MAXILLOFACIAL

PROSTHESIS
INTRODUCTION
Maxillofacial prosthesis is the art and
science of functional, or cosmetic
reconstruction by means of non-living
substitutes for those regions in the maxilla,
mandible, and face that are missing or
defective because of surgical intervention,
trauma, pathology, or developmental or
congenital malformation.
Types of maxillofacial defects
A.Types of maxillary defects
Maxillary defects can be broadly classified as:-
a) Congenital
- Cleft Lip
- Cleft Palate
b) Acquired
- Total Maxillectomy
- Partial Maxillectomy

Congenital maxillary defects
Most common congenital maxillary defects include
cleft lip and cleft palate.
Other defects like sub-mucous cleft palate, pierre
robin syndrome, hemifacial microsomia are treated
using same principles followed in the management
of cleft lip and cleft palate.
Cleft Lip and Cleft palate
Cleft Lip occurs due to improper fusion between
fronto-nasal and maxillary process.
If occurs on one side leads to unilateral cleft and if
occurs in both sides then bilateral cleft.

Aetiology includes infections, drugs (phenytoin,
ethanol,and barbiturates), poor diet, harmonal
imbalance in 1
st
trimester and genetic factors.
Cleft lip with or without cleft palate occurs in ratio of
1:1000.
Twice common in males as compared to female.
Classification Of Clefts
classification based: on extent of defect classified into
three types:-
CLASS 1: Cleft lip with alveolus (primary
palate).
CLASS 2: Cleft of hard and soft palate
(secondary palate).
CLASS 3: Combination of 1 and 2.



a) Bilateral Cleft Lip b) Single Median
Cleft Lip
CLASS 1
CLASS 2
Classification of Clefts
CLASS 3
Veaus Classification Of Cleft Palate.
Veaus (1922) classified cleft palate into 4 types mainly:-
CLASS 1: Cleft involving soft palate. Can also be
sub-mucous Cleft, which appears normal.
CLASS 2: Midline Cleft involving bone, present only
on posterior part of palate
CLASS 3: Unilateral Cleft extending along mid-
palatine suture and a suture between pre maxilla
and palatine shelf.
CLASS 4: Unilateral Cleft extending along mid-
palatine suture and both sutures between pre-
maxilla and palatine shelf.
Veaus Classification Of Cleft Palate
CLASS 1
CLASS 2
CLASS 3

CLASS 4
Acquired Maxillary Defects
Most acquired maxillary defects occur due to
surgical resection of tumours.
Benign lesions require smaller resection and are
easy to restore.
Malignant tumours require extensive resection,
which are very difficult to restore.
Types of Acquired Maxillary Defects
Maxillary defects are usually classified based on
their extent.
If both maxillae are resected, defect is considered
as total maxillectomy.
Resection of one or a part of maxilla or palate is
considered as partial maxillectomy.
Aramany proposed a classification of partial
maxillary defects based on their extent.
CLASS 1: it is unilateral defect involving one half of
the arch and adjacent palatine shelf. The defect
extend to midline (all teeth in that side of the arch
are missing).
CLASS 2: it is a unilateral defect involving one side
of the arch posterior to the canine (teeth posterior to
canine are absent).
CLASS 3: defect involving the centre of palatine
shelves (all the teeth are present).
Types Of Acquired Maxillary Defects
CLASS 1
CLASS 2
CLASS 3
CLASS 4: it is bilateral defect involving one
side of the arch along with the entire pre-
maxilla (all anteriors along with posteriors of
one side are missing).
CLASS 5: it is bilateral posterior defect (teeth
anterior to second premolar are present).
CLASS 6: it is bilateral anterior defect (teeth
anterior to second premolar are absent).


CLASS 4
CLASS 5
CLASS 6
B. Types Of Mandibular Defects
Congenital Defects Of Mandible
Congenital mandibular defects that require
maxillofacial prosthesis are uncommon.
Common congenital defects of mandible includes
micrognathia, mandibulofacial dysostosis, ankylosis
of tempromandibular joint.
Acquired Defects Of Mandible
Neoplastic resection is one of the most common causes
for an acquired mandibular defect.
Common neoplasia which advocate need for resection
are squamous cell carcinoma of tongue, oropharynx and
floor of the mouth.
These tumours are usually treated by surgery, radiation
or both.


