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Obturators/ orthodontic seminars

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Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.

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  • 1. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 2. ObturatorsObturators INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.comwww.indiandentalacademy.comwww.indiandentalacademy.com
  • 3. ContentsContents  IntroductionIntroduction  DefinitionsDefinitions  Maxillofacial defect classificationMaxillofacial defect classification  Care for patient with acquired defectsCare for patient with acquired defects  Intraoral Prosthesis design considerationsIntraoral Prosthesis design considerations  Benefits of surgical preservationBenefits of surgical preservation  Obturator prosthesisObturator prosthesis  Speech aid prosthesisSpeech aid prosthesis  ConclusionConclusion  ReferencesReferences www.indiandentalacademy.comwww.indiandentalacademy.com
  • 4. IntroductionIntroduction www.indiandentalacademy.comwww.indiandentalacademy.com
  • 5. DefinitionsDefinitions  Obturator: are maxillofacial prosthesis used to close aObturator: are maxillofacial prosthesis used to close a congenital or acquired tissue opening, primarily of thecongenital or acquired tissue opening, primarily of the hard palate and/ or contiguous alveolar/soft tissuehard palate and/ or contiguous alveolar/soft tissue structures – GPT 8structures – GPT 8  Surgical obturator: a temporary maxillofacial prosthesisSurgical obturator: a temporary maxillofacial prosthesis inserted during or immediately following surgicalinserted during or immediately following surgical traumatic loss of a portion or all of one or both maxillarytraumatic loss of a portion or all of one or both maxillary bones and continuous alveolar structures (i.e. gingivalbones and continuous alveolar structures (i.e. gingival tissue, teeth). – GPT 8tissue, teeth). – GPT 8 www.indiandentalacademy.comwww.indiandentalacademy.com
  • 6.  Interim obturator: a maxillofacial prosthesis which IsInterim obturator: a maxillofacial prosthesis which Is made following completion of initial healing followingmade following completion of initial healing following surgical resection of a portion or all of one or bothsurgical resection of a portion or all of one or both maxillae; frequently many or all teeth in the defect areamaxillae; frequently many or all teeth in the defect area are replaced by this prosthesis. GPT 8are replaced by this prosthesis. GPT 8  Palatal augmentation prosthesis : a removablePalatal augmentation prosthesis : a removable maxillofacial prosthesis which alters the hard and/or softmaxillofacial prosthesis which alters the hard and/or soft palate's topographical form adjacent to the tongue. GPTpalate's topographical form adjacent to the tongue. GPT 88 www.indiandentalacademy.comwww.indiandentalacademy.com
  • 7.  Palatal lift prosthesis: on maxillofacial prosthesis whichPalatal lift prosthesis: on maxillofacial prosthesis which elevates the soft palate superiorly and aids in restorationelevates the soft palate superiorly and aids in restoration of soft palate functions which may be lost due to anof soft palate functions which may be lost due to an acquired, congenital or developmental defect. GPT 8acquired, congenital or developmental defect. GPT 8  Speech aid prosthesis: a removable maxillofacialSpeech aid prosthesis: a removable maxillofacial prosthesis used to restore an acquired or congenitalprosthesis used to restore an acquired or congenital defect of the soft palate with a portion extending into thedefect of the soft palate with a portion extending into the pharynx to separate the oropharynx and nasopharynxpharynx to separate the oropharynx and nasopharynx during phonation and deglutition, thereby completing theduring phonation and deglutition, thereby completing the palatopharyngeal sphincter. GPT 8palatopharyngeal sphincter. GPT 8 www.indiandentalacademy.comwww.indiandentalacademy.com
  • 8. Maxillofacial classificationMaxillofacial classification  Patients can be categorized by maxillofacial defects thatPatients can be categorized by maxillofacial defects that are acquired, congenital, or developmental.are acquired, congenital, or developmental.  Acquired: e.g. include soft or hard palate defectsAcquired: e.g. include soft or hard palate defects resulting from removal of SCC of that region.resulting from removal of SCC of that region.  Congenital defects: e.g. include various degrees ofCongenital defects: e.g. include various degrees of clefts of hard and soft palate.clefts of hard and soft palate.  Developmental defectsDevelopmental defects www.indiandentalacademy.comwww.indiandentalacademy.com
  • 9. Classification based onClassification based on prosthesis underprosthesis under considerationconsideration Extraoral : cranial orExtraoral : cranial or facial replacementfacial replacement Intraoral : involvingIntraoral : involving the oral cavitythe oral cavity www.indiandentalacademy.comwww.indiandentalacademy.com
  • 10. Duration and time of use Treatment Interim Definitive www.indiandentalacademy.comwww.indiandentalacademy.com
