total glossectomy, the mandibular tongue prosthesis is the treatment of
choice.
However, in a situation involving an edentulous patient and an irradiated, resorbed
mandibular ridge or a patient with a very mutilated dentition, palatal augmentation
prosthesis should be considered.
The major goals in prosthodontic rehabilitation of the total glossectomy
patient without surgical reconstruction are to:
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Reduce the size of the oral cavity, which improves resonance.
Direct the food bolus into the oropharynx with the aid of a trough.
Protect the underlying fragile mucosa if skin flaps were not used.
Develop surface contact with the surrounding structures during
speech and swallowing.
Improve appearance and psychosocial adjustment.
Mandibular Tongue Prosthesis:
One objective for the prosthetic tongue is to increase the speakers
potential for shaping the voice tract to achieve closer to normal resonance.
The dome-shaped tongue prosthesis fills the palatal vault, anterior-to-posterior and
laterally, as much as the normal tongue when the mandible and teeth are closed.
It has been suggested that three prosthetic tongues be made: one for
speech one for swallowing, and one for both speech and swallowing.
a) The prosthetic tongue for speech
1- It should have
An anterior elevation to facilitate
articulation of the anterior
linguoalveolar sounds t and d.
It should also have a posterior

elevation to aid in the articulation of
the posterior linguopalatal sounds g and k. Both elevations
help to shape the oral cavity, thus improving vowel
production in general.
2- Retention: When the mandibular arch is partially edentulous, the
tongue prosthesis is incorporated into a removable partial
denture. The retentive meshwork of the framework is extended
into the defect to include a major portion of the floor of the
mouth and to provide support for the impression material.
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3- Construction: To construct the prosthetic tongue for speech,
gray stick compound elevations, is luted to the anterior
portion of the framework and the patient is asked to
occlude the teeth.
Compound is then added o the posterior portion of the
framework and the patient is asked again to occlude the
teeth.
Contact with the palate should be evident in both areas of
compound. Both anterior and posterior elevations are
reduced 2 to 3 mm and a layer of Iowa wax is flowed onto
the surface.
The patient is asked to repeat t, d, k, g, and attempt
swallowing.
b) The prosthetic tongue for swallowing
It is waxed in the form of a sloping trough like
base in the posterior aspect to help guide the
food bolus into the oropharynx.
Both types of tongue prosthesis may be fabricated as interchangeable speech and
swallowing prostheses attached via the retentive button on the base portion of the
prosthesis.
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c) The mandibular tongue prosthesis which include both
features of swallowing and speech
In some instances, the mandibular tongue prosthesis
can be constructed to include both features of
swallowing and speech in a highly motivated patient.
Construction: The framework with the processed acrylic resin base
that contains the oral mushroom projection is used for this
purpose.
A heavy mix of Coe-Comfort tissue-conditioning material is
added to the base and the patient is asked to move the mandible
while pronouncing t, d, k, g as the material sets.
A trough like groove is created in the posterior middle aspect of
the traced tongue, with the aid of a speech pathologist.
The Coe-Comfort tracing is duplicated in silicone with
appropriate intrinsic coloration and attached mechanically on the
mushroom like projection of the acrylic-resin base.
speech can be improved by adding a flexible tongue of silicone rubber to the
mandibular prosthesis.
The body of the tongue prosthesis is held in place by developing a snap-ring and undercut
design in the mandibular denture base at the level of the occlusal table.
The tip of the tongue is flexible and elevated 2 to 3 mm above the denture base.
This position permits a positive contact with the palate during the formation of
linguoalveolar sounds and when the mandible approaches the closest speaking space.
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Prosthetic Treatment of Partial Glossectomy
Indication:
Prosthodontic treatment for partial glossectomy is necessary when
the patient experiences difficulty in speaking and/or managing a
food bolus.
In cases where a patient has had a parital glossectomy and a partial
mandibulectomy; there is a greater need for glossectomy prosthesis.
Types: Either the palatal augmentation prosthesis or mandibular
augmentation prosthesis may be fabricated.
The function of the augmentation prosthesis is to fill the volume
deficiency between the remaining tongue and the mandible and the palate.
The choice between mandibular or palatal augmentation prosthesis depends
upon
the availability of abutment teeth,
the extent and site of the tongue deficiency,
Patient acceptance.
Mandibular Augmentation Prosthesis
Construction:
A conventional or interim mandibular removable denture is constructed
following the conventional prosthetic technique .
a thick mix of Coe-Comfort tissue-conditioning material is added to the
lingual flange in the area of the tongue deficiency.
The prosthesis with the Coe-Comfort is inserted into the patients mouth,
and the patient is instructed to swallow, open and close, and pronounce
certain phonemes depending on the site of the resection.
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o Anterior resection situations require the use of consonant sounds
such as t and d,
o while posterior defects require glottal stop execution such as k and g
sounds,
the augmented part of the prosthesis is processed with autopolymerized
acrylic resin.
for an edentulous patient, the mandibular final impression is made utilizing the neutral
zone technique and the denture is processed accordingly.
Edentulous patient with partial resection of left
tongue.
Mandibular augmentation prosthesis
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Palatal Augmentation Prosthesis
The palatal augmentation prosthesis (PAP) has been defined as A palatal
prosthesis that allows reshaping of the hard palate to improve tongue/palate
contact during speech and swallowing because of impaired tongue mobility
as a result of surgery, trauma, or neurological/motor deficits.
When using the palatal augmentation prosthesis, the
palatal vault is re-established at a lower level than
normal, requiring less bulk and mobility of the tongue
for appropriate palatolingual contacts during speech
and swallowing.
The purpose of this prosthesis is the restoration of

deglutition, and speech potential in patients with
reduced tongue volume and movement
.
Defining the contour of the palatal vault requires a compromise between

the needs for speech and swallowing, because the location and degree of
linguopalatal contact differ between these two processes.
If the palatal vault is lowered sufficiently to permit optimal tongue

movement for swallowing, speech is adversely affected.
If the palatal vault is shaped to optimize speech, tongue movement

during swallowing may be restricted.
To alleviate the problem, the alternation between two magnetically retained

palatal vaults providing optimal linguopalatal contact for either speech or
swallowing was recommended.
Construction:
In dentate or partially dentate patients, a maxillary framework is
designed following conventional prosthodontic techniques with an
added mid palatal meshwork to retain the augmentation portion of the
prosthesis.
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Functional molding of the augmentation portion of the prosthesis is
done during attempts at speech production, and a swallowing.
In the edentulous patient, conventional maxillary and mandibular complete
dentures are fabricated and used for a brief time (usually 2 weeks) before the
maxillary denture is augmented to compensate for the tongue deficiency.
A thick mix of tissue-conditioning material is added to the palatal
portion of the maxillary denture.
While the material is still moldable, the patient is instructed to
swallow and to pronounce certain phonemes, depending upon the
location of the deficiency.
A plaster matrix is fabricated and the tissue-conditioning material is
replaced with autopolymerized acrylic resin.
The palatal augmentation should be made hollow to reduce its
weight
Extraoral Maxillofacial Prosthesis
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"It is the God given right of every human being to appear human". Ernest L. DaBreo
Introduction
Maxillofacial prosthetics is a branch of dentistry that deals with congenital and
acquired defects of the head and neck.
Maxillofacial prosthetics integrates parts of multiple disciplines including head
and neck oncology, plastic surgery, speech, and other related disciplines.
Method of restoration
Restoration of facial defects can be accomplished either surgically, prosthetically,
or by using a combination of both methods.
The choice of method depends on many factors such as size and location of the
defect, age of patient, mobile tissue (eyelid ,lip),
prosthetic approach has the following three main advantage
It requires little or no surgery.
The patient spends less time away from home and job.
The reconstruction often has a more natural appearance
The prosthetic approach is superior to the surgical approach if the defect is large
or the blood supply to the area is compromised
Superior color match and patient acceptance, especially in nasal or auricular
prostheses, make prosthetic rehabilitation superior to the surgical approach.
Drawbacks of prosthetic approach include
The necessity of fastening the appliance to the skin daily.
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Removing the appliance daily.
The occasional need of constructing a new prosthesis.
Objectives of Maxillofacial Rehabilitation
1. Restoration of esthetics or cosmetic appearance of the patient.
2. Restoration of function.
3. Protection of tissues.
4. Therapeutic or healing effect.
5. Psychological therapy.
STANDARDS FOR FACIAL RESTORATIONS
NATURAL APPEARANCE
Correct form and size
Material must simulates normal healthy tissues with respect to : texture,
translucency, weight, and color
The molding material should have approximately the same flexibility as human
tissue in order to blend the margins of the prosthesis to adjacent tissues.
Prosthetic material should be sufficiently translucent to simulate skin effectively.
The color of the prosthesis must appear similar to the surrounding tissue.
RETENTION
Natural appearance also depends on holding the completed prosthesis in its proper
relation to the head
Retention of the extraoral prosthesis is limited to the resistance of gravitational
forces and the weight of the prosthesis . see retention of maxillofacial prosthesis
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COMFORT
The wearer of the prosthesis must be able to depend on comfortable attachment of
the prosthesis to the tissues for extended period of time.
The fitting surface must be formed to fit closely to the tissues and to be free of any
rough areas that can cause irritation .
DURABILITY
The durability of a facial prosthesis is primarily dependent upon both prosthetic and
human factors
selection of proper materials and fabrication techniques
mental attitude of the wearer
All users of prostheses must be properly trained and instructed in the wearing and
care of the prosthesis at the time it is being fitted and delivered.
Disease in an area previously afflicted may recur causing tissue changes and
requiring the rebuilding of the prosthesis .
Evaluation and Treatment Planning
Preoperative evaluation of the patient, as with any head and neck cancer patient
provides for optimal preparation of the patient and planning of the treatment.
A good oral hygiene protocol is mandatory for dentulous patients. Preservation
and restoration of such teeth may provide a much better fitting prosthesis. In case
of combined cases
Effective communication between the surgeon and the maxilloacial prosthodontist
is essential for developing a realistic treatment plan or rehabilitation of patients
undergoing resection .
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The team concept, in which the head and neck surgeon, speech pathologist,
radiating oncologist, maxillofacial prosthodontist, and other members of the health
profession function together in planning the rehabilitation and primary modes of
therapy, ensures the patient's early and successful rehabilitation.
Prognosis:
Patients should be informed of the many variables that influence the course of
treatment and treatment outcome.
Care should be taken in preparing the patient for a realistic treatment result,
emphasizing the limitations of prosthetic treatment in simulating the natural
missing structures
Patient assessment
Case history
Optical &dental checks
Clinical assessment
1. The size and extent of the planned prosthesis
2. The optimum position of leading margins
3. Identification of mobile and supporting soft tissue
4. Sensitive or tender areas
5. Area of hypertrophic scarring
6. Needed preprosthetic surgery (thinning or releasing), reshaping, or removal
of redundant tissues
7. X ray
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Facial Pr ost het ic Mat er ial
The materials used in the different phases of the fabrication of the maxillofacial
prosthesis are : impression materials, modeling materials and fabricating materials .