Involvement of deep cervical lymph nodes is
common and hence radical neck dissection is
necessary.
Resection of mandible may often lead to speech
and swallowing dysfunction, which are very difficult
to manage.
Types Of Acquired Mandibular
Defects
Based on amount of resection or bone loss (extent),
mandibular defects can be classified as :-
Continuity Defect: Here superior portion of
mandible is resected and lower border is left intact.
These defects do not show any deviation and are
easy to restore.

Discontinuity Defect: here entire segment of
mandible is resected. Since there is no
connection between remaining parts of
mandible, there will be midline deviation of
mandible due to movement of bone.
Deviation may also occur when remaining
ends are surgically approximated in order to
produce continuity. The amount of facial
disfigurement of these defects is remarkable.
Types Of Acquired Mandibular Defects
Continuity Defect
Discontinuity Defect
Velo-Pharyngeal Defects
They are basically defects of palate, which affects
closure of naso-pharyngeal and oro-pharyngeal
isthmus. This lack of closure affects speech.
Causes Of Velo-Pharyngeal Defects
These defects may result from:-
Congenital malformation (cleft palate)
Developmental aberrations (short hard or soft
palate)
Acquired neurological defects
Surgical resection of neoplasms leading to hyper-
nasality and decrease in intelligibility of speech.
Types Of Volo-Pharyngeal Defects
They can be classified into congenital and acquired
defects.
Congenital Velo-pharyngeal Defects
They are further classified based on physiological and
structural integerity of tissues
Physiological Velo-Pharyngeal Defects (palatal
Incompetence): The velo-pharyngeal structures are
normal but mechanism of closure is absent.
Examples includes patients with neurological
diseases like myasthenia gravis, cerebovascular
accidents like closed head injuries.

Velo-Pharyngeal defects due to poor
structural integrity (palatal insufficiency):
Movements of velo-pharyngeal structures are
normal but length of soft palate is inadequate
to ensure complete velo-pharyngeal closure.
Examples are cleft palate and soft palate.
Acquired Velo-Pharyngeal Defects
They are broadly classified into defects due to
surgical resection of neoplasms and defects
due to trauma and neurological deficiencies.

Treatment Of Velo-Pharyngeal Defects
Congenital Velo-Pharyngeal defects due to palatal
insuffiency can be restored by surgical
reconstruction followed with insertion of an obturator
to correct residual palatal insufficiencies.
Congenital Velo-Pharyngeal defects due to poor
structural integrity can be treated with palatal
surgery.
Acquired Velo-Pharyngeal defects due to surgical
resection can be treated by surgical reconstruction
and prosthodontic rehabilitation (E.g. obturator)
Acquired Velo-Pharyngeal defects due to trauma
and neurological deficiencies can be treated by
prosthodontics rehabilitation using palatal lift
prosthesis.
EXTRAORAL DEFECTS
Extraoral defects occur due to trauma, neoplasms or
congenital malformation. Extraoral defects that occur
due to trauma are dealt separately under traumatic
defects.
The common neoplasia of head and neck include:-
Epithelial tumor
Connective tissue tumor
Extraoral congenital malformation that required
maxillofacial prosthesis include :
Auricular defect
Nasal defect
Ocular defect
Lip and cheek defect
Combination of above
TRAUMATIC DEFECTS
Trauma can be classified as intentional and unintentional.
Intentional include suicide and unintentional include falls,
traffic accidents, burns, etc.
Maxillofacial trauma grossly involves hard tissue fracture
like cranial fracture and soft tissue injuries involving TMJ.
Traumatic patient are usually managed in 4 phases:-
1. First phase- In this there is initial stabilization of patient and
lasts for two weeks.
2. Early management phase, treatment like splintig, RCT,
intermaxillary fixation are done, extend from 2 to 6 weeks
3. Phase of intermediate management- In this treatment
prosthesis is provided to bring tissue to normal contour,
duration is 3months
4. Phase of definitive management- Extends from six months
to three years, permanent prosthesis like CD, FPD, Implant
are fabricated.