  • 11. Etiology of palatal and PNS defectsEtiology of palatal and PNS defects  Almost all acquired palatal defects a result of resectionAlmost all acquired palatal defects a result of resection of neoplasms.of neoplasms. -Curtis (JPD 1967:18;70)-Curtis (JPD 1967:18;70)  Head & Neck Cancer inflicts a formidable physical,Head & Neck Cancer inflicts a formidable physical, psychological and socio-economic burden on patients,psychological and socio-economic burden on patients, their families and on health care providers.their families and on health care providers.  Relatively unknownRelatively unknown  Lack of public awarenessLack of public awareness  60% late presentation60% late presentation  Dental profession has an important role to play in theDental profession has an important role to play in the prevention and early detection of HNCprevention and early detection of HNC www.indiandentalacademy.comwww.indiandentalacademy.com
  • 12. Primary Prevention  Education  Largely preventable disease  Tobacco use, along with alcohol, accounts for 75% - 90% oral, pharyngeal, laryngeal, esophageal cancers (US Surgeon General 2000) www.indiandentalacademy.comwww.indiandentalacademy.com
  • 13. Secondary preventionSecondary prevention Informed Public  Non healing ulcer  Red/white speckled area  Red velvety area  Pigmented area or lump  Neck mass  Speech changes  Swallowing difficulty  Unilateral sore throat Dental Profession  Opportunistic Screening  High index of suspicion  Quick early diagnosis  Early appropriate referral www.indiandentalacademy.comwww.indiandentalacademy.com
  • 14. Multidisciplinary team approachMultidisciplinary team approach www.indiandentalacademy.comwww.indiandentalacademy.com
  • 15. Prosthetic treatment for patientsProsthetic treatment for patients with acquired surgical defectswith acquired surgical defects  Prosthodontic treatment can be an arbitrarily divided intoProsthodontic treatment can be an arbitrarily divided into - initial phase- initial phase - secondary phase- secondary phase  Acquired defects of the hard and soft palate can beAcquired defects of the hard and soft palate can be managed by the use ofmanaged by the use of  Removable prosthesisRemovable prosthesis  Surgical closureSurgical closure  Implant supportedImplant supported www.indiandentalacademy.comwww.indiandentalacademy.com
  • 16. Care for patient with acquiredCare for patient with acquired defectsdefects  Initial emphasis is on surgical requirements,Initial emphasis is on surgical requirements, later prosthetic requirementslater prosthetic requirements  Divided intoDivided into • Pre operativePre operative • IntraoperativeIntraoperative • InterimInterim • Definitive careDefinitive care www.indiandentalacademy.comwww.indiandentalacademy.com
  • 17. Pre and Intraoperative carePre and Intraoperative care  Planning should begin before surgeryPlanning should begin before surgery  Patients should be seen by the Prosthodontist beforePatients should be seen by the Prosthodontist before the surgerythe surgery  Dental objectivesDental objectives - Removal of potential dental, postoperative ComplicationsRemoval of potential dental, postoperative Complications - Planning for subsequent prosthetic treatmentPlanning for subsequent prosthetic treatment - Make recommendations for surgical site preparation thatMake recommendations for surgical site preparation that may improve surgical integritymay improve surgical integrity www.indiandentalacademy.comwww.indiandentalacademy.com
  • 18. - Temporary restoration for large carious lesionsTemporary restoration for large carious lesions - Treatment of acute conditionsTreatment of acute conditions - Extraction of hopeless teethExtraction of hopeless teeth - Impression is made for fabrication of surgical obturatorImpression is made for fabrication of surgical obturator - Initiation of planning for definitive prosthesisInitiation of planning for definitive prosthesis www.indiandentalacademy.comwww.indiandentalacademy.com
  • 19. Surgical obturationSurgical obturation  Accomplished by a variety of restorations and materialsAccomplished by a variety of restorations and materials  James- Raines 1955: spongesJames- Raines 1955: sponges  Steadman 1957: gutta perchaSteadman 1957: gutta percha  Hammond 1966, King 1978: inflatable bulbHammond 1966, King 1978: inflatable bulb  It may be either delayed surgical obturation {six to tenIt may be either delayed surgical obturation {six to ten days later} or immediate surgical obturation, indicated fordays later} or immediate surgical obturation, indicated for most patientsmost patients www.indiandentalacademy.comwww.indiandentalacademy.com
  • 20. Immediate surgical obturatorImmediate surgical obturator  Objective is to separate oral and nasal cavitiesObjective is to separate oral and nasal cavities AdvantagesAdvantages - Prosthesis acts as a matrix for dressingProsthesis acts as a matrix for dressing - Reduced wound contaminationReduced wound contamination - Speech is betterSpeech is better - Deglutition, nasogastric tube can be removed earlyDeglutition, nasogastric tube can be removed early - Psychological supportPsychological support Surgical prosthesis not removed- seven to ten days postSurgical prosthesis not removed- seven to ten days post surgicallysurgically www.indiandentalacademy.comwww.indiandentalacademy.com