I- Impression materials
the manner of setting non - elastic materials elastic material
Set by chemical reaction
irreversible
Set by temperature change
Plaster of paris
Zzinc oxide - eugenol and
similar pasts
Peripheral seal materials
Impression compound
composition
Impression wax
Gutta percha
Irreversible hydrocolloid
alginate
Elastomers:
Reversible hydrocolloid Agar
The chemistry, manipulation, properties and applications of each material is discribed in
details in the text books of dental materials. The clinical techniques will be described
later in chapter two and in other chapters according to the type of prosthesis.
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II- Modeling materials
The modeling materials should have the following intrinsic properties.
1- They should be malleable to facilitate contouring and adjustments.
2- have sufficient body and strength to permit sculping and withstand slight abuse.
3- It should be possible to sculpt texture into this material which will be imparted
to the finished mold.
4- The closer the color of the material in to skin tone.
5- It should be inexpensive and available.
The Commonly Used Modeling Materials Are:
1- Modeling Clay (Sculptors Clay)
A water-base clay which, when allowed to dry, becomes a hard stone-like substance.
Advantages
1- Consistency can be adjusted by adding water.
2- Lends itself to gross sculpting of sweeping planes.
3- Takes texture well.
4- Can be feathered on the edge.
5- Readily available.
6- Inexpensive.
Disadvantages
1- Must be kept moist at al times. If allowed to dry it tends to crack and flake.
2- If the modeling must be set aside for any length of time the cloth utilized to keep it
moist tends to wipe out the finer texture which has been incorporated into the
model.
3- It is gray in color, and the color differential causes visual distortion.
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2- Plaster
Advantages
2- Easily and quickly prepared for
use.
3- Can be shaped or molded in its
plastic state.
4- Inexpensive.
Disadvantages
1- Lacks elasticity.
2- Cannot be used in undercuts .
3- Relatively short setting time.
4- Has a tendency to flake on the
surface.
5- Adding materials to build contour
is difficult.
3- Plastolene
A prepared modeling clay with oil base or fullers earth with oil base
Advantages
1- Always ready for use.
2- Requires comparatively little care.
3- Easily malleable.
4- Takes texture well
5- Withstands slight abuse well.
6- Can take and keep a feather edge.
Disadvantages
1- Color does not match skin tone .
2- Oil base could seep into stone model and affect the finished product..
3- More expensive than sculptors clay.
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4- Waxes
Advantages
1- Color is similar to skin tone .
3- Takes texture well.
4- Easy to smooth .
5- Withstand abuse.
6- Takes and keeps a feather edge.
Disadvantages
1- Model must be carved rather than sculpted.
2- Oil base could seep into stone model and affect the finished product.
3- Brittle when cool.
The choice of modeling material should depend upon knowledge and experience with the
materials. The patient should be present during the modeling phase. Any discrepancies in
the model can then be picked up and corrected before making the final molds.
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III Materials used in fabrications of
maxillofacial prosthesis
The materials used for fabrication of maxillofacial prosthesis should have specific
physical and chemical requirements depending upon the anatomic location and the main
purpose for which the device is designed. Thus the requirements of a material for an
intraoral prosthesis are quite different from those for an extraoral prosthesis.
The basic requirements of material for intraoral prosthesis:
1- Tissue Tolerance
It must have a smooth surface, be non-irritating and compatible with oral tissue.
2- Strength and Durability
The material must be sufficiently strong and rigid to withstand forces of
mastication and to resist distortion over a period of time.
3- Proper Thermal Conductivity
The thermal conductivity of the material should not be too high or too law.
4- Nonsorption
The material must resist sorption of moisture present within the oral cavity, such
as saliva, water, and fluid food.
5- Cleansability : The material must be readily cleaned and hygienic
6- Integration with other materials without injury to either component.
7- Ease of casting, molding or processing.
8- The material should has a cosmetic appearance.
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The basic requirements of extraoral prosthetic material:
1- Tissue Compatibility
The material should not irritate or injure the tissue upon which it is rest.
2- Flexibility
The material must be soft and pliable like flesh and skin to simulate the feel of
facial tissues.
3- Translucence
The material must be translucent, that is, its light -transmitting quality must be
similar to that of the skin. Translucence of a material offer greater significance in
those case in which the lifelike coloring can be attained best by coloring the
material intrinsically rather that extrinsically.
4- Lightness
The material must be light in weight so that little difficulty will be encountered for
keeping the prosthesis properly and securely in place.
5- Durability
The material must not be affected physically or chemically by the tissues in
contact with it, or by the adhesive used for its retention
6- Thermal Conductivity
The material must be a poor conductor of heat to avoid irritation of the tissues
when rapid and considerable change in temperature occurs.
7. Color stability
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8. Ease of Processing
The material must be readily amenable to molding or casting by techniques
employed in a dental or similary equipped laboratory.
Actually most extraoral prosthesis prepared by the maxillofacial prosthetist
usually require the use of special apparatus.
9. Ease of Duplication
The material must lend itself readily to duplication by use of either the original
permanent mold or a master model so that in case of loss, discoloration, or general
deterioration of the prosthesis a new duplicate can be made with minimal effort
and expenses.
10. Availability
The material should be available in the market and inexpensive.
11. Hygienic
It should be easily cleaned without damage or deterioration.
The materials used in maxillofacial prosthetics may be rigid materials and / or
flexible materials.
12. Minimal conductivity
13. Edge strength
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The materials formerly and currently used for construction of
extraoral prostheses
Rigid Materials
Generally rigid materials are more useful in the fabrication of intraoral prostheses
except in certain areas of denture prostheses coming in contact with sensitive
intraoral areas, or areas with undercuts.
Flexible Materials
Flexible materials is considered the material of choice for facial prosthetic
restorations except for some workers who prefer a rigid material for facial and
certain other extraoral prostheses.
The advantages of flexible materials over rigid materials for facial prostheses are:
1- Its natural feel when in contact with tissues, ease of fit and adaptability to the
irregularities and undercuts at the site of deformity.
2- Ability of the edges of the prosthesis to respond in some degree to the movements
of adjacent parts of the face.
3- Ease of its removal after casting from a rigid mold, which allows keeping the mold
intact for future use.
4- Its adaptability for producing hollow and lightweight prostheses by the so-called
slush molding technique.
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Classification of materials used for construction of extraoral
prosthses
This classification includes those not in use today only because of the historic interest,
and occasional usefulness of them today.
Rigid materials Flexible materials
Materials of limited interest
1-wood & Ivory.
2-Metals.
a-Copper, Silver, or Gold and their
alloys.
b-Aluminum.
3- Vulcanite.
4-Cellulose plastics.
a-Cellulose nitrate.
b-Cellulose acetate.
Materials of major Interest
Acrylic plastics.
1-Gelatin-glycerin mixtures.
2-Latex and its derivates (Rubber).
a-Heat curing variety.
b-Room temperature curing
variety
(prevulcanized liquid latex).
Materials of major Interest
1-Plasticized plastics.
2-Slicone rubbers.
a-Heat curing variety.
b-Room-temperature -curing
variety.
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Wood and Ivory
These materials have excellent tissue compatibility but the law thermal
conductivity and poor pliability, translucence, cleansability and molding ability
make them not use today.
Metal or Metallic Alloys
Prostheses made from metal or their alloys are very durable and light in weight as
they can made hollow. These types of prostheses are difficult to fabricate by
casting swedging or electrodeposition and the results are not lifelike owing to
their opecity.
The advantages of these prostheses are that they can be soldered or locked to some
other prosthesis in the maxillofacial region to aid retention. Also the strength and
the smooth surface of metal make it a material of choice for certain intraoral
maxillofacial prostheses
Vulcanite
In the late 19
th
century, certain workers began using vulcanite for constructing
facial restorations. The surface of this material was painted in order to match the
color of the skin.
It is a rigid material which was used extensively in making a full denture and in
prosthetic reconstruction of the face before the introduction of translucent rigid
plastics. Its ease of molding compatibility with the tissue and comparative strength
and lightness are some of the characteristics that made it suitable for facial
prosthesis in early days. Its lack of translucence is its chief objectionable feature.
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Cellulose Plastics
cellulose nitrate or cellulose acetate (celluloid. Are earlier plastics that can be
molded between dies and counterdies to produce a very light weight prosthesis.
Hand painting must be done to give the prosthesis a realistic appearance.
Gelatin, glycerin mixture
The esthetic results of this material is good, it is simulating the pliability, texture,
and translucence of the skin. The prosthesis made from this material last only a
week at most. So it could be used in an emergency for fabrication of temporary
prosthesis.
Rubber
Conventional rubber produced by compounding the latex with sulfer and
valcanizing it under heat and pressure. This process needs heavy and expensive
equipment not available in an ordinary dental laboratory. So its never have wide
application in maxillofacial prosthetics.
Prevulcanized Latex
This type of liquid rubber can be poured into a plaster mold and that, upon drying,
is converted into tough rubber. The use of this type of latex elemenate the need of
expensive metal dies for molding and hence this material has proved very useful in
facial prosthetics.
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Materials of Major Importance
A- Acrylic Plastics
Methyl Methacrylate :
Either heat or self (poly) methyl methacrylate ,which used
for denture bases, may be used for certain types of
extraoral prostheses, especially when strength and
durability are desired. Repairs of or additions to the acrylic
prostheses are not difficult.
Palamed :
Palamed is a cross-linked copolymer of methacrylics and acrylics. It consist of a
powder and liquid which, when combined form a doughlike material. This
material is packed into a closed mold and cured in a hot water bath. When
processed, the prosthesis has a spongelike center and a continuous skinlike
covering. The molds should be underfilled (by 10%) to permit expansion of the
material and formation of the spongelike center.
The thicker section of the prosthesis are quite elastic, but the thinner one will be
more plastic, since the center portion of the thinner sections is less foamlike.
Removal of the prosthesis from the mold after processing is a delicate procedure
which can be facilitated by dipping it into warm water (45 C for 10 minutes)
thereby softening the prosthesis.
B- Plasticized plastics
These plastics owe their resilient character to the presence of a plasticizing agent
in the resin. Pigments may be add to obtain the suitable color. These materials are
usually set by heating. These materials gives better pliability, tranlucence, color
and flexibility that are so desirable for facial prosthesis.
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Plasticized vinyl plastics are the most commonly used materials in facial
prosthetics. These materials are
Vinyl Chloride (polyvinyl chloride - PVC),
It is copolymer of Vinyl Chloride and Vinyl Acetate (the
monomer of these two materials are mixed in proper
proportion and polymerized ) this material has excellent
molding characteristics.
The main disadvantage of the plasticized plastics is that they become hard by
migration of the plasticizing agent out of the plastic.