TYPES OF MAXILLOFACIAL
PROSTHESIS
COMPLETE DENTURES IN
MAXILLOFACIAL PROSTHETICS

Maxillofacial defects in completely edentulous patients
are usually restored with modified complete dentures.
Since the size and extent of the defects are highly
variable, there are no clearcut principles to govern the
fabrication of the prosthesis.
Complete Dentures for Cleft Lip and Cleft Palate
Patients
It is difficult to plan a complete denture for a cleft palate
patient because the size of the maxilla will be very small
compared to the mandible due to lack of downward and
forward growth.
The palatal vault will be shallow in these patients
alongwith a decreased residual ridge height; this may
lead to compromised stability.



Since the inter-arch distance is usually increased, a class
three relationship is common.
Sufficient support cannot be obtained due to the lack of
bony palate.
Scarring of the soft palate may indiscriminate the vibrating
lines.
The posterior palatal seal cannot be recorded for such
cases. Scar tissues rebound under pressure. Hence relief
should be provided.
The patient should be warned about the compromises in
treatment.
While impression making, small fistulous openings should
be blocked out using a gauze dipped in petroleum jelly.



Metallic oxide and plaster impression material should be
avoided because they may get entangled into the
fistulous openings. Light bodied elastomers are
preferred.
Conventional border moulding should be done using
custom-made special trays. A light bodied rubber base
impression should be made using the border-moulded
tray.
The posterior border of the denture base should end in
the depression between the scars to avoid interference
from the tongue.
The maxillary occlusal rim should be contoured
according to the scarred lip contour.
For aesthetic reasons, the maxillary teeth should be
placed in the maximum possible vertical dimension.
Lower teeth are usually set first and consecutively used
as a guide to set the maxillary anteriors.



Due to the presence of scars, it may be difficult to
record the correct depth of the labial sulcus. The lips
should be repeatedly moved downward, forward and
laterally to record the depth properly.
It may be difficult to fabricate a good temporary
denture base. Hence a permanent denture base
should be fabricated for better stability.
It is advisable to have the patient present during teeth
arrangement.
The tooth adjacent to the labial scar usually lateral
incisor should be set above the occlusal plane with a
slight lingual rotation. This helps to make the scar
less conspicuous.
The labial flange of the denture should be reduced for
aesthetic reasons.



After processing the denture, smalll acrylic projections
and irregularities should be trimmed away prior to
insertion.
Over extension in the labial vestibule should be
corrected only after trying the prosthesis using disclosing
wax.
An obturator bulb may be necessary to seal a posterior
palatal cleft. The bulb can be fabricated over the denture
few weeks after denture insertion.
Complete dentures for total maxilectomy
defects
In these patients, a huge defect will be present in the
upper jaw. One half of the residual ridge will be missing.
Retention will be very poor because of air leakage, poor
support and stability, reduced tissue bearing surface
area and lack of a proper peripheral seal.

The contour of the defect and the remaining portion of the
hard, palate should be used/ engaged to maximise the
retention of the prosthesis.
Similarly the height and contour of the remaining residual
alveolar ridge will determine the stability of the denture.
The portion of the complete denture that extends into the
defect is denoted as the obturator of the denture.
Patients with square or ovoid arch have better retention and
stability than those with tapered arches. This is due to the
increase in surface area.
The junction between the skin graft lining placed on the
defect and the oral mucosa will form a scar band. This scar
band is flexible enough to allow the insertion of the
prosthesis and taut enough to prevent sudden dislodgement
of the prosthesis.
It acts like a 'purse string' providing emergency retention.
Hence, it is important for the denture extension to
engage this scar band for better retention.
Additional-retention can be obtained by extending the
denture into the nasal surface of the soft palate or into
the nasal aperture. A flexible material should be used for
these extensions to prevent irritation to the respiratory
epithelium above.
Impression is usually made using irreversible
hydrocolloids. The surface of the defect should be
cleaned free of mucous crusting prior to impression
making.