  • 21. Design considerationsDesign considerations www.indiandentalacademy.comwww.indiandentalacademy.com
  • 22. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 23. FabricationFabrication www.indiandentalacademy.comwww.indiandentalacademy.com
  • 24. Delayed surgical obturationDelayed surgical obturation  Placed seven to ten days post surgicallyPlaced seven to ten days post surgically  Patient is the edentulous and surgical effect is extensivePatient is the edentulous and surgical effect is extensive this approach is the treatment of choicethis approach is the treatment of choice  Posterior occlusal ramps helps keep the prosthesis inPosterior occlusal ramps helps keep the prosthesis in place for edentulous patientsplace for edentulous patients  Existing dentures may also be usedExisting dentures may also be used www.indiandentalacademy.comwww.indiandentalacademy.com
  • 25. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 26. Common complicationsCommon complications  Mostly related to tissue trauma and associatedMostly related to tissue trauma and associated discomfortdiscomfort  Inadequate retentionInadequate retention  Incomplete obturation with associated leakageIncomplete obturation with associated leakage  Tissue effects of radiotherapy and chemotherapyTissue effects of radiotherapy and chemotherapy www.indiandentalacademy.comwww.indiandentalacademy.com
  • 27. Defect and oral hygieneDefect and oral hygiene  Following surgical pack removal, the defect site willFollowing surgical pack removal, the defect site will mature with time.mature with time.  Patient’s apprehensions regarding his new oral findingsPatient’s apprehensions regarding his new oral findings must be addressedmust be addressed  As they become more familiar with the defect theyAs they become more familiar with the defect they should be encouraged to clean the defect of food debrisshould be encouraged to clean the defect of food debris and mucous secretions routinelyand mucous secretions routinely  Defect hygiene will allow timelier healing and ability toDefect hygiene will allow timelier healing and ability to adequately fit a prosthesisadequately fit a prosthesis www.indiandentalacademy.comwww.indiandentalacademy.com
  • 28. Defect and oral hygieneDefect and oral hygiene  Common hygiene practices include;Common hygiene practices include; - Lavage procedures, including rinsing, using bulb syringeLavage procedures, including rinsing, using bulb syringe or modified oral irrigation deviceor modified oral irrigation device - Manual cleaning with sponge-handled cleaning aidManual cleaning with sponge-handled cleaning aid - Daily Fluoride application for radiotherapy patientsDaily Fluoride application for radiotherapy patients www.indiandentalacademy.comwww.indiandentalacademy.com
  • 29. Interim obturatorInterim obturator  Interim prosthesis are wireInterim prosthesis are wire retained do not have teethretained do not have teeth initially but later may be addedinitially but later may be added after a period ofafter a period of accommodationaccommodation  Duration of interim phase isDuration of interim phase is three monthsthree months  Primary objective is to allowPrimary objective is to allow the patient to pass from activethe patient to pass from active surgical phase to observationalsurgical phase to observational phase with minimumphase with minimum complicationscomplications www.indiandentalacademy.comwww.indiandentalacademy.com
  • 30. Definitive careDefinitive care  3-4 months post surgery3-4 months post surgery depending on size of defect,depending on size of defect, progress of healing, tumorprogress of healing, tumor prognosis, presence orprognosis, presence or absence of teeth, definitiveabsence of teeth, definitive obturator is planned.obturator is planned.  Defect is engaged moreDefect is engaged more aggressively for edentulousaggressively for edentulous patients hence healingpatients hence healing period is prolonged.period is prolonged. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 31. GoalsGoals  Well supported, stable, retentive prosthesis that isWell supported, stable, retentive prosthesis that is acceptable in appearance and exhibits minimumacceptable in appearance and exhibits minimum movement under function.movement under function.  Thereby preserving maximum amount of supportingThereby preserving maximum amount of supporting tissuetissue  Can be achieved by:Can be achieved by: www.indiandentalacademy.comwww.indiandentalacademy.com
  • 32. Surgical preservation for prosthetic benefit  Surgical outcomes that impact prosthetic success: - Those that impact the amount of max. structure removed - Those that impact the structural integrity and quality of defect www.indiandentalacademy.comwww.indiandentalacademy.com
  • 33.  Primary prosthetic objectives are: - Restoration of physical separation of oral and nasal cavities to restore - Mastication - Deglutition - Speech - Facial contour www.indiandentalacademy.comwww.indiandentalacademy.com
