Management of edent pt wt cleft palate/ oral surgery courses

PROSTHETIC MANAGEMENT OF A
PARTIALLY EDENTULOUS PATIENT
HAVING CLEFT INVOLVING BOTH
HARD AND SOFT PALATE.
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

INTRODUCTION
ANATOMY OF HARD AND SOFT PALATE
CLASSIFICATION OF CLEFT LIP AND
PALATE
REVIEW OF LITERATURE
DISABILITIES OCCASIONED BY THE
PRESENCE OF CLEFT PALATE

DIAGNOSIS AND TREATMENT PLANNING
INDICATIONS FOR PROSTHESIS IN
UN-OPERATED PALATES
INDICATIONS FOR PROSTHESIS IN OPERATED
PALATES
REQUIREMENTS OF SPEECH APPLIANCES

PROSTHETIC REHABILITATION OF CLEFT PALATE
PATIENTS
PROSTHETIC SPEECH APPLIANCE FOR CHILDREN
TYPES OF OBTURATOR
RATIONALE AND CONSTRUCTION OF PHARYNGEAL
BULB
PROSTHESIS FOR ADULTS
COMMON ERRORS IN THE CLINICAL MANAGEMENT OF
CONGENITAL DEFECTS
SUMMARY AND CONCLUSION
REFERENCES

INTRODUCTION
HISTORY TELLS US THAT CLEFTS OF THE LIP AND
PALATE WERE CONSIDERED AS :
 MARKS OF BEAUTY
 SUPERNATURAL ABILITY
 MAJOR LIFE THREATENING ABNORMALITIES
AIM OF HABILITATION OF CLEFT PALATE PATIENTS IS
TO ENABLE HANDICAPPED INDIVIDUALS TO ASSUME AN
EFFECTIVE POSITION IN SOCIETY.

ACCORDING TO DR.HERBERT COOPER :
“A PHYSICAL DEFECT SUCH AS CLEFT PALATE DOES
NOT NECESSARILY CONSTITUTE A SOCIAL
HANDICAP . ALTHOUGH THE DEFECT IS ALWAYS
PRESENT, THE PATIENT MUST LEARN TO ACCEPT
THE THINGS WHICH CANNOT BE CHANGED, MUST
BE ENCOURAGED TO CHANGE THE THINGS THAT
CAN BE CHANGED AND MUST BE TAUGHT TO KNOW
THE DIFFERENCE.”

DEVELOPMENT OF PALATE
IN 1910, POHLMAN GAVE A CONCEPT WHICH
STATES THAT THE PRIMORDIA OF THE FACE
CONTRIBUTING TO THE PRIMARY PALATE ARE
BASICALLY UNITED BY EPITHELIUM AND THAT
MESODERMAL PROLIFERTAION PROVIDES SUPPORT
BENEATH THESE AREAS ; WITHOUT THIS SUPPORT,
THE EPITHELIUM WILL BREAK DOWN AND A CLEFT
WILL BE APPARENT AT THAT POINT.

DURING THE 5th
AND 6th
WEEKS OF EMBRYONIC
DEVELOPMENT, THE PRIMARY PALATE IS FORMED.THIS
PRIMORDIAL STRUCTURE GIVES RISE TO :
 UPPER LIP
 ANTERIOR PORTION OF THE ALVEOLAR PROCESS
 PREMAXILLA

DEVELOPMENT OF
SECONDARY/DEFINITIVE PALATE
TWO LATERAL MAX. PALATAL SHELVES
PRIMARY PALATE OF FRONTONASAL PROMINENCE
--MAKE UP THE SECONDARY/DEFINITIVE PALATE.
DURING THE 8th
WEEK OF INTRAUTERINE LIFE, THE
LATERAL SHELVES ALTER FROM VERTICAL TO
HORIZONTAL.