Undercuts in the defect are loaded with syringe material
prior to seating the tray material.
Diagnostic casts are fabricated using dental plaster and the
unfavourable undercuts are blocked out on the cast.
Sectional border moulding is preferred. The peripheral areas
are moulded first. Next the graft area in the defect is
moulded followed by the scar band.
Soft palate tracing is more important in these cases
because it determines the functional stability of the
prosthesis during speech and swallowing.
Modelling plastic is relieved to provide space for the
impression material and impression making is done as usual.
The vertical dimension of occlusion should be recorded in the
conventional manner. Soft wax, registration paste or silicone
can be used as the recording medium.
Since the maxillary cast in these patients will usually be large
(as it includes the defect), modified articulators like TMJ
articulators can be used for articulation.
Occlusion is set according to the contours of the wax rims and
the anatomical landmarks. Denture try-in is done as usual.
The master cast may have larger extensions than those in the
trial base. Hence over-extensions are possible in the final
prosthesis.


Soft silicone materials can be used for the obturator
segment of the prosthesis. The silicone obturator can have
a stud type connection with the denture so that the obturator
component can be changed as required.

The tissue surface of the denture should be highly polished
using pumice to reduce the frictional assault produced by
the dentures to the tissues during function.

Pressure indicating paste or disclosing waxes can be used
to check for overextension of the prosthesis.

Usually these dentures may require relining as the defect
may remodel due to tissue organization.


Complete dentures for partial maxillectomy
defects
These patients have better prognosis than total
maxillectomoy defects.
The rotation of the denture may vary according to the
location of the defect.
The prognosis of the denture may vary according to the size
of the defect.
Fabrication procedure is as described for total maxillectomy
defects
Complete dentures for lateral discontinuity
defects of the mandible
here only one half or two-thirds of the mandible is present.
Hence, the retention and stability are compromised.
Most patients with such defects would have been treated with
therapeutic radiation and hence will have an atrophic and
fragile mucosa, susceptible to soft tissue irritation and
ulceration.
Reduced salivary output and presence of thick mucinous saliva
will impair retention.
A-bnormal pathway of mandibular closure will induce lateral
dislodging forces on the denture. Mandibular deviation with
abnormal profile and jaw relation will affect the normal
arrangement of artificial teeth.

The factors that determine the prognosis of these dentures are:
The extent of bone and soft tissue resection (smaller
resection has better prognosIs).
The involvement of tongue, floor of mouth and buccal
mucosa during resection.
The motor and sensory control of the tongue.
The mobility and bulk of the tongue.
Mandibular deviation
Position of the tongue (if the base of the tongue was
resected it will have a retruded position).
The nature of mandibular movements.
Postsurgical lip closure and control (usually the lower lip
on the resected side will be retracted posteriorly leading
to lip and cheek biting).
Post-radiation effects


While border moulding, the non-resected side should be
traced to its full depth.
The lingual flange of the resected and non-resected side
should be recorded accurately to improve both the
placement and retention of the denture.
The support of the prosthesis can be obtained from the
buccal shelf, crest of the ridge, retromolar pad and the soft
tissue pad posterior to the bony resection.
The lip and cheek on the resected side will be heavily
scarred and can dislodge the prosthesis. The denture flange
should be designed such that it repositions the lower lip on
the resected side.This labial flange is referred to as the Lip
plumper.
While recording the jaw relation, the labial / fullness of the
maxillary occlusal rim should be reduced in order to make
the jaw discrepancy less conspicuous.

The vertical dimension of occlusion should be reduced or
patients with Iimited tongue movement in order to
facilitate speech.
The posterior teeth on the non-resected side should be
positioned more buccally in order to transmit more forces
along the supporting areas.
The posterior teeth on the resected side should be
positioned lingual to the crest so that the occlusion is
improved. The scars in the buccal mucosa may be
unyielding and displace the denture. This is prevented by
the lingual placement of the teeth.
Occlusal ramps should be developed on the opposing
maxillary denture according to the severity in the
occlusal discrepancy. The occlusal ramp should be
placed buccally in the resected side and palataly on the
non-resected side.
The mandibular teeth should be able to contact the ramp
without any guidance. Tracing wax is added over the
ramps and the mandibular movements should be earned
out to check for positive contact.
Other steps in the fabrication of the prosthesis are
carried out as ususal.
The patient should be instructed to avoif uding denture
during recall visits to improve oclusion.
Lip plumpers may be added with auto-polymerising resin
in order to reduce lip biting.
Removable Partial Dentures for a Cleft Lip and Cleft
Palate Patient
Fabrication is similar to that for a normal patient.
Removable partial dentures with a palatal lift - prosthesis
with/without an obturator should be provided for patients
with cleft lip associated with soft palate defect
(velopharyngeal deficiency).
Tortuous fistula like openings may be present in patients
where a bone graft was not provided to fill the cleft. In
order to prevent the impression material from entangling
into these defects, gauze dipped in petroleum jelly
should be placed over the site during impression making.