PVC hazardous to health and the environment. They argue that PVC plants emit
toxic pollution during its production and that products made of PVC emit toxic
compounds during their usage and in disposal. This is due to toxic chemicals
added to it in production.
e.g. Realastic and Mediplas..
Realastic
It is a polyvinyl chloride compound (PVC) which solidifies into a flexible material
when heated. Tinting can be accomplished both internally and externally,
Ultraviolet light causes a combining of organic chains and subsequent yellowing
and hardening of the material. The manufacturer has recommended a cream
conditioner, to be applied nightly to the prosthesis, which seems to prolong its life.
However, use of this cream on the margins will affect the retention because the
adhesive will not adhere to the prosthesis.
Because of the short life of this material, metal molds are suggested so that
additional prostheses can be made from the original model. The main disadvantage
is the additional time required to make metal molds.
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Mediplas
Mediplas is a heat-curing plastisol that is basically a polyvinyl organic compound.
It can be cured within a stone mold, but the use of metal molds is recommended
which facilitate the many remkes necessitated by the short life of this material.
About 10 minutes at 140 C is required for curing this material in an open plaster or
metal mold. When closed plaster molds in standard dental flasks are used, the
curing time is about 2.5 hours.
Overheating should be avoided during curing because this material has a tendency
to darken when exposed to excessive heat. However if undercured, it may cause a
skin reaction.
The material loses part of its flexibility because of absorption of cosmetics and
adhesives, which neutralize the plasticizer.
Replacement time for this prosthesis would be very short, especially with the
exposure to sunlight. This material is most appropriate for persons who spend
most of their time indoors.
C- Silicone Rubbers
These materials retain their original pliability for longer periods. It is extremely
inert and does not deteriorate.
There are two basic variations of silicone rubber (based on the manner of
processing):
- Heat cured silicone.
- Silicone cured by addition of an activator to the uncured material..
The complexity of the heat cured process precludes its use in most prosthetic
laboratories.
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Room-temperature vulcanizing (RTV) silicone rubber are now used successfully
in maxillofacial prosthesis. e.g. Silastic 382, Silastic 399, and Dermasil.
Silastic 382 (RTV)
It is a medical grade silicone rubber material supplied in the form of a thick white
liquid with separate container of an organometallic catalyst.
When the catalyst combined with the rubber, vulcanizes it without the use of heat
or pressure.
The working time of Silastic can be varied from 2-60 minutes by adjusting the
amount of the catalyst. The catalyst and rubber are mixed on a flat surface to
minimize the inclusion of air bubbles. Silastic 382 can be molded without
difficulty with simple bench press pressure, or the material can be poured. Repairs
can be made to this material if the surface is cleaned meticulously with xylene and
a fresh mixture of material added.
Internal coloring may be difficult because the raw material is white. To overcome
this problem and to increase the translucency, clear silastic S5392 can be used.
Edge strength of silastic is a problem, and the use of white nylon stocking material
embedded in the prosthesis will give added strength.
To decrease the weight of the prosthesis, a foam type silastic (S5370) can be used
for the internal portion of a thick prosthesis. Mechanical retention employing
undercuts, magnets, or other means is preferred than the use of adhesive to
prolong the life of the prosthesis. The average life of a silastic prosthesis is about
6-8 months.
Silastic 399
It is a RTV rubber which has all properties of silastic 502, the great difference
being color. Silastic 399 is in the form of a clear gel, which makes tinting
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appreciably easier. Two catalysts are also required with this material , which
makes this procedure no more difficult but requires more time.
Dermasil
It is a self-curing silicone in which catalyst is used to initiate the reaction. It is a
clear base material in which ground pigment is added to obtain the proper shade.
The difference between the appearance of Dermasil while it is being mixed and
when it has been cured makes test samples highly desirable. The last samples
should have the same thickness as the prosthesis in order to determine if the
overlay of color will produce the needed color or not.
The margins are fragile and should be reinforced with nylon stocking material.
In painting the color into the mold., speed is a factor. If one section of color is
allowed to set before the other is added, the finished prosthesis will have a
splotchy appearance.
Extrinsic color is desirable if it is applied by means of an air brush, but if the
coating is applied too thickly, it becomes extremely glossy and appears artificial.
1900-1940 vulcanite, latex, and gelatin and glue mixtures had been tried for these
prostheses but they were deficient in several aspects.' These earlier materials were not
flexible enough. Trials were carried out to test various types of synthetic plastics,
however, polyvinyl resins proved the most successful.
In 1937 Acrylic resin Prosthesis replace vulcanite & pvc material
In 1953, a group of dentists founded the American Academy of Maxillofacial
Prosthetics.
1960-1970: introduction of elastomers and silicon rubber
1970-1990: modified polysiloxane elastomer & polyurithane elastomer
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1990 till present: new generation of acrylic resin , polyphosphazenes (permanent
resilient denture liner),, and silicone block copolymer (j prosthod: January 2010, review of
maxillofacial materials)
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Impr ession Techniques
The success of maxillofacial prosthesis is actually depends upon the taking of an accurate
impression of the existing deformity. From this impression a positive cast is made.
Interoral impression techniques
The techniques of obtaining accurate intraoral impressions is well known.
However, the variation in the patients preoperative or postoperative oral anatomy
should be considered. Incomplete palatal closures are often present and these
should be blocked out with lubricated cotton or gauze to which a piece of dental
floss has been tied.
The areas need blocking out prior to impressions are determined by careful
examination, and the guideline should be, when in doubt about undercuts and
impression removal pack the defect.
The defect may also require some special addition or correction to the tray. This is
done by adding periphery wax or hard stick compound to build the try up or out to
capture the anatomy as needed.
Extraoral impression techniques
The obtaining of facial impression (mask) and preparing a working model
(moulage) is important to fabricate facial prosthesis.
The impression materials vary in the end result.
-Reversible hydrocolloid or plaster of paris give the best accuracy.
-Irreversible hydrocolloid or silicone gives good detail quickly.
-Orthopedic plaster bands or impression compound produces general contours, but
not very much detail.
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Patient preparation before facial impression
Patient position:
The patient should be reclined in a dental chair or, better, lying on a table with his head
slightly elevated. This position achieves a relaxed muscle tone of the face and easier
material application.
Preparation of patient:
1-The patient is draped with a sheet and the hair is
boxed out leaving the areas to be reproduced
uncovered.
2- The face should be free of make-up and eye-
glasses.
3- The eyelashes, eyebrows, mustache, beard, etc. should receive a coating of
separating medium as petroleum or cocoa butter.
4- The undercuts of the defect and the nostrils are blocked out with wet gauze or
cotton.
5- The face or the part to be reproduced should be boxed in with red wax strips
held in place by an assistant.
6- An adequate airway is maintained with straws into nostrils or mouth, or with
care, a small amount paint brush can be gently used to apply the impression
material to the nose up to but not including the nares.
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Reversible hydrocolloid
The hydrocolloid is applied using a small paint brush ,to build up a thickness of 3
-4 mm of the material. Before complete setting of the hydrocolloid L-shaped paper
clips are added ( only one end of each paper clips is imbedded into the material ) .
After cooling in about 5 minutes, plaster of paris is applied to a thickness of 8 to
12 mm to reinforcement the hydrocolloid via the paper clips (Fig. 2-4). After the
plaster set the patient is asked to wrinkle his face to loosen the impression. The
boxed impression is removed and checked. The impression is placed in cool
water until poured into stone to form the moulage.
A. Reversible hydrocolloid is applied to the face. B. L- shaped clips is added. C. Plaster
of Paris is applied. D. Impression is removed.
Moulage made from the impression .
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Irreversible hydrocolloid
The technique is similar to the reversible hydrocolloid with some variations that
the alginate powder is mixed with cool water. Excess water should be used to help
the material to flow readily into all depressions. The material is poured over the
face and pushed into the desired areas with brush or spatula. L-shaped paper clips
are inserted before the material set.
Plaster of Paris is applied after the material has set. After removal of the
impression the mask is rinsed and immediately poured up, using stone.
Silicone
The use of room temperature-vulcanizing (RTV)silicone is more expensive than
any other material. However the material has the following advantages:
-Gives good detail of the face.
-Many pours can be made if needed.
-can be stored easily with little deformation.
The use of this material is very easy, the material is applied directly to the face
with spatula to make thin build-up. Thin layer of gauze are applied all over with
light pressing into place for reinforcement, then more silicone is added. After
setting of the material the impression is removed and poured.
Plaster of Paris
This material gives excellent accuracy but it should not be used when the defect is
fresh, or where deep undercuts exist.
A light petroleum casting is applied to the whole area of impression. The plaster
should be thinly mixed and painted on the face. Papaer clips are not used, the
plaster is added and built up. The plaster is allowed to harden initially, then
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removed before its exothermic stage is reached. Separating medium should be
applied to the mask before pouring the model.
Orthopedic plaster band
This material is not register the fine details of the face and the resulting moulage is
fine for constructing radiation-protector shields.
The orthopedic plaster band are cut to the width of the face while they are still dry.
Six strips are dipped in cool water and contoured over the lubricated face. Once
set, the mask is removed and separating medium is applied before the model is
poured.
A. Orthopedic Plaster band is applied to the patient face. B. Built up of additional layers.
Impression compound
This material gives rapid but rough impression. The moulage obtained is fine for
construction of radiation-protector shield.
The compound is warmed, flattened to the size of the face,and applied to the face
with light adaptation. After few minutes the compound mask is removed and
poured.
Mostafa Fayad
Recent advances in modeling of extraoral defect
Journal of Indian Prosthodontic Society | December 2005 | Vol 5 | Issue 4
Drawback of conventional impression techniques
Patient discomfort.
Displacement or distortion of the soft tissues.
Time consuming in modeling and carving.
The technique relay upon the operator skill and individual ability.
The basic steps involved in automated fabrication of extraoral prosthesis composed of 3
phases
1. Collection of 3-D anatomic data(3-D facial measurements) using scanning
techniques
Computerized Tomography (CT) Scanning
Magnetic Resonance Imaging (MRI) Scanning
3-D Optical Scanning
2. Generation of 3-D computer model (blueprint) of the extraoral defect
3. Manufacture of physical prototype.
Computer Numerically Controlled (CNC) milling
Rapid Prototyping
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Col l ect ion of 3-dimensional anat omic dat a using scanning
t echniques
Computerized Tomography (CT) scanning
Advantages and Limitations
Computed tomography scans are readily available.
The use of CT scans allows parts of the body to be serially recorded slice
by slice. The 3-dimensional computed data obtained can be used to
construct an anatomic model or prosthesis of exactly the same dimensions
and geometry of the deformed side of the face.
Limitation of CT: The use of CT scans to obtain 3-D anatomic data cannot
be ethically justified because of the high dose of radiation administered.
Magnetic Resonance Imaging (MRI) scanning
Advantages and Limitations
Magnetic resonance image scanning is a non-invasive (zero radiation)
alternative that projects a 3-dimensional image of the soft tissues together
with bone.