  • 34.  When possibleWhen possible preservation of as muchpreservation of as much of inferior sinus floor,of inferior sinus floor, hard palate, alveolus andhard palate, alveolus and teeth should beteeth should be consideredconsidered  If resection leaves <1/3If resection leaves <1/3rdrd soft palate entire softsoft palate entire soft palate must be removedpalate must be removed except in edentulousexcept in edentulous patientspatients  Use of split thickness skinUse of split thickness skin graftsgrafts www.indiandentalacademy.comwww.indiandentalacademy.com
  • 35. Types of prosthesisTypes of prosthesis Obturator prosthesis Speech aid prosthesis Others www.indiandentalacademy.comwww.indiandentalacademy.com
  • 36. Obturator Speech aid prosthesis www.indiandentalacademy.comwww.indiandentalacademy.com
  • 37. Obturator prosthesisObturator prosthesis  The defining characteristic of an obturatorThe defining characteristic of an obturator prosthesis is that it serves to restore separationprosthesis is that it serves to restore separation of the oral and adjacent cavities following surgicalof the oral and adjacent cavities following surgical resection of tumors of nasal and paranasal regionresection of tumors of nasal and paranasal region www.indiandentalacademy.comwww.indiandentalacademy.com
  • 38. Armany classification www.indiandentalacademy.comwww.indiandentalacademy.com
  • 39. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 40. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 41. Treatment concepts  Factors to be considered - Movement of the prosthesis - Tissue changes - Covering prosthesis - Extension into defect - Teeth - Weight of prosthesis www.indiandentalacademy.comwww.indiandentalacademy.com
  • 42. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 43. Edentulous patients with totalEdentulous patients with total maxillectomy defectsmaxillectomy defects  With any large defect restoration in the classical sense isWith any large defect restoration in the classical sense is not possiblenot possible  According to Desjardins (1978) the contours of theAccording to Desjardins (1978) the contours of the defect must be used to maximize RSS for the prosthesisdefect must be used to maximize RSS for the prosthesis  In most patients acceptable RSS can be gained from:In most patients acceptable RSS can be gained from: - Residual palatal structureResidual palatal structure - Engaging the defectEngaging the defect www.indiandentalacademy.comwww.indiandentalacademy.com
  • 44. Residual palatal structure www.indiandentalacademy.comwww.indiandentalacademy.com
  • 45. The defectThe defect  Acceptable retention canAcceptable retention can be gained by engagingbe gained by engaging key areas in the defectkey areas in the defect www.indiandentalacademy.comwww.indiandentalacademy.com
  • 46.  Lateral portion of the obturator exhibits greatest degree of movement, retention can be improved by appropriate obturator- tissue contact superolaterally. (Brown, 1968) www.indiandentalacademy.comwww.indiandentalacademy.com
  • 47. Steps in fabricationSteps in fabrication  Preliminary impressionPreliminary impression  Master impressionMaster impression  Vertical dimension of occlusionVertical dimension of occlusion  Occlusal scheme selectionOcclusal scheme selection  ProcessingProcessing  Delivery and follow upDelivery and follow up www.indiandentalacademy.comwww.indiandentalacademy.com
  • 48. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 49. Edentulous patients with partialEdentulous patients with partial maxillectomy defectsmaxillectomy defects  More of the hard palateMore of the hard palate may be available formay be available for supportsupport  Retention may beRetention may be compromised as accesscompromised as access to the defect is limitedto the defect is limited  Defect should beDefect should be optimally utilized, softoptimally utilized, soft silicones are especiallysilicones are especially usefuluseful www.indiandentalacademy.comwww.indiandentalacademy.com
  • 50. Dentulous patients with total or partial maxillectomy defects  Prognosis improves with availability of teeth to assist with RSS  Treatment concepts - Location of the defect - Movement of the prosthesis - Length of the lever arm - Arch form - Teeth - Partial denture design - Prosthetic procedures www.indiandentalacademy.comwww.indiandentalacademy.com
  • 51. Basic principles of obturator deignBasic principles of obturator deign  The system of forces :The system of forces : - Vertical dislodging force – reduce weight of prosthesisVertical dislodging force – reduce weight of prosthesis - Occlusal vertical force – multiple rests and maximumOcclusal vertical force – multiple rests and maximum coveragecoverage - Lateral forces – proper occlusal schemeLateral forces – proper occlusal scheme - Anterior – posterior movement counteracted by proximalAnterior – posterior movement counteracted by proximal guide planesguide planes www.indiandentalacademy.comwww.indiandentalacademy.com
  • 52. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 53. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 54. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 55. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 56. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 57. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 58. Lab proceduresLab procedures  Fabrication of obturatorFabrication of obturator - SolidSolid - Open bulbOpen bulb - Hollow bulbHollow bulb - 2-piece2-piece - Single pieceSingle piece www.indiandentalacademy.comwww.indiandentalacademy.com