There will be severe scarring in the healed soft tissue.
These tissue scars will appear as tortuous folds of firm
mucosa. In such cases, the removable partial denture
should be designed such that its margins follow the scars
and do not cross the scars.
The thickness of the beading along the margins of the
major connector should be reduced for these patients.
Removable Partial Dentures for Total Maxillectomy
Defects
The size of the defect influences the stability of the
prosthesis. Bigger defects provide minimal support and the
prosthesis will be heavy and bulky. The prosthesis will have
maximal rotation on the defective side and the gravitational
forces (downward pull) may aggravate the problem.

The prosthesis should be designed to distribute
masticatory forces to the edentulous ridge and the
remaining teeth in a balanced manner. The mucosal and
bony support will be compromised due to surgical
resection.
Square or ovoid arch forms have a better prognosis than
tapered arch forms. Tapered arch forms have reduced
surface area. This can lead to rotation and movement of
the prosthesis into the defect during mastication.
Preservation of remaining teeth is a primary concern of
treatment. The prosthesis should be designed such that
the abutment teeth are protected from excessive forces.
The occlusion on the defective side will determine the .
occlusal forces acting on the abutment teeth.
Compromised abutment teeth may be treated
endodontically and the crown can be amputated. The
remaining root can be used as an over denture abutment.
The fulcrum line of the prosthesis is influenced by the
following factors:
Position of the occlusal and cingulum rests.
Size and configuration of the defect.
Location and magnitude of the masticatory forces on
part of the prosthesis that restores the defect.
The patients may exhibit varying degrees of trismus. If
the depth of the palate and the height of the artificial teeth
or components of the partial denture is greater than the
maximum opening distance between the incisor teeth, the
prosthesis cannot be inserted or removed.
The patient usually tends to bite on the anterior teeth.
The masticatory forces on the artificial anterior teeth can
displace the denture. Hence, the patient should be
instructed to masticate primarily on the non-defctive side.
The finish lines of the cast metal framework should be on
the palatal mucosa and 2 mm short of the palatal shelf.
Removable Partial Dentures for Partial Maxillectomy
Defects
The prosthodontic considerations are similar to total
maxillectomy cases. But these patients have a " better
prognosis.
The presence of a canine on the defective side
enhances the stability and support.
If there are remaining natural teeth on the defective side,
the fulcrum line shifts posteriorly. The indirect retainers
should be placed as anterior to the fulcrum line as
possible.
Placement of a retainer adjacent to the defect
increases the stability and retention.
The fabrication is similar to that for total
maxillectomy defects.
If there are small defects, gauze pieces should
be used to block the defects to prevent the
impression material from entering the paranasal
sinuses.
If there are edematous turbinates extending onto
the palate, it will interfere with the restoration of
the palatal contour. These turbinates have to be
surgically removed before impression making.