The possible disadvantages remain the length of time the patient is required
to remain motionless during the entire length of scanning and the high cost
entailed.
A further exclusion of this method would arise when many stainless steel
wires have been previously used to secure jaw fragments in corrective
surgery.
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Optical scanning
The optical 3-dimensional (3-D) scanning unit provides a point cloud or virtual model of
the face.
Two main types of optical scanning were used
1. 3-D scanner based on self calibrating fringe projection technology (Kolibri-
mobile)
2. 3-D laser scanning system
The requirements of optical scanning include
1. The body part (for example, the face) should be viewed from different directions
simultaneously
2. The measurements should be made within seconds
3. the system should be mobile and simple to use
3-D scanner based on self calibrating fringe projection technology (Kolibri-
mobile)
It is a mobile, multiview 3-D measuring system
that facilitates the fully automatic recording of the
body part from various directions in one
measuring process.
The maximum field diameter of the system i.e. the
area that can be recorded at one time is 650 mm.
Therefore, the complete human face can be
recorded in a single operation.
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Advantages
a. The system is mobile.
b. Simple to use.
c. Measurements are made within seconds (approximately 20 seconds)
d. The complete human face can be recorded in a single operation.
e. The procedure avoids the stress experienced by patients when conventional
modeling methods are used.
f. Avoids exposure to radiation when using a CT or MRI.
3-D laser scanning system
The system based on 3D eye-safe laser scanners
A laser scan of the full face takes 30 seconds and is a non-invasive
means of collecting digitized data.
The laser scanner and CAD/CAM systems used in the fabrication of
auricular prosthesis in the late 90s.
Some of the constraints to the use of this technique remain loss of some information of
the ear caused by light reflection from the hair and inaccessibility of the internal undercut
surfaces of the ear by the vertically projected lines of the laser beam.
These problems were overcome by a 3-D laser scanning system developed recently to
produce a 3-D dental cast known as emodel.
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Gener at ion of a 3-D Comput er Model (bl uepr int ) of t he
ext r aor al def ect
Once accurate geometric information of the defect is collected using the scanning
techniques, the information is imported into the scanning systems proprietary
computer aided design (CAD) software package for manipulation and the
production of a blueprint (CAD model) from which the prototype is
manufactured.
Manuf act ur e of a physical pr ot ot ype
Computer Numerically Controlled (CNC) milling
Data obtained by optical laser scanners have been used in conjunction with
computer software which converts 3-D data sets into an instruction sequence for a
CNC milling machine to prepare a reverse model of the normal ear.
Limitations
Milling machines reproduce only the outer surface contours. The details
of the internal geometry (undercut contours) are created by freehand
carving (by the technician). These limitations led to the development of
rapid prototyping techniques.
Rapid Prototyping (RP)
it operates on the principle of depositing material in layers or slices to build up a
model rather than forming a model from a solid block thus offering a great
advantage of creating all the internal geometry as well rather than just the outer
surface contours as with a milling machine.
There are currently many variants that are marketed, but the 3 dominant
technologies include:
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a. Stereolithography: uses an ultraviolet laser to solidify a liquid plastic (resin)
layer by layer
b. Laser sintering: uses a laser to selectively fuse a thin layer of powered plastic
or metal to previously fused layers and;
c. Laminated object manufacturing: laminates thin sheets of material
successively and cuts and destroys material with a laser, leaving behind a
solid laminated part.
In each of these techniques, the layers added can be thinner than 0.5 mm with a vertical
wall thickness of as low as 0.2 mm.
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Nasal Pr ost hesis
Because it is a single entity (that is, there is no contralateral equivalent as with eyes and
ears), the nose is the easiest and technically simplest prosthesis to fabricate.
Ideal requirements of material used for nasal prosthesis:
1- Esthetics:
o Produce fine details.
o The same color, texture, form and translucency.
2- Fabrication:
o Easy manipulation.
o Suitable working time.
3- Physical properties:
o Strong enough.
o Sufficient flexibility (used on movable tissue
bed).
o Dimensional stable.
o Light in weight.
o Suitable edge strength (permit thinning or fathering margins).
o Low thermal conductivity.
4- Biological and chemical properties:
o Resist various chemicals.
o Stable with salivary and nasal secretions and adhesives.
o Non toxic and non allergic.
o Biocompatible.
o Durability.
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Restoration of nasal defects:
Nasal defects occur 2ry to: neoplasm trauma.
Most of partial nasal defects restored with surgery.
Most of total nasal defects restored prosthetically.
Presurgical consultation with surgeon is important to defect, if the
defect is to be permanently or temporary restored with a prosthesis.
1- Partial Rhinectomy Defects:
The surgeon may restore the defect temporarily with a prosthesis in order
to delay the surgical construction after the observation period is elapsed.
Covering the defect with local flap may delay discovery of the recurrent
tumor (basal cell carcinoma) which cause metastasis and destruction of
local adjacent tissues.
2- Total Rhinectomy Defects:
Prosthetic restoration are preferable than surgical recontouring.
The surgeon is advised to remove the nasal bones and the rest of the nose to
make it ideally (flat or concave surface) to make the prosthesis that
duplicate presurgical nasal contours.
Placement of split-thickness skin graft over exposed area is preferable.
Patient should be informed about benefits and limitation of the prosthesis.
Photographs of patients with similar defects may be used to educate the
patient.
Conversation with the rihnectomy patient who is wearing nasal prosthesis
may be helpful.
Patient expectations to the prosthesis should be realistic.
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Family members encourage to be present during consultation.
Psychological consultation and evaluation should be short before resection.
Before resection, facial impression and photographs should be obtained.
Before taking impression, the undesirable undercuts should be blocked out
with gauze.
Types of nasal prosthesis:
1- Temporary nasal prosthesis:
- The wound is sufficiently healed (3 - 4 weeks) after surgery, this allow for
placement of temporary nasal prosthesis.
- Patient is happy so, he can resume the social interaction and return to work.
- The material of choice is (heat polymerized methyl methacrylate), because:
a) It can be retained with temporary denture liners.
b) Allow for scar contraction and organization of wound.
- Retention of the prosthesis is aided by medical grade skin adhesive.
- The wound is sufficiently contracted and organized soft tissue bed is
formed (3 4 months) after surgery, this allow for fabrication of definitive
prosthesis.
2- Definitive nasal prosthesis:
- Flat defect with intact nasolabial fold is the best to restored.
- Retaining the nasal bones compromise the contours of the finished
prosthesis.
- Defect with surgical margins out of the nasolabial fold may be difficult
to restore due to exposure of the line of junction.
- Margins onto the upper lip may be masked with facial hair.
- Definitive prosthesis with flexible material are:
a) More comfortable to the patient.
b) Retained in position for long period, especially if patient have
highly mobile soft tissue bed.
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Procedures:
- Impression making:
1- It is advisable to take impression with patient in upright position. Because,
horizontal position will distort the soft tissue bed.
2- Elastic impression material (irreversible hydrocolloid)
Alginate is used and thinned to increase flow by adding
50 % water more than usual.
3- Opening of the nasal passage should be blocked with
gauze to prevent escape of material to the nasal passage
(asphyxia).
4- A facial cast is made, then master special tray is
fabricated and confined to the defect area.
5- Using a syringe we inject the flowable material in the undercut areas. But,
take into consideration not to compress the soft tissue bed.
6- Load the special tray with impression material in position. The excess
material should be removed periodically by index finger.
7- When the impression is set it will be removed and poured by dental stone to
fabricate the master cast.
- Wax pattern carving:
1- It is important in carving to produce the same contour, texture and proper
placement of the line of junction.
2- If presurgical cast is not available, the wax is adapted to cast and basic
contour is done.
3- Patient should have multiple presurgical photographs for reference.
4- It is preferred to have a family member during carving for better perception
of contours than the patient.
5- Ala of the nose should be in a proper location in relation to nasolabial fold.
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6- Care must be taken not to make the nose wide in Alar region (equal to
inter-canine distance).
7- Nares should be symmetrical and resemble the presurgical contours.
8- Junction between Columella and skin should be right angle or acute angle,
in order to be difficult to seen under the tip of the nose.
9- Tip and Dorsum of the nose should be resemble presurgical contour.
10-The bridge area shouldn't be wide and this is verified by wearing of eye
glasses.
11-Eye glasses frames may improve appearance, if possible margins of the
prosthesis extend to mask the superior and lateral margins beneath it.
12-If we can't mask the margins for any reason, care should be taken to feather
the margin of the nasal prosthesis. i.e. (smooth transition between the skin
and the prosthesis).
- Processing:
1- Wax pattern is invested in suitable mold material.
2- Basic shade of the prosthesis should match the lightest color in area.
3- If the basic shade is darker, it will be impossible to have esthetic match.
4- Extrinsic coloration done under presence of the patient and under good
light.
5- Evaluation of coloration under varied (different) light sources.
- Delivery:
1- Hollowing the inner surface as much as possible decrease the weight of the
prosthesis.
2- Retention is achieved by using medical grade skin adhesive.
3- The patient must be followed up periodically.
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3- Partial Nasal Prosthesis:
- Fabricated as the same way as total nasal prosthesis.
- More line of junction will be exposed than total nasal prosthesis.
- For achieving good esthetic results, it should be carefully colored and feathered
to mask the transition between skin and prosthesis.
Mostafa Fayad
Eye pr ost hesis
Anatomy:
Occular Prosthesis: It is a plastic prosthesis used when an eye is surgically
removed. It is an artificial replacement for the bulb of the eye.
SCLERAL SHELLS: A scleral shell is an ocular prosthesis that is worn over an
existing eye
Orbital Prosthesis : Replaces Eye and surrounding tissues
When the entire content of the orbit (including muscles fascia, eyelids, conjunctiva
and the lacrimal apparatus) is removed, the artificial replacement is referred to as
an orbital prosthesis.
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Conformer: It is a temporary clear plastic prosthesis used after surgery to
maintain the size of the socket.
Ocular prosthesis
The artificial eye is made of acrylic (polymethylmethacrylate)
Component of artificial ocular prosthesis
1- PMMA powder with intrinsic pigments in order to replicate
the base colors of the natural sclera
- clear PMMA
2- PMMA corneal-pupil piece
3- Prefabricated iris button
The position of the iris was determined with the help of landmarks make the patient look
in a straight to line
A layer of clear plastic is added to seal in the painting and provide the glossy appearance
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Materials of construction:
a) Plastic acrylic eye:
Advantages:
1- Not fragile as glass and don't cause etching sensation.
2- It is custom made easy to adjust size, form and contours.
3- Easily adapted to individual esthetic requirements.
4- Actual 3 dimensional effect in Iris construction.
5- Perforated Iris buttons can be socketed.
6- Permits elimination of time consuming steps as multiple mold
construction.
7- Method is easy to teach.
b) Glass eye:
Disadvantages:
1- Extremely fragile may explode in eye socket.