  • 59. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 60. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 61. One step hollow bulb obturatorOne step hollow bulb obturator www.indiandentalacademy.comwww.indiandentalacademy.com
  • 62. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 63. Speech considerationsSpeech considerations  Surgical removal of a portion of maxilla if not restored,Surgical removal of a portion of maxilla if not restored, surgically / prosthodontically, can create a serioussurgically / prosthodontically, can create a serious problem for speaker for several reasons:problem for speaker for several reasons: - Oral- nasal resonance balance lost leading to hypernasalOral- nasal resonance balance lost leading to hypernasal speechspeech - Articulation of speech lost with loss of palatal tissueArticulation of speech lost with loss of palatal tissue - Loss of anterior teeth further complicates speechLoss of anterior teeth further complicates speech articulationarticulation www.indiandentalacademy.comwww.indiandentalacademy.com
  • 64.  Bloomer and Hawk, 1973, suggested that maxillaryBloomer and Hawk, 1973, suggested that maxillary resection affects palatopharyngeal function by,resection affects palatopharyngeal function by, - Destroying attachment for pharyngeal musculatureDestroying attachment for pharyngeal musculature - Denervation of pharyngeal musculatureDenervation of pharyngeal musculature - Relative shrinkage and immobilization of soft palateRelative shrinkage and immobilization of soft palate through scar contractionthrough scar contraction  When maxillectomy is confined to the bony palate,When maxillectomy is confined to the bony palate, speech following placement of a prosthesis is withinspeech following placement of a prosthesis is within normal limits.normal limits. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 65. Restoration of soft palate defectsRestoration of soft palate defects www.indiandentalacademy.comwww.indiandentalacademy.com
  • 66. Palatopharyngeal functionPalatopharyngeal function ::  Hypernasality and decreased intelligibility of speechHypernasality and decreased intelligibility of speech may result from congenital or acquired defects ofmay result from congenital or acquired defects of palatopharyngeal mechanism.palatopharyngeal mechanism.  Palatopharyngeal deficiency may result from:Palatopharyngeal deficiency may result from:  Congenital malformations such as cleft palateCongenital malformations such as cleft palate  Short hard or soft palateShort hard or soft palate  Deep nasopharynxDeep nasopharynx  Acquired neurological deficitsAcquired neurological deficits  Surgical resection of Neoplastic diseaseSurgical resection of Neoplastic disease www.indiandentalacademy.comwww.indiandentalacademy.com
  • 67.  Palatal insufficiencyPalatal insufficiency andand palatal incompetencepalatal incompetence are oftenare often used to define palatopharyngeal deficitsused to define palatopharyngeal deficits  Palatal insufficiency: patients with inadequate length ofPalatal insufficiency: patients with inadequate length of soft palate affect palatopharyngeal closure butsoft palate affect palatopharyngeal closure but movement of remaining tissue is under normal limitsmovement of remaining tissue is under normal limits  Deficiency is secondary to structural limitation. ExampleDeficiency is secondary to structural limitation. Example patients with congenital developmental deficiency andpatients with congenital developmental deficiency and acquired soft palate defectsacquired soft palate defects www.indiandentalacademy.comwww.indiandentalacademy.com
  • 68.  Palatal incompetence: refers to patients withPalatal incompetence: refers to patients with essentially normal palatopharyngeal structure, butessentially normal palatopharyngeal structure, but intact mechanism is unable to effectintact mechanism is unable to effect palatopharyngeal closure.palatopharyngeal closure.  Example : patients with neurological disease suchExample : patients with neurological disease such as bulbar poliomyelitis, myasthenia gravis, oras bulbar poliomyelitis, myasthenia gravis, or neurological deficiency secondary toneurological deficiency secondary to cerebrovascular accidentcerebrovascular accident www.indiandentalacademy.comwww.indiandentalacademy.com
  • 69. Palatopharyngeal deficits Palatopharyngeal insufficiency - Speech aid appliance used Palatopharyngeal incompetence - Palatal lift appliance used www.indiandentalacademy.comwww.indiandentalacademy.com