Removable Partial Dentures for Other
Acquired Maxillary Defects
Small, localised defects can occur after excision of benign
lesions. The alveolar ridge and the teeth are minimally
involved in the resection. The obturotor must maintain
contact with the soft palate as it lifts from the prosthesis
during function. The obturator acts as a shield and directs
the liquids and food into the oropharynx.
A scar band is usually present at the junction of the oral
and nasal mucosa. The prosthesis should extend as
superiorly as possible without interfering with the nasal
functions.
Removal of large portions of the orbital floor can lead to
misalignment of the eyeballs and diplopia. A flexible
superior orbital extension can be attached with obturator to
uplift the orbital contents. Care must betaken to avoid
excessive contact and trauma to the fragile nasal mucosa.
Removable Partial Dentures for Continuity
Maintained or Re-established Mandibular
Defects
Removable Partial Dentures foe Anterior Defects:-
The anterior edentulous segment shows unusual soft
tissue configurations and compromise bony support.
Large defects show obliterated vestibules and lack of
attached , mucosa. These cases may require vestibulo-
p!asty and placement of skin grafts.
A scar band is usually present across the residual
anterior alveolar ridge between the lip and the tongue.
These bands can displace the prosthesis and can be
traumatised by the prosthesis.
Occlusal abnormalities will occur in cases with anterior
discontinuity defects, which were improperly restored
with poorly positioned segments. The occlusion is rarely
altered in - cases with continuity defects and the pattern
of mandibular movement is normal.
Masticatory efficiency may be compromised when there
is a large anterior defect. Implants may be needed for
additional support.
Removable Partial Dentures for Lateral Defects
These patients will have posterior teeth only - on one
side of the arch. Presence of long lever arms and
compromised supporting tissues may complicate the
situation.
During mastication, the anterior and posterior proximal
plates move freely during function. The labial retainer on
the cuspid disengages under occlusal load. This excess
load on the abutments is avoided.
The posterior retainer and lingual plating aid in retention
and bracing.
Maximum coverage of the edentulous area is needed.
The patient is instructed to bite on the non defective side with the
remaining mandibular teeth.
FIXED PARTIAL DENTURES IN MAXILLOFACIAL
PROSTHETICS
Fixed Partial Denture for a Cleft Lip and Cleft Palate
Patient
If bone raft was done to complete an alveolar cleft, an
implant supported single tooth replacement or a regular
three-unit bridge can be fabricated.
If bone graft was not provided to fill the alveolar cleft, a fixed
partial denture with additional secondary abutments on
either side of the defect should be involved.
Discoloured natural teeth should be restored with composite
or porcelain veneers.
OBRURATORS AND VELO-
PHARYNGEAL PROSTHESIS
OBRURATORS
"A prosthesis used to close a congenital or
acquired tissue opening primarily of the hard
palate and/or contiguous alveolar structures.
Prosthetic restoration of the defect often
includes use of a surgical obturat.
Rehabilitation of maxillary resection is done in
three phases. During the first phase, a surgical
obturator is placed. An interim obturator is
placed in the second phase and a definitive
obturator is placed during the third or final
phase.
Types of Obturators
Obturators can be classified:
Based on the phase of treatment
Based on the material used
Based on the area of restoration
Based on the Phase of Treatment
Surgical obturators
It is defined as, "A temporary prosthesis used to
restore the continuity of the hard palate
immediately after surgery or traumatic loss of a
portion or all of the hard palate and or continuous
alveolar structures (i.e., gingival tissue, teeth)".
It is of two types namely:-
Immediate surgical obturator: It is inserted at the time
of surgery.
Delayed surgical obturator: It is inserted 7 to 10 days
after surgery.
Interim obturators:-
It is defined as, "A prosthesis that is made several
weeks or months following the surgical resection of a
portion of one or both maxillae. It frequently includes
replacement of teeth in the defect area, This
prosthesis, when used, replaces the surgical obturator
that is placed immediately following the resection and
may be subsequently replaced with a definitive
obturator" .
Definitive obturators:-
It is defined as, "A prosthesis that artificially replaces
part or all of the maxilla and the associated teeth lost
due to surgery or trauma.
Based on the Material Used :-
Based on the material used, obturators can be classifie
in to:
Metal obturators
Resin obturators
SIlIcone obturators
Based on the Area of Restoration
Palatal obturator
Meatal obturator
Clinical Considerations
Surgical obturator is inserted on the day of the surgery.
A preliminary cast is obtained before surgery on which a
mock surgery is performed.
A clear acrylic plate is fabricated and inserted after
surgery.
If the patient is dentulous, retention is obtained with simple
clasps.
If the patient is edentulous, the obturator is wired into the
alveolar ridge and the zygomatic arch.
The immediate surgical obturator is retained for 7 to 10
days after surgery.
A delayed surgical obturator is inserted 7 to 10 days after
surgery.
This may be converted into an interim obturator by the
addition of a lining material.
This obturator is retained for 3 to 4 months post
surgically. It is replaced with an interim or definitive
obturator after complete healing of the surgical wound.
Uses
Provides a stable matrix for surgical packing.
Reduces oral contamination.
Speech will be effective post-operatively.
Permits deglutition
Reduces the psychological impact of the surgery
May reduce the period of hospitalisation.