2- Glass interact with fluid of the socket.
3- Difficult to fit properly in relation to defect.
4- Giving the wearer the appearance of Exophthalmoses.
Examination of eye socket:
1- Knowledge of the anatomic features of the eye is essential.
2- Existing muscle movements should be studied.
3- Type of operation by the surgeon: enucleation evisceration.
4- If there is implant sphere was embedded at the time of surgery or not and what the
type of its material (gold glass).
5- The amount of orbital adipose tissue present.
6- Extent of muscle atrophy.
7- Contour and tonus of the eye lids.
Mostafa Fayad
Technique of fabrication of the ocular prosthesis:
1- Painting of the Iris disk.
2- The Iris button.
3- The wax form.
4- Molding.
5- The sclera.
6- Veining technique.
7- Conjunctiva.
8- Polishing and fitting.
Mostafa Fayad
Clinical Procedures:
- 2 methods were stated:
a) The most commonly used make a scleral pattern from stainless steel ball
bearing.
b) Using alginate impression to register the contents of enucleated socket.
- It is important for surgeon to place a conformer in the socket after enucleation
(except when unusual amount of hemorrhage) made of acrylic must be large
enough to support eye lids and keep them from collapsing until construction of the
artificial eye.
-
a) Scleral pattern from stainless steal ball bearing:
1- A ball bearing is selected as sphere to make the scleral pattern.
2- Hard base plate wax is softened over the Bunsen flame and compressed over
the ball bearing.
3- It is very important to relief the wax against the (Whitnall's ligament).
4- The wax pattern is trimmed to proper size and shape tried in socket.
5- The center of the Iris marked on the wax.
6- The Iris button is fixed to the hard wax cup using soft green wax.
7- Make any correction to place Iris into proper alignment and position.
8- Special yellow high heat wax is used to buildup smooth and spherical
prosthesis.
9- The prosthesis tried in the socket to check for: optimal lid form, mobility and
Iris line up.
b) Registration of socket using alginate impression:
1) Making Impression:
Preparation of the patient:
1- The hair is boxed out by using cloth towels.
2- The face should be free from make up and eye glasses.
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3- The facial hair should be isolated by a means of separating medium.
4- The eye brow and supra-orbital tissue of the defective eye are retracted.
5- Full width of the face (1 inch above eye brow and to upper lip) is boxed.
6- Patient instructed to close his remaining eye and breath through his mouth.
Impression procedure:
1- Using reversible hydrocolloid (50% water : 50% impression).
2- When material are heated to proper temperature, consistency and ready to
be used the operator tests the material with little finger for proper
temperature before applying over patient skin.
3- The impression material is painted on patient face with camel's hair brush
starting from undercuts and point of the greatest depth then the entire
box area building up at least 3 mm layer of material.
4- Pre bend L-shaped clips is inserted for reinforcement.
5- Wait for 5 minutes for setting of impression and proper reinforcement of
clips.
6- Sufficient thickness of Plaster of Paris is poured removed after initial
setting by asking the patient to wrinkle his face and put in cold water to
prevent cracking of impression under exothermal setting of Plaster.
7- Check accuracy of impression.
2) Making stone cast:
o Pouring the impression with dental stone with vibrator to prevent air
bubbles.
3) Selecting the eye:
o This is performed in the 2
nd
appointment.
o It must match remaining eye.
o Left or right, size shape, color and blood vessels should be similar.
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4) Carving clay pattern:
- Care should be taken in:
1- Restore symmetrically the wrinkles and opening of the eye lids.
2- Restore symmetrically the shape of inner and outer corners of the eye.
3- Distance from bridge of the nose to the Pupil of the remaining eye should
be equal.
4- The eye should be centrally located in the clay.
Plastic Eye Care Information
Yearly Checkups
evaluate the eye's fit and appearance
Polishing to removes protein and salt irritating deposits
Removal and Cleaning
All artificial eye wearers were told to remove and clean the prosthesis on a
regular basis to keeps the eye socket mildly irritated. Prosthesis cleaning is
typically performed once or twice a week
Eye Drops
Oily lubricant may be recommended in case of dry eye
Most patients get a new prosthesis every 3 to 5 years because even with excellent
maintenance, the tissues around the prosthesis can change and the artificial eye
can become scratched.

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Orbital prosthesis
Implant retained orbital prosthesis
Implant fixtures placed in lateral portion of supraorbital rim
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Aur icul ar pr ost hesis
Anatomy and morphology
The ear or pinna is made up of
(1) a cartilaginous framework,
(2) fatty tissues, and
(3) an external covering of skin,
All of which impart to the ear its characteristic shape, color, and texture.
Causes of auricular defect
Form
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Construction
Impression technique
Waxing up ,Try in & flasking
Delivery
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Implant retained auricular prosthesis
Magnet-retained auricular prosthesis
Design and Fabrication of Auricular Prostheses by CAD/CAM
System
The mirrored image would serve as a basis for the ear prosthesis
Mostafa Fayad
Skin cell culture on an ear-shaped scaffold created by fused
deposition modelling Cai h. et al. Biomed Mater Eng. 2005
Tissue engineering, where cells attach and grow on a scaffold, has the potential to
produce replacement ears made from natural tissues and replace the need for
rubber prosthetic ears.
A three-dimensional image of the ear was used to manufacture ear-shaped
scaffolds from ABS (acrylonitrile/butadiene/styrene) plastic using FDM.
Human dermal fibroblasts were seeded on the scaffold (coated with fibronectin)
to attach and grow in culture medium in an incubator for two weeks.
Human keratinocytes were then seeded on to the fibroblast layer to attempt to
produce a more realistic skin covering.
The morphology of the cells were observed using scanning electron microscopy.
The results show that a realistic ear-shaped scaffold can be made using FDM. Human fibroblasts
were found to attach and grow. Human keratinocytes were successfully attached and grown on top of
the fibroblasts and this resulted in a skin covering over the scaffold.
Mostafa Fayad
Maxillofacial Prosthetic Management of a Patient with Hemifacial
Microsomia
Definition:
Hemifacial microsomia (HFM) is a disorder that results from the
underdevelopment of structures within the first and second branchial arches.
It is also the second most common craniofacial malformation, following cleft lip
and palate.
Due to a wide range of phenotypic expressions, a variety of names have been used
to describe HFM. They include Goldenhar syndrome, otomandibular dysostosis,
first and second branchial arch syndrome, oculoauriculovertebral sequence, lateral
facial dysplasia, and craniofacial microsomia.
Etiology
The etiology of HFM is complex. Teratogens, such as retinoic acid primidone and
thalidomide, as well as genetic factors have been implicated.
Both autosomal dominant and recessive inheritance patterns have been postulated
to explain familial cases of HFM.
Clinical manifestations
The clinical manifestations of HFM include a wide range of expressions. The
disorder is especially recognized by its facial asymmetry, due to the agenesis,
hypoplasia and/or displacement of the pinna. Maxillary, temporal, and malar
bones on the involved side are often reduced in size and flattened.
Furthermore, some patients may exhibit an underdeveloped mastoid region.
The eye on the side of the defect may be slightly lower than its counterpart,
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The external ear of the involved side may range from distortion to complete
aplasia.
In some cases, bilateral anomalous pinnas and conduction deafness due to middle
ear abnormalities are observed.
Intraorally
patients with HFM may have hyperplastic or aplastic enamel,
significant delay of tooth development on the affected side,
Absence of the mandibular third molar and other teeth on the affected
side.
Chalky opacities in enamel are often found on the maxillary central and
lateral incisors on the affected side and serve as a distinguishing feature in
individuals with HFM.
cleft lip and/or palate,
hypoplasia of facial muscles,
Unilateral colobomas of the superior eyelid.
Management
craniofacial anomaly was treated using an implant-retained auricular
prosthesis for replacement of the pinna.
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Cr aniof acial impl ant s
Since the introduction of percutaneous endosseous implants for use with
bone conduction hearing aids in 1977, implants also have acquired an
important role in the prosthetic rehabilitation of patients with craniofacial
defects.
In 1983, Tjellstrom published results regarding osseointegrated
Craniofacial implants to retain auricular prostheses and also, bone-conducting
hearing aids.
In 1995, craniofacial osseointegrated implants were determined to be safe and
effective for this application by the United States Food and Drug Administration
(FDA).
Prerequisites of successful implant:
- The tissue bed should be free of infection.
- The tissue should be able to be closed over the implant without pressure.
- The tissue should have adequate blood supply.
Ideal characteristics of cranial implant:
1- It must be non carcinogenic:
o Physical rather than chemical factors are responsible for the change from
normal to tumor cells in the implanted animal.
o The implant should have a configuration which allows for the fibrosing of
the tissue through it and thereby disturbs cellular function less.
2- It must not cause excessive inflammation or foreign body reactions:
o A slight amount of inflammatory process is desired. This serves 2 functions
in implant patient:
1
st
: aids in fixating the implant in position.
2
nd
: it provides barriers to infection spreading the length of the prostheses.
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3- It must be biostable:
o The ideal material should be biodegradable. But, it is not available so, the
biostable material is the one of choice.
4- It must be strong enough to withstand stresses:
o The stresses shouldn't cause implant fatigue and cause fracture.
5- It must be small enough to require a minimum tissue to cover:
o In both traumatic and surgical defects, the amount of tissue coverage has
been decreased or compromised.
6- It must be readily available and easy to fabricate.
7- It must be capable of being sterilized:
o This will prevent infection and subsequent complications.
Materials used for implant:
a) Tantalum:
o Contains: 18:8 stainless steel and chrome cobalt alloy.
o Comes in the form of sheets, wire, ribbon and mesh.
b) Chrome cobalt alloys:
o Well accepted by the body and have high rate of success.
c) Methyl methacrylate, Polyethylene and Silicone:
o manipulated in the dental laboratory.
d) Animal shells, Grounds, Coconut shells, Hard rubber, Plaster of Paris and
Gummed cork.
Position of craniofacial implants
o Implants in the mastoid process retain auricular prostheses.
o Orbital rim implants may anchor orbital prostheses
o Implants placed in malar bone and/or the anterior nasal
spine can be used to secure nasal prostheses.
Mostafa Fayad
Advantages of Implant retentive maxillofacial prosthesis
less wear and tear on the prosthesis, and daily cleaning is faster and easier.
Both of these factors contribute to extended life of the prosthesis.
Adhesive related skin irritation is eliminated and implants provide more reliable
retention of the prosthesis.
Precise placement of the prosthesis is assured as the retentive elements
automatically guide the prosthesis to its correct position.
less risk of discoloration through the use of adhesives
Osseointegration in irradiated bone
The adverse biological of ionizing radiation include
Alterations in the cellular components of bone, involving significant reductions in
the numbers of viable osteoblasts and osteocytes,
The development of areas of fatty degeneration within the bone marrow spaces.