  • 70. Normal PalatopharyngealNormal Palatopharyngeal Function For SpeechFunction For Speech  When impairment of the palatopharyngeal port isWhen impairment of the palatopharyngeal port is present, speech is typically characterized by excessivepresent, speech is typically characterized by excessive nasal resonance (hypernasality), inappropriate audiblenasal resonance (hypernasality), inappropriate audible nasal air emission, and a decrease in intraoral airnasal air emission, and a decrease in intraoral air pressure during the production of oral speech sounds.pressure during the production of oral speech sounds. Speech may be only partially intelligibleSpeech may be only partially intelligible  Velopharyngeal incompetence is the functional inabilityVelopharyngeal incompetence is the functional inability of the soft palate to effect complete seal with theof the soft palate to effect complete seal with the posterior and / or lateral pharyngeal wallsposterior and / or lateral pharyngeal walls www.indiandentalacademy.comwww.indiandentalacademy.com
  • 71. Clinical Features ofClinical Features of velopharyngeal incompetencevelopharyngeal incompetence  Escape of air resulting in nasal speech that may beEscape of air resulting in nasal speech that may be unintelligible.unintelligible.  Middle ear infections like otitis media due to obstructionMiddle ear infections like otitis media due to obstruction of eustachian tube.of eustachian tube.  Nasal regurgitationNasal regurgitation  Psychological problemsPsychological problems  Social discriminationSocial discrimination www.indiandentalacademy.comwww.indiandentalacademy.com
  • 72. Indications for prosthodonticIndications for prosthodontic carecare For un-operated patientsFor un-operated patients  A wide cleft with a deficient soft palateA wide cleft with a deficient soft palate  A wide cleft of the Hard PalateA wide cleft of the Hard Palate  Neuromuscular deficit of the soft palate and pharynxNeuromuscular deficit of the soft palate and pharynx  Delayed surgeryDelayed surgery  Expansion prosthesis to improve spatial relationsExpansion prosthesis to improve spatial relations  Combined prosthesis and orthodontic applianceCombined prosthesis and orthodontic appliance In operated patientsIn operated patients  Incompetent palatopharyngeal mechanismIncompetent palatopharyngeal mechanism  Surgical FailuresSurgical Failures www.indiandentalacademy.comwww.indiandentalacademy.com
  • 73. ContraindicationsContraindications  Feasibility of surgical repairFeasibility of surgical repair  Mental RetardationMental Retardation  Uncooperative patient and parentsUncooperative patient and parents  Uncontrolled dental cariesUncontrolled dental caries  Lack of a trained prosthodontistLack of a trained prosthodontist Objectives in prosthodontic speech applianceObjectives in prosthodontic speech appliance constructions:constructions:  Restoring socially acceptable speechRestoring socially acceptable speech  Restoration of the masticating apparatusRestoration of the masticating apparatus  Esthetic facial and dental harmonyEsthetic facial and dental harmony  Psychologic adjustment of the patient to the conditionPsychologic adjustment of the patient to the condition www.indiandentalacademy.comwww.indiandentalacademy.com
  • 74. Diagnosis of palatopharyngealDiagnosis of palatopharyngeal incompetenceincompetence  Oral assessmentOral assessment  Speech assessmentSpeech assessment  Videofluorographic assessmentVideofluorographic assessment  VideonasoendoscopyVideonasoendoscopy www.indiandentalacademy.comwww.indiandentalacademy.com
  • 75. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 76. Speech BulbSpeech Bulb www.indiandentalacademy.comwww.indiandentalacademy.com
  • 77. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 78. Palatal Lift www.indiandentalacademy.comwww.indiandentalacademy.com
  • 79. Palatal LiftPalatal Lift www.indiandentalacademy.comwww.indiandentalacademy.com
  • 80. Palatal LiftPalatal Lift www.indiandentalacademy.comwww.indiandentalacademy.com
  • 81. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 82. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 83. Meatal obturator prosthesis  First described by Schalit (1946) later advocated by Sharry (1958) www.indiandentalacademy.comwww.indiandentalacademy.com
  • 84. MeatalMeatal obturatorobturator www.indiandentalacademy.comwww.indiandentalacademy.com
  • 85. Palatal augmentation prosthesisPalatal augmentation prosthesis  When surgical resection involving the tongue and / orWhen surgical resection involving the tongue and / or floor of mouth limits the mobility, it affects both speechfloor of mouth limits the mobility, it affects both speech and deglutitionand deglutition  With tongue mobility limitation, the contour of the palateWith tongue mobility limitation, the contour of the palate can be augmented by a prosthesis to modify the spacecan be augmented by a prosthesis to modify the space of Dondersof Donders  To allow food manipulation to be more easily transmittedTo allow food manipulation to be more easily transmitted posteriorly Into the oropharynxposteriorly Into the oropharynx  Prosthesis movement potential as lowProsthesis movement potential as low  Diagnostic resin prosthesis is given, followed by castDiagnostic resin prosthesis is given, followed by cast metal prosthesismetal prosthesis www.indiandentalacademy.comwww.indiandentalacademy.com
  • 86. Procedures for Building anProcedures for Building an Intraoral Prosthesis to AssistIntraoral Prosthesis to Assist Speech or SwallowingSpeech or Swallowing www.indiandentalacademy.comwww.indiandentalacademy.com