Meatal Obturator
It is a special type of obturator that extends upto
the nasal meatus.
It establishes closure with the nasal structures at a
level posterior and superior to the posterior border
of hard palate. The closure is established against
the conchae and the roof of the nasal cavity.
It separates the oral and the nasal cavities.
It is indicated in patients with extensive soft palate
defects.
Disadvantages
Nasal air emission cannot be controlled because it
is in an area where there is no muscle function.
Nasal resonance will be altered.
Palatal Lift Prosthesis
It is a special type of obturator, which is a definitive prosthesis with a
posterior extension.
It is helpful in restoring palato-pharyngeal incompetence where the
soft palate musculature is compromised, E.g. myasthenia gravis,
bulbar poliomyelitis. cerebral palsy.
It can be clubbed with an obturator if needed.
Advantages:-
Minimised gag response
Tongue physiology swallowing, mastication and speech are not
compromised.
Access to the nasopharynx for the obturator is facilitated.
The palatal lift portion can be added later as desired.
Contraindications
If adequate retention is not available for the basic prosthesis.
If the palate is not displacable.
Un-cooperative patients.

EXTRA-ORAL PROSTHESIS
Auricular Prosthesis
It is an ear prosthesis.
It is fabricated from impressions made with silicone or irreversible
hydrocolloids. During impression making, the patient is made to lie
in a supine position. The defect area should be confined with wax.
50% additional water
can be added while mixing irreversible hydrocolloids to increase the
flow.
A plaster with gauze backing can be used to support the impression.
The shape of the ear can be formed with reference to a pre-surgical
cast or using the healthy ear. This procedure of shaping the ear is
known as sculpting.
Stippling is done to match the texture of the prosthesis with the
adjacent skin. It also facilitates extrinsic tinting. It provides
mechanical retention for extrinsic colorants.
Feathering is done on the margins of the wax pattern.
Extra-Oral Prosthesis
The prosthesis is flasked in a three part mould and the
material (acrylic or silicone) is processed as usuaI.
The retention of the prosthesis is through ear-glass
frames or tissue adhesives or extensIon of prosthesis
into ear canal. Nowadays osseointegrated implant
retained prosthesis are given.
Nasal Prosthesis
It is fabricated for rhinectomy patients.
There are two types of nasal prosthesis namely
temporary and permanent.
The temporary prosthesis is placed 3 to 4 weeks after
surgery. It is usually made of heat cure acrylic as it can
be relined. Most of the' temporary prosthesis are
retained with adhesives. It can be used for a maximum
of 3 to 4 months.
The permanent prosthesis is fabricated as described for
auricular prosthesis.
During impression making, care should be taken to block
the nasal passages and prevent the entry of impression
material.
Nasal Prosthesis
Ocular Prosthesis
It is used to replace enucleated eyes. One should
remember that the lacrimal aparatus (eyelids and
associated glands) is intact in these patients. Hence the
prosthesis only replaces eyeball. The impression is
made with irreversible hydrocolloids.
A special tray is fabricated.
The secondary impression is made with irreversible
hydrocolloids.
Casts are poured in two sections with two keyways in the
first pour and separating medium. Sclera is fabricated
with wax.
It is tried in the eye socket and evaluated for Iid
contours.
Following which, it is flasked and de-waxed.
Special scleral white acrylic resin is available for such
procedures.
Scleral resin is packed, processed, trimmed and polished as usual.
Next the ocular barf prosthesis is tried in the patient's defect.
The position of the iris is determined during the trial procedure. The
patient is made to relax. The dentist should mark the location of the
iris by comparing it with the unaffected eye on the other side.
The iris is placed and fused to the scleral prosthesis. A cut back is
created in the sclera to seat the iris button.
Characteristic pigmentations on the iris can be apprhended
according to the shade of the other ' eye. This procedure is known
as Iris painting.
Patient's Instructions
The patient is asked to remove the prosthesis atleast
once a day for cleaning.
The prosthesis should never be exposed to alcohol as it
may discolour the prosthesis and the painting.
TREATMENT PROSTHESIS
A treatment prosthesis can be defined as, "A prosthetic
appliance used for the purpose of treating or conditioning
the tissues that are called on to support and retain it"
Commonly used treatment appliances include surgical
obturators, mandibular training flanges and radiation
appliances.