The blood vessels undergo progressive endarteritis, hyalinization and fibrosis,
thus resulting in regional ischemia
Several papers have raised concerns by describing significantly shorter survival
rates when implants were placed in irradiated craniofacial bones, compared with
non-irradiated sites
Experimental and clinical findings indicate previous irradiation in therapeutic
doses is not an absolute contraindication for implant insertion.
It is recommended that some time elapse (minimally 1 year) before implant
placement in irradiated bone.
Hyperbaric oxygen (HBO) therapy can be used to improve the implant success
rate, by 38% according to the literature . However, in the mastoid region, HBO
therapy might not be necessary before placement of the implants unless the patient
has been irradiated with high radiation doses
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It is possible to place craniofacial implants in patients with oncological lesions of
the head and neck during ablative surgery. especially when radiotherapy is
indicated, the possible advantages are the following:
1- Initial osseointegration takes place before irradiation and insertion of
implants in a compromised area can be avoided;
2- Earlier prosthetic rehabilitation; and
3- Surgical intervention in irradiated tissue is limited to second-stage surgery
However, there is general concern among head and neck surgeons and
radiotherapists that metal implants within the irradiated field may be cause
scattering, lead to overdose in the adjacent tissue over the course of radiation
therapy.
This could lead to three consequences:
1) Smaller irradiation dose reaching the tumor if it is situated behind the
implants;
2) Possible loss of osseointegration and implant failure because of the higher
irradiation dose; and
3) Increased risk of osteoradionecrosis developing in the bone adjacent to the
implant
Mostafa Fayad
Cranial prosthesis
Cranioplasty:
- The greatest progress in cranioplasty has been made in the development and
application of various plastic and non metallic alloplastic materials.
- Gold plates were inserted into skull defects. Then, inert metals were
used such as Vitallium, Ticonium, Tantalum and Stainless steel.
- The use of acrylic resin (Methyl methacrylate) is the most recent
development in this field.
Etiology of Cranial Defects
Trauma accounts for the majority of cranial defects
Infected bone flap
Excision of osteomas and other benign locally invasive lesions
Indications for cranioplasty:
1- Trauma.
2- Osteomyelitis of the skull.
3- Gun shoot wound.
4- Congenital defects.
5- Neoplasm of both cranial and
intracranial origin.
6- Epilepsy.
7- Pulsating and painful defects.
8- Danger of trauma at site of defect.
9- Deforming and unsightly defects.
10-Headache, pain and tenderness at
site of defect.
Precautions for cranioplasty:
1- Cranioplasty was not performed in presence of wound contamination or acute
chronic inflammation.
2- In one stage method of cranioplasty : methyl methacrylate has been almost
exclusively for both small and moderate large skull defects.
3- Split rib grafts have been used for large defects (Osteomyelitis).
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Objective of Cranioplasty
For cosmetic reasons
For brain protection
Local discomfort at the site of the cranial defect
Methods of Cranioplasty
(1) Osteoplastic reconstruction
(2) Restoration with alloplastic implants.
Complications of cranioplasty:
1. Infection.
2. Instability of the prosthesis.
3. Erosion of the overlying skin.
4. C.S.F. leakage through dural laceration.
5. Epidural granuloma.
6. Hematoma.
7. Pneumothorax following rib removal.
8. Thermal damage to the surround tissue from the heat of polymerization of methyl
methacrylate.
Mostafa Fayad
Techniques of Cranial implant:
a) Technique of Methyl methacrylate cranial implant:
- Skin incision is designed to allow complete exposure of the
margins of the bone defect.
- Care must be taken to avoid lacerating the underlying dura
and brain.
- Periosteal elevator is used to fee the dura from the bone
edges.
- If the dura is full or tense, hyperventilation of the patient is
required to decrease intra-cranial pressure.
- The bone edges is freshened, rounded, and slightly beveled
with rongeurs. This also may be done using high speed drill
to provide a ledge which provide greater stability of the
plastic plate.
- When the preparation has been completed, a sterile liquid
monomer and powder polymer are mixed and takes 5 to 6
minutes to obtain doughy mass that can be conveniently molded.
- The material is placed over moistened cotton and shaped with fingers or a small
roller to a size approximating the defect and to the thickness of the surrounding
bone.
- A thin flange of acrylic around the periphery of the defect will provide increased
stability and also safety in that it prevents the implant from sinking into the
underlying tissue as a result of external pressure.
- The plate is then removed, and final hardening occurs outside the skull (Heat
generation).
- Many surgeons feel that a better fit is obtained if the plate isn't removed and final
hardening occurs in situ.
Mostafa Fayad
- Cooled Ringer's or normal saline irrigant should be continuously directed onto the
plate and surrounding tissue until the heat generated by polymerization has been
dissipated. (7:9 min.)
- All rongeur or dental burs are used to trim rough and sharp edges and to remove
excess material.
- For greater stability as well as for cosmetic purposes, wire may be used to bridge a
defect and may then be incorporated into the methyl methacrylate plate.
Advantages:
1. Excellent cosmetic results and easy to achieve.
2. Have same density and strength as bone.
3. Transparent to x-rays.
4. The material is inert and lacks the physical effects of metal plates as temperature
change and electric phenomena.
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b) Split rip graft cranioplasty:
- Indicated for larger defects.
- Portions of the 9
th
or 10
th
ribs are generally used.
- After proper length of rib has been resected, the piece is split longitudinally with a
sharp thin chisel.
- The technique of exposing the skull defect and dura is the same as previous
technique.
- Part of the outer table is removed from the defect margins to form a ledge into
which the ends of the rib are inserted.
- Fixation is obtained with wire inserted through small holes drilled into the rib.
- The wound is closed in the usual manner.
- Head protection is recommended for several weeks until stabilization occurs.
Disadvantages:
1. The necessity of a separate incision.
2. Incomplete coverage of the defect.
3. There is a period required for stabilization.
c) Technique of Polyethylene Cranial Implant:
Advantages:
1. High density and high impact strength.
2. It is available in sheets and with proper compression molding.
3. Very strong and stress free product.
4. Inert.
5. Light in weight.
6. Radiolucent.
7. Easily trimmed at the time of surgery.
8. Cover large skull defects with good cosmetic results.
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Steps of obtaining prostheses:
1. Impression taking with alginate impression material.
2. Modeling in stone.
3. Patterning with wax.
4. Flasking.
5. Compression molding at approximately 300 F.
6. Finishing.
7. Cold sterilization.
d) Technique of Tantalum Cranial Implant:
- To obtain the natural shape of the skull, it is important that
the head be shaved before the impression is made.
- The defect is palpated and the peripheral border is marked
with indelible pencil at a margin of approximately 1 to 2
cm from the penciled lines.
- The area is boxed in with boxing wax.
- The impression is made by applying irreversible hydrocolloid to the entire surface
of the boxed-in area.
- Pre-bent paper clips opened to an L shape are inserted in the impression material
for reinforcement.
- After setting of the irreversible hydrocolloid, quick setting plaster of Paris is added
for backing.
- When the plaster has set, the impression is gently removed from the skull and the
pencil line is reoutlined with indelible pencil.
- Dental stone is then poured slowly into the impression.
- Once the stone has set, the impression is separated from the moulage.
- At this stage, the prosthodontist study the moulage to determine whether an inlay
or onlay implant should be used.
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- With an Inlay implant, a shoulder rest is prepared around the defect at the
periphery line 1mm deep to compensate for the tissue overlying the defect.
- The depressed area of the moulage is filled in with modeling clay or plaster to
bring the contour out to normal.
- One baseplate thickness of wax is applied to the pencil line as a pattern to cutout
the tantalum metal.
- The moulage is used as a die and after using separating medium, a counter die is
poured using a thick mix of stone.
- After setting, the 2 halves of the mold are separated and the tantalum pattern is
placed between the dies and the dies are inserted under press.
- After molding of the tantalum, it is peforated by the use of round burs size 5 : 8 to
allow the connective tissue to penetrate the implant and neutralize its physical
property.
- After making perforations, the implant is finished by rubber points, polished,
scrubbed, and immersed in nitric acid to eliminate contamination.
- The tissue bed is prepared in the same manner as described for methyl
methacrylate.
- The sterilized perforated tantalum implant is then seated over the cranial defect
and fixed with 4 to 6 stainless steel wires to the surrounding skull.
- The wound is closed in layers as usual manner.
Disadvantages associated with metal cranial implants.
Their high thermal conductivity may precipitate headaches and other neurological
symptoms.
Their electrical conductivity precludes accurate interpretation of
electroencephalograms.
Some metals, are radiopaque and may prevent interpretation of routine
radiographic studies.
Mostafa Fayad
Perforated Tantalum Implants for Reconstruction of Facial Bones:
- Used for reconstructing other defected facial bones, such as the infraorbital bone,
the zygomatic orbital malar bone, the symphysis and associated mandibular
defects.
- Used in case of T.M.J. ankylosis after accident.
Silicone Implant for Reconstruction of Facial Bones:
- Used for reconstruction of the dorsum of the nose, the floor of the orbit, the malar
bone, the forehead, and the mandibular ridge.
- Used to build out the retrognathic chin and to build the helix of the ear.
- The silicone implant material must be perforated to provide tissue growth which
will retain the prosthesis in place.
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Stereolithographic Model
Three-dimensional (3-D) modeling by deposition of U.V light cure epoxy resin
Rapid prototyping technology
The use of computer-controlled milling process to
manufacture models from blocks of polyurethane foam
STEREOLITHOGRAPHY
Advantages.
Anatomically 3 dimensionally accurate.
Disadvantages.
Expensive to have built. Poor tooth detail.
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Coloration of maxillofacial prosthesis
RULES
The patient must always be present for the color match
Accurate color match is the final determinant in creating
an acceptable prosthesis
Realistic cosmetic matching depends on the combination of in-depth intrinsic and
extrinsic colorations
Depth of color and translucency achieved through intrinsic technique
Surface detail (b.v., freckles and moles) achieved through extrinsic technique
The extrinsic coloration uses a medical-grade adhesive combined with xylene and
earth pigments,
Trial and error
Obtaining color match
a) Traditional trial & error method
Intrinsic color technique
Intrinsic coloration composed of base shade and localized color.
Base color : represent the majority of the tissue color
Localized color: as Tip of the nose , Outer concha & ear lobule
The technique of applying the localized color must be in layering method to produce
good depth of color with gradual change from base color to localized color
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The application of localized color must be done firstly then the base color
Obtaining the correct base shade complicated by
1. Incorporation of air into the silicone during mixing
2. Thickness of the mix
3. Background color of mixing container
Consideration
Color match must be done in a room with neutral gray walls
Avoid hard demarcation of color layers
Use small amount of clear elastomer just below the surface of the prosthesis to
create translucent pigmentation
The edges of the prosthesis must blend into the surrounding tissue with the same
color balance
Extrinsic coloring must be carried out at the fitting appointment and should be
kept to a minimum
Extrinsic color technique
It used to compensate slight color imbalance
Extrinsic color used to apply freckle, mole and capillaries
After applying of extrinsic coloration a thin layer of medical
adhesive must be applied over the entire surface and tamped
with wet gauze to attain surface texture.