  • 87. Preliminary Dental Work-upPreliminary Dental Work-up  Oral HygieneOral Hygiene must be satisfactory or else, prosthesis willmust be satisfactory or else, prosthesis will increase risk for…increase risk for…  DecayDecay  InflammationInflammation  Fungal infectionFungal infection  Radiographs are needed to…Radiographs are needed to…  Check for adequate bone support for retentionCheck for adequate bone support for retention • Important for good stability and supportImportant for good stability and support  Check for decayCheck for decay www.indiandentalacademy.comwww.indiandentalacademy.com
  • 88.  Examine Preliminary ImpressionsExamine Preliminary Impressions  Determine strategies forDetermine strategies for fitfit && retentionretention::  1. Select teeth for retention1. Select teeth for retention  2. Changing or shaping tooth as needed2. Changing or shaping tooth as needed  3. Adding material to tooth structure, molar bands,3. Adding material to tooth structure, molar bands, crowns, or resincrowns, or resin www.indiandentalacademy.comwww.indiandentalacademy.com
  • 89. Preliminary Dental WorkPreliminary Dental Work  Crowns: if tooth has large restoration(s) and integrity isCrowns: if tooth has large restoration(s) and integrity is compromisedcompromised  common in older patientscommon in older patients  Resin: if tooth is small, misshapen, conical, orResin: if tooth is small, misshapen, conical, or underdevelopedunderdeveloped  resin added to healthy tooth to provide a “notch”resin added to healthy tooth to provide a “notch” /anchor for wire/anchor for wire  common in younger patientscommon in younger patients www.indiandentalacademy.comwww.indiandentalacademy.com
  • 90. Designing the Prosthesis:Designing the Prosthesis:  Use oral examination of bite to:Use oral examination of bite to:  Place clasps where they do not interfere with dentalPlace clasps where they do not interfere with dental bitebite  Use an acrylic (plastic) or metal baseUse an acrylic (plastic) or metal base  Acrylic: for young patients who:Acrylic: for young patients who: • may need several prosthesismay need several prosthesis • have less certain prognosis for successhave less certain prognosis for success • may train out of prosthesismay train out of prosthesis www.indiandentalacademy.comwww.indiandentalacademy.com
  • 91. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 92. Prosthesis Design continued...Prosthesis Design continued...  Use metal base: with older patientsUse metal base: with older patients  Benefit: more stable and durableBenefit: more stable and durable www.indiandentalacademy.comwww.indiandentalacademy.com
  • 93. Initial Prosthesis:Initial Prosthesis:  There is no soft palate portion yet (inactive)There is no soft palate portion yet (inactive)  Try in mouthTry in mouth  Adjust acrylic for intimate fitAdjust acrylic for intimate fit  Inspect visuallyInspect visually  Pressure indicator paste will identify wherePressure indicator paste will identify where adjustments are neededadjustments are needed www.indiandentalacademy.comwww.indiandentalacademy.com
  • 94. Initial Prosthesis continued...Initial Prosthesis continued...  If patient is young, has cognitive impairment, orIf patient is young, has cognitive impairment, or strong gag reflex:strong gag reflex:  take it slowly, ensure patient comfort firsttake it slowly, ensure patient comfort first  wear for 1-2 weeks prior to adding lift or bulbwear for 1-2 weeks prior to adding lift or bulb portionportion  Educate patient:Educate patient:  oral hygiene and eatingoral hygiene and eating  wearing timewearing time  increased salivaincreased saliva  taking it in and outtaking it in and out www.indiandentalacademy.comwww.indiandentalacademy.com
  • 95. Additions and ModificationsAdditions and Modifications  Prior to adding: oral exam, check for ulcerations, andPrior to adding: oral exam, check for ulcerations, and make adjustmentsmake adjustments  Acrylic base: add wire loop and small amount ofAcrylic base: add wire loop and small amount of acrylicacrylic  depending on patient cooperation and tolerance,depending on patient cooperation and tolerance, use thermo-plastic wax to build “tail”use thermo-plastic wax to build “tail”  Metal base: already has wire loop built inMetal base: already has wire loop built in  add wax for lift or bulbadd wax for lift or bulb  After adding wax, convert to acrylic, polish, andAfter adding wax, convert to acrylic, polish, and deliverdeliver www.indiandentalacademy.comwww.indiandentalacademy.com
  • 96. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 97. Adding/ModificationsAdding/Modifications continued...continued...  After adding wax for bulb, continue to shape / defineAfter adding wax for bulb, continue to shape / define for optimal speechfor optimal speech  convert to acrylic, polish, and deliverconvert to acrylic, polish, and deliver  Add or subtract to lift or bulb at any time using waxAdd or subtract to lift or bulb at any time using wax www.indiandentalacademy.comwww.indiandentalacademy.com