 DURING THE PALATAL CLOSURE THE MANDIBLE
BECOMES MORE PROGNATHIC, THE VERTICAL DIMENSION
OF THE STOMODIAL CHAMBER INCREASES,BUT THE
MAX.WIDTH REMAINS STABLE, ALLOWING SHELF
CONTACT TO OCCUR.
THE FORWARD GROWTH OF MECKEL’S CARTILAGE
RELOCATES THE TONGUE MORE ANTERIORLY.

DEFINITIONS
CLEFT PALATE:
AN OPENING IN THE ROOF OF THE MOUTH AND/OR IN
THE FUNCTIONAL SOFT PALATE.A DEFORMITY OF THE
PALATE FROM IMPROPER UNION OR LACK OF UNION DURING
THE SECOND MONTH OF INTRA UTERINE DEVELOPMENT OF
THE MAX. PROCESS WITH THE MEDIAL NASAL PROCESS.
A CLEFT IN THE PALATE BETWEEN THE TWO PALATAL
PROCESSES .IF BOTH THE HARD AND SOFT PALATE AND
INVOLVED IT IS TERMED URANOSTAPHYLOSCHISIS ; IF ONLY
THE SOFT PALATE IS DIVIDED ,IT IS TERMED URANOSCHISIS.

PALATAL LIFT PROSTHESIS:
A REMOVABLE PROSTHESIS THAT AIDS IN
VELOPHARYNGEAL CLOSURE BY ELEVATING AN
INCOMPLETE SOFT PALATE THAT IS DISFUNCTIONAL DUE
TO CLEFTING , SURGERY , TRAUMA OR UNKNOWN
PARALYSIS.

CLASSIFICATION:
 Cleft of the primary palate can be either unilateral or
bilatereral and complete or incomplete,with varying
degrees of incompleteness.
 With clefts of the secondary palate the same holds true.

 PRIMARY PALATE:
– SUBTOTAL UNILATERAL
– SUBTOTAL BILATERAL
– TOTAL UNILATERAL
– TOTAL BILATERAL
STARK’S CLASSIFICATION:
SECONDARY PALATE:
SUBTOTAL
TOTAL
SECONDARY SUBTOTAL
PRIMARY AND SECONDARY:
–TOTAL UNILATERAL
–TOTAL BILATERAL

MORLEY’S CLASSIFICATION
GROUP I – PREALVEOLAR CLEFTS
Unilateral
Bilateral
Median
GROUP II – ALVEOLAR CLEFTS
Unilateral
Bilateral
Median
GROUP III – POST ALVEOLAR CLEFTS
Soft palate
Soft & hard palate
Sub mucous cleftwww.indiandentalacademy.com

VEAU’S CLASSIFICATION:
TYPE I : DEFECT OF RED PORTION OF THE LIP (VERMILION )
TYPE II : CLEFTS WHICH INCLUDE VERMILION AND A
PORTION OF THE LIP MUSCULATURE UPTO THE NOSTRIL ON
AFFECTED SIDE BUT NOT INCLUDING THE FLOOR OF THE
NOSTRIL.
TYPE III: UNILATERAL COMPLETE CLEFTS INVOLVING THE
FULL THICKNESS OF THE LIP TYPICALLY ACCOMPANIED BY
A MARKED DEFORMITY OF THE NOSE.
TYPE IV : BILATERAL CLEFTS OF THE LIP EITHER PARTIAL,
COMPLETE OR IN COMBINATION.
::

VEAU’S CLASSIFICATION
CLASS I CLASS II CLASS III CLASS IV
NORMAL

REVIEW OF LITERATURE:
MOHAMMAD MAZAHERI (1961) OBSERVED THAT LACK OF LATERAL
AND VERTICAL GROWTH OF THE MAXILLAE AND OVERCLOSURE OF
VERTICAL DIMENSION ARE OFTEN SEEN IN CLEFT PALATE
PATIENTS. COMPLETE DENTURES SUPPORTED BY NATURAL TEETH
ARE THE IDEAL TREATMENT FOR THESE PATIENTS.