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b) Computerized color formulation
This done by computing a pigment formula with color formulation software that
matches a measured skin color
Advantages
1. Reduced clinical time
2. The formula can be mixed repeatedly and accurately
3. Metamerism is minimized since the formula obtained under three different
illumination sources .
4. Translucency can be controlled as pigment loading done acc. to the color
formulation software
Spectrophotometer &colorimeter
Spectrophotometers use an optical mechanism to break down light
entering the instrument into it's component parts and measuring
them in an objective manner
Colorimeter consists of sensor and simple data processor, it is less
complex than spectrophotometer And used for comparison of
similar colors and adjustment of small color difference
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Int er im ext r aor al pr ost hesis
An interim extraoral prosthesis used for the rehabilitation of a patient treated for
osteoradionecrosis of the mandible
Speech
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Speech
Speech is a learned process that used the anatomic structures designed primarily
for respiration and deglutition. There are no organs of speech per se. As a learned
process, speech develops over an extended period.
Components of speech:
The speech can be divided into the following components:
Respiration : During respiration, inhalation and exhalation are approximately equal in
duration and the airflow is regular and repetitive. During speech, the inhalation is
shortened and the exhalation phase is prolonged and is not repetitive. Prolongation of
exhalation is achieved by the valve mechanisms along the laryngeal, pharyngeal and oral
components of the respiratory truct. These valves impede the expired air and help to
create speech signals. If the vital capacity of the lungs is compromised, as in emphysema,
speech will be perceived as breathy. The reduced volume and pressure of the expired air
cause poor projection of voice.
Phonation :Speech requires a multitude of position, varying tensions, vibratory cycles,
and intricate coordination of the vocal folds with other structures. If the focal folds are
partially or completely closed, they impede the expired air. With the proper degree of
tension and pressure, the vocal folds may vibrated and thus impart phonation. The tension
and position of the vocal folds will determine the pitch of the phonated sound. If the
larynx is resected the patient must learn to use the esophagus or a substitute mechanical
device (electrolarynx) as an alternative phonating system.
Resonation: The sounds produced at the level of the vocal folds are augmented and
modified by the chambers above the level of the glottis. The pharynx, the oral cavity, and
the nasal cavity are providing tonal quality and act as resonating chamber by amplifying
voice. If palatopharyngeal closure is compromised, or if the structureal integrity or the
Speech
Mostafa Fayad 2
size of the oral, pharyngeal or nasal cavities has been altered, a compromised voice
quality will occur.
Articulation: The amplified, resonated sound is formulated into meaningful speech by
the articulators, i.e., by changing the special relationship of the tongue, the lips, the
cheeks, the teeth and the palate to each other. The tongue is the single most important
articulator of speech because of its ability to changes in movement and shape.
Neural integration: Speech in integrated by the central nervous system. At least 17000
different motor patterns are required during speech. A cerebrovascular accident may
compromise the ability of the patient to formulate meaningful speech, even though all
structures used to produce speech are anatomically normal.
The ability to hear sounds (Audition) : Hearing permits reception and interpretation of
acoustic signals and allows the speaker to monitor and control speech output.
Compromised hearing can preclude accurate feedback and affect speech.
Speech and Maxillofacial Prosthetics
resonance and articulation are distorted by cleft lip and cleft palate. These two
components of speech are the readily influenced by maxillofacial prosthodontic
rehabilitation.
A-Patients with cleft palate exhibit excessive nasal resonance because the inadequacy of
the velopharyngeal closure. This results in nasal sounds (hypernasality).
B- The sounds not affected by palatal clefts are the vowels (A,I, E,O and U) and nasal
consonants (M,N and NG).
C- The articulation of the other consonants is affected in varying degrees, depending on
the degree of oral pressure required for each sound. These sounds are deprived of their
normal explosive character (e.g. P and K) and give the voice a typical hollow nasal
quality.
Speech
Mostafa Fayad 3
The Techniques of Normal Speech
The initial sound of speech is produced in the larynx and travels as a vibrating air
stream either through the mouth where it is articulated by the tongue, lips, palate and
teeth, or through the nose where the nasal cavities and associated sinuses produce a nasal
resonance. The rapid and accurate positioning of the soft palate is essential for the
production of the correct sound. When speaking, all sounds except for those of m, n and
ng, the soft palate is raised preventing all nasal escape of air which is thus wholly
directed through the mouth where it is modulated in one of three ways.
1-The vowel sounds
The vowel sounds A,E,I,O,U are formed by a continuous air flow escaped through the
mouth. The shape of which is altered for the various vowels by raising or lowering the
tongue and by altering the shape of the exit through the lips. The air was escaped through
the mouth in the form of a single chamber for the A , O , U sounds and a duple chamber
for the I and E sounds. The division occurring through the dorsum of the tongue
touching the anterior part of the soft palate.
2-Stopped consonants:
The stopped consonants are produced by first of all stopping the air stream momentarely
and then allowing it to escape through a cavity shaped to produce the sound in question.
Examples of these are
B and P sounds (labials). The air streams is stopped momentarily by closure of the lips
and then released explosively when thelips are suddenly parted .
T and D sounds (linguodentals); The stop is made by the tip of the tongue being
pressed against the palatal surfaces of the upper front teeth.
G and K sounds (lingo-palatals); The momentary stop is made by the back of the tongue
being pressed hard against the hard palate.
Speech
Mostafa Fayad 4
The first phase of the B sound. The
lips are closed and therefore the
airstream is stopped when it reaches
them and is held there under pressure,
the second phase of B: sound. The
lips are suddenly opened and the
stopped airstream is released
producing the B sound.
For the F and D sounds, the stop is made
with tip of tongue and the palatal surface
of the upper anterior teeth.
The stop is made with tongue and
palate for the G sound.
3-The fricatives consonants sounds
Some sounds are termed fricatives to describe the friction. Like way in which they are
produced. The fricatives S , Z and C sounds; are produced by allowing the air stream
under pressure from the lungs to escape through a finely adjusted slit formed between the
dorsum of the tongue and the palate.
The M , N and NG sounds; these nasal consonants are the only sounds produced with the
soft palate lowered, allowing the air stream to escape through the nose. In the M sound
the air take the nasal route only. In the N and Ng sounds the escape is partially through
the nose and partially through the mouth.
Generally, the oral cavity and the sinus act as resonant chambers, and the muscles of the
abdomen
Speech
Mostafa Fayad 5
The factors in denture construction affecting phonation
The vowel sounds:
The tip of the tongue in all vowel sounds lies on the floor of the mouth either in
contact with or close to the lingual surfaces of the lower anterior teeth and gums. The
application of this in denture construction is that the lower anterior teeth should not be set
lingual to the alveolar ridge so that they do not impede the tongue positioning for these
sounds;.
Since the vowels E and I necessitate contact between the tongue and soft palate,
the upper denture base must be kept thin, and the posterior border should be tapered and
merge into the soft tissue in order to avoid irritating the dorsum of the tongue, which
might occur if this surface of the denture was allowed to remain thick and square-ended.
The consonant sounds
These sounds may be classified thus
1- Labials: Formed by the lips (e.g. B, P, M).
The anterior teeth and the denture flange must support the lips for these sounds.
2- Labiodentals: Formed by the lips and teeth (e.g. F, V, Ph).
These sounds are produced by the air stream being stopped and explosively released
when the wet-dry line of the vermilion border of the lower lip breaks contact with the
incisal edge of the upper anterior teeth (Fig 5-4). If the occlusal plane is set either too
high or too low or if the anterior teeth are placed too far palatally and fail to provide
proper lip support, difficulty in pronouncing these sounds may occur.
3- Linguodentals: Formed by the tongue and teeth (e.g. Th).
Speech
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This sound (as in thin , then) is the result of air flow restricted by the tongue against
the incisal edge of upper and/or lower incisors. The proper adjustment of the occlusal
plane and the proper positioning of the anterior teeth are necessary for these sounds.
4 -Linguopalatals: Formed by the tongue and palate.
The palate serves two speech functions, resonation and articulation. In articulation,
it directs the air stream. The linguopalatals sounds can be divided according to the part of
palate that make contact with the tongue during speech.
a- Tongue and anterior portion of the hard palate (e.g. S, C soft, Z, D, T, R, L).
With T and D, the tongue makes firm contact with the anterior part of the hard
palate, and suddenly drawn downwards, producing an explosive sound. When producing
the S , C soft, Z , R and L sounds, contact occurs between the tongue and the most
anterior part of the hard palate, including the lingual surface of the upper and lower
incisors, any thickening of the denture base in this region may cause incorrect formation
of thesesounds.
The lower lip is brought into contact with the incisal edges of the upper
anterior teeth during production of the F, V and Ph sounds.
In case of S , C soft and Z sounds, a slit-like channel is formed between the
tongue and the palate through which the air hisses. If this channel is obstructed by
thickening the anterior part of the upper denture covering the hard palate, by placing the
anterior teeth too far back, or by lack of near contact of the upper and lower incisors, a
noticeable lisping may be produced. However , if the channel is too narrow, due to
Speech
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cramped tongue, too narrow dental arch, or placing the anterior teeth too far anteriorly
whistling will result.
The procedure for correcting whistling is to thicken the center of the palate sothat
the tongue does not have to extend up, so far into the narrow palatal vault. This allows
the escape way, for air to be broad and thin.
A lisp with denture can be corrected by reversing the procedure and providing a
narrow concentrated airway for theS sound.
The correct positioning of the anterior teeth (antroposteriorly) important for
proper sounds of S, C (soft), Z, R, and L and for preventing both lisping and whistling.
b- Tongue and portion of the hard palate posterior to that of (a) (e.g. J, CH, SH, L, R)
Faulty phonation of these consonants sounds may be results from thickening of
this part of the denture base covering the hard palate.
With the C soft, S, Z, CH and J sounds the teeth come very close together; if the
vertical dimension is excessive, a clicking teeth will results with these sounds.
c- Tongue and soft palate (e.g. C hard, k, G, NG).
Difficulty in pronouncing these sounds results if the posterior border of the upper denture
is thick and does not merge into the soft tissues.
5- Nasal (e.g. M, N, NG).
In these consonants sounds the air stream is allowed to escape into the nasal cavity.
A careful consideration should be given to the following aspects of denture
construction to prevent or reduce the speech defects:
1- Denture thickness and peripheral outline
Speech
Mostafa Fayad 8
unduly thick denture bases may cause :
loss of tongue
loss of tone
incorrect phonation.
- The periphery of the denture must not be overextended .
- The thickness of the denture base covering the palate should not be thick.
- The artificial ragae should not be over-pronounced.
2- Vertical dimension
- high vertical dimension cause clicking teeth with Ch and J sounds
construct the denture with proper vertical dimension.
3- The occlusal plane
If the occlusal plane is set too high the correct positioning of the lower lip may be
difficult. If the plane is too law, the lip will overlap the labial surfaces of the upper
anterior teeth to a greater extent than is required for normal phonation and the F, V and
Ph sounds might be affected.
4- The anteroposterior postion of the incisors
The labiopalatal position of the upper anterior teeth is important for the correct formation
of the labiodental F,V and Ph and some palatolinguals S, C soft and Z, lisping with
result if the anterior teeth are placed too far palatally.
5- The post-dam area
Errors of construction in this region involve the vowels I and E and some
palatolingual consonants K,NG, G and C had.
Speech
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If the denture base was made thick in the post-dam area, or the edge finished
square instead of tapering, the dorsum of the tongue will be irritated, impeding speech
and nausea may occurs.
Indirectly the post-dam seal influences phonation by increase the denture
retention, because in case of loss upper enture the patient tries to suck maxillary denture
into position, using tongue to hold it, hence, mouth does not open widely, speech
becomes muffeld.
6- Width of dental arch
The artificial teeth should be placed in the neutral zone.
If the arch form of the denture is too narrow the tongue will be cramped, thus
affecting the size and shape of the air channel and the lateral margins of the tongue make
contact with the palatal surface of the upper posterior teeth. These results in faulty
phonation of some consonants as T, D, S, M, N, K, G, and H.
7- Relationship of the upper anterior to the lower anterior teeth
The consonants S, Ch, J , and Z requires near contact of the upper and lower
incisors so that the air stream is allowed to escape through a slight opening between the
teeth.
In abnormal protrusive and retrusive jaw relationships, some difficulty may be
experienced in the formation of these sounds, and the anteroposterior adjustment of the
upper and lower anterior teeth become necessary.
Some phonatic complaints associated with prosthesis
1- Loss of tone and incorrect phonation
Causes: - Decrease of air volume and loss of tongue room resulting from too
narrow dental arch.
Speech
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- Unduly thick denture bases (especially this part covering the palate).
- Overextended denture and periphery.
Treatment: - Broaden and widen archform.
- Use narrow teeth.
- Reduce the thickness of the denture base.
- Adjust denture periphery.
2 -Drooling
Causes: - Arch form too constricted.
- Reduced vertical dimension.
- Poor muscle support.
Treatment: - Widen and boarden the arch form
- Restore proper vertical dimension.
- Teeth should be placed to support soft tissue more firmly.
3- Limited jaw mobility and low intensity of speech production:
Causes: - Denture looseness; patient tries to suck maxillary denture into position,
using tongue to holdit, hence, mouth does not open widely, speech
becomes muffled, and jaws move little.
Treatment: - Check dentures for lack of adaptation, improper border extensions,
insufficient posterior palatal seal and deflective occlusal contacts.
Then correct the defect.
Speech
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4- Phonetic Sh instead of S
Treatment: - Have a slight vertical overlap.
- Increase vertical dimension.
-Set lower so incisal edges can approximate maxillary teeth to
within 1 mm.
5-Clicking sound
causes: - High vertical dimension.
- Use of porcelain teeth.
- Poor retention of the denture.
Treatment: - Decrease the vertical dimention.
- Use risen teeth.
- Treat the cause of poor retention.
6-Lisping and whistling:
mensioned before.
Retention of Maxillofacial Prosthesis
I-Retention of Intraoral Prostheses
A-Anatomic Retention:
This includes the use of both hard and soft tissues (teeth, mucosal and bony
tissues). Large alveolar ridge and high palatal vaults generally provide more
retention than flatter ridges. Anatomic undercut areas play an important role in
retention of prosthesis. The success of intraoral retention relates to the size and
location of the defect and the type of the mouth, dentulous or edentulous e.g.
For edentulous patient with any palatal perforation, retention in the classical sense
of complete denture is impossible. Even in dentulous patient with resected
maxilla, clasping only will not give better results. The movement of the prosthesis
will make stress on the abutment teeth and may result in loss of the abutment. So
more than one method of retention should be used.
B-Mechanical Retention: (Temporary or Permanent)
Temporary Mechanical Retention:
1- A stainless steel wrought wire of 18-gauge size can be quickly
adapted to a cast of the remaining teeth to retain the temporary
prosthesis during the healing period. Preformed stainless steel wire
clasps include Adams, Akers, or Hawley labial wires may be used
Preformed stainless steel bands or crowns with prewelded brackets can be adapted to
increase retentive form of a mutilated or conical tooth.
2- wiring the denture to infraorbital or zygomatic bones to obturate a
maxillary defect is recommended for edentulous patient..
Retention of prosthesis: Upper through circumzygomatic wiring
and lower through circummandibular wiring.
Permanent Mechanical Retention:
1-Cast clasps
The most common method for retaining a prosthesis is the use
of cast metal clasps. There are many different types of cast
metal clasps e.g. cast circumferential clasp, ring clasp and I-Bar
clasp .
2-Prefabricated precision attachments:
These attachments can be placed into cast crowns for the best esthetic and mechanical
retention.
3-Semiprecision attachments, custom made
This attachments are formed in the wax pattern, using a specially shaped mandrel
mounted on the parallelometer .
4-Snap-on attachment
A Baker bar or Anderson bar is the rod
connecting two crowns of abutment, and the
clip engages this rod.
5-Overdentures
Improved retention may be obtained by one of the several attachment devices or by lining
the overdenture with one of the resilient denture liners to utilize available tooth
undercuts.
6-Overlay (Telescoping) Crown and Thimble Crown
This type is used when an overlay denture is planned or an
extremely malposed tooth is needed for stability.
It is also indicated when a major change in the vertical or
centric dimension occur , as in cleft lip-cleft palate, and
prognathic mandibles.
Fig. (A) Thimble crowns cemented on prognathic patient,
(B) Telescoping crowns imbedded in the denture.
7-Swing-lock attachments
Swing-lock partial denture design using long flexible
arm to engage anterior and posterior abutment teeth.
The swing-lock design should not be used at all
unless splinting of the posterior teeth is first
accomplished.
8- Retaining buccal flange
Retaining buccal flange engaging both tooth and tissue undercuts
9-Using the undercuts in the defect
Soft silicone material is used to engage the undercuts in
the defect moreaggressively.
10-Engagement of the skin graft and scar band formed at the skin graft-mucosal
junction .
J unction of oral mucosa and skin graft lining can give accessory retention and should be
used whenever possible.
(A) J unction of oral mucosa and skin graft, (B) Lateral defect space traced in compound showing
construction of scar band and extension to lateral shelf created by tumor removal.
11-Magnets
Small steel magnets are embedded beneath the molar and premolar teeth of upper and
lower dentures and arranged with similar poles opposite each other. At least two magnets
are required for the lower denture and four magnets for the upper denture.
This effective method of retention may be useful in cases of hemi-maxillectomy, or
extremely atrophied ridges. The use of magnets in two piece prosthesis is advocated.
12-Using of springs
The opposing arch can be used to assist in the retention of the maxillary prosthesis by
attaching a spiral spring to the prosthesis in the premolar region. These spiral springs are
made of coiled stainless steel or gold-plated base metal and have their ends attached to
swivels in the premolar areas on both sides of upper and lower dentures.
(A) Spring - retained prosthesis, (B) Spring - retained denture with obturator.
Nylon springs of continental origin are available and have the advantage of being thin
and not collecting food .
Their life is limited to about six months, and the method of their attachment to the
denture, which is a nylon ball and socket joint, is not very efficient. If this were improved
they would be very satisfactory.
The disadvantages of nylon springs are:
1-The constant pressure may cause excessive alveolar
absorption
2-The mucous membrane may not tolerate the constant
pressure.
3-The inner surfaces of the cheeks may become sore from
frictional contact with the springs.
4-Lateral movements are extremely restricted.
5-Collecting foods and become unhygienic.
13-Implants in the intact side
Improved retention may be obtained by one of the several attachment which can be used
with the implants.
14-Adhesives (fixatives), Prosthetic Adhesives, 1970
These materials improve fit, comfort and retention of the prosthesis by producing a high
viscous layer between the denture and its supporting tissues.
This material is necessary to aid retention in the following cases:
a- Large surgical wound.
b- Flat palate.
c- Nonexistent maxillary tuberosities.
d- Missing of soft tissue undercuts in the area of
surgery.
e- Diminished salivary flow due to pre-and
postredication therapy.
f- loss immediate upper denture due to alveolar absorption .
The requirements of adhesives are
1. Highly adherent;
2. Nontoxicthat is, nonirritating to the tissues;
3. Elastic at the point of contact to the skin;
4. Non injurious to the prosthesis;
5. Highly durable;
6. Easily cleansed from the surface of the prosthesis as well as from the soft tissue
involved.
Disadvantages
1-It gives a temporary retention .
2-It has an unpleasant feel when pressed out from beneath the denture.
3-It is of little use for retaining lower dentures.
4-Its constant use may cause constipation.
The troubles with adhesive
Difficult to clean
They collect dirt and are unhygienic
Unreliable (swimming, sweating or greasy skin)
Awkward to position correctly
The application of the adhesive may be messy and time-
consuming.
The edges of the prosthesis must often be thickened or reinforced with fabric to
resist tearing that may occur as the adhesive is cleaned from the prosthesis on a
daily basis.
The adhesive may cause skin irritation,
Retention by the skin adhesive may be unreliable, especially if the prosthesis is large, the
weather humid, or if the patient has oily skin. Proper positioning of the prosthesis is
difficult in the absence of key anatomical landmarks; especially if the patient has
compromised manual dexterity or visual acuity.
II-Retention of Extra-oral Prosthesis:
A-Anatomic retention
The dynamic extra-oral retention depends on many factors. These factors are
related to the size and location of the defect, tissue mobility, undercuts and the
wright of the prosthetic material.
Both hard and soft tissues should be used; The hard tissue act as a base and
provide a better seal of the prosthesis with the use of adhesive. While the soft
tissues are more troublesome because of their flexibility, mobility, lack of support,
low resistance to displacement.
B-Mechanical retention
In cases of large defects involving half of the face additional retention is needed
beside the use of adhesives.
The use of eye glasses with elastic strap as an indirect mechanical retention to
retain the prosthesis.
The magnets may be imbedded in a nasal or orbital prosthesis to retain it to the
maxillary obturator.
C-Adhesives
The adhesives aid retention, marginal seal, border adaptation, and recures the
prosthesis against accidental dislodgment. Generally, each material provides its
own adhesive according to its physical and chemical properties.
D- Combination of anatomic, mechanical and adhesive retention:
In caseof large facial replacements all available means of retention should be used
to obtain better stability and retention.

Maxillofacial Prosthetics Theory and Practice

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Maxillofacial Prosthetics Theory and Practice

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MAXILLOFACIAL PROSTHETICS

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