  • 98. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 99. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 100. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 101. Palatal Drop FormationPalatal Drop Formation  Similar to process for building lift/bulbSimilar to process for building lift/bulb  Lower palatal vault or create a posteriorLower palatal vault or create a posterior “ramp” to increase tongue contact“ramp” to increase tongue contact  Add / modify based on:Add / modify based on:  auditory perceptual judgments of speechauditory perceptual judgments of speech soundssounds • stronger lingual stops, fricatives, affricatesstronger lingual stops, fricatives, affricates  tongue contact during swallowtongue contact during swallow • improved bolus controlimproved bolus control • no leaks / pocketingno leaks / pocketing www.indiandentalacademy.comwww.indiandentalacademy.com
  • 102. Adequacy of ProsthesisAdequacy of Prosthesis  Visual exam of prosthesis in mouthVisual exam of prosthesis in mouth  Auditory-perceptual judgments of speechAuditory-perceptual judgments of speech  Nasendoscopy of speech with prosthesisNasendoscopy of speech with prosthesis in placein place  Patient report:Patient report:  comfort & stabilitycomfort & stability  speech & swallow improvementsspeech & swallow improvements www.indiandentalacademy.comwww.indiandentalacademy.com
  • 103. Modifying ProsthesisModifying Prosthesis  Add to velar / pharyngeal area withAdd to velar / pharyngeal area with temporary waxtemporary wax  How much at each visit is dependent uponHow much at each visit is dependent upon patient tolerancepatient tolerance  Goal is to provide optimal speechGoal is to provide optimal speech  audio-perceptual judgmentsaudio-perceptual judgments • initially: excessive closure or hyponasality?initially: excessive closure or hyponasality?  nasendoscopy viewnasendoscopy view www.indiandentalacademy.comwww.indiandentalacademy.com
  • 104. ““Training Out” of the ProsthesisTraining Out” of the Prosthesis  Once optimal closure is achieved, wear forOnce optimal closure is achieved, wear for approximately six monthsapproximately six months  Systematic reduction programSystematic reduction program  1-2 month intervals1-2 month intervals  reduce 1-2 mm each timereduce 1-2 mm each time  Speech bulb: lateral reductionsSpeech bulb: lateral reductions  Palatal lift: top, sides, back reductionsPalatal lift: top, sides, back reductions www.indiandentalacademy.comwww.indiandentalacademy.com
  • 105. ““Training Out” of the ProsthesisTraining Out” of the Prosthesis  Continue reductions as long as the speakerContinue reductions as long as the speaker can compensate by producing acceptablecan compensate by producing acceptable speechspeech  total reduction:total reduction:  nonsurgical approach to VP managementnonsurgical approach to VP management  partial reduction:partial reduction:  more permanent closure of VP mechanismmore permanent closure of VP mechanism requiredrequired • pharyngeal flap? more permanent prosthesis?pharyngeal flap? more permanent prosthesis? www.indiandentalacademy.comwww.indiandentalacademy.com
  • 106. www.indiandentalacademy.comwww.indiandentalacademy.com
  • 107. ReferencesReferences  Maxillofacial rehabilitation. Beumer, Curtis &Maxillofacial rehabilitation. Beumer, Curtis & FritellFritell  McCraken’s removable denture prosthodonticsMcCraken’s removable denture prosthodontics 1111thth eded  Maxillofacial prosthetics. ChalianMaxillofacial prosthetics. Chalian  Diagnosis and treatment planning. LaneyDiagnosis and treatment planning. Laney  GPT - 8GPT - 8 www.indiandentalacademy.comwww.indiandentalacademy.com
  • 108. ReferencesReferences  Sandeep Kumar, Veena Hegde. Prosthodontics inSandeep Kumar, Veena Hegde. Prosthodontics in Velopharyngeal Incompetence. JIPS, (under publication)Velopharyngeal Incompetence. JIPS, (under publication)  Armany MA. Basic principles of obturator design forArmany MA. Basic principles of obturator design for partially edentulous patients. Part I: Classification. Jpartially edentulous patients. Part I: Classification. J Prosthet Dent 1978;40:554-557Prosthet Dent 1978;40:554-557  Armany MA. Basic principles of obturator design forArmany MA. Basic principles of obturator design for partially edentulous patients. Part II: Design principles. Jpartially edentulous patients. Part II: Design principles. J Prosthet Dent 1978;40:656-662Prosthet Dent 1978;40:656-662 www.indiandentalacademy.comwww.indiandentalacademy.com
  • 109. ReferencesReferences  Wright MS. Design for maximal attention of obturatorWright MS. Design for maximal attention of obturator prosthesis for hemimaxillectomy patients. J Prosthetprosthesis for hemimaxillectomy patients. J Prosthet Dent 1982;47:88-91Dent 1982;47:88-91  Kelly KE. Partial denture design applicable to theKelly KE. Partial denture design applicable to the maxillofacial patient. J Prosthet Dent 15:168-75maxillofacial patient. J Prosthet Dent 15:168-75  Lauciello RK.. Flexible temporary obturators for patientsLauciello RK.. Flexible temporary obturators for patients with severely limited jaw opening. J Prosthet Dentwith severely limited jaw opening. J Prosthet Dent 1983;49:523-261983;49:523-26 www.indiandentalacademy.comwww.indiandentalacademy.com
  • 110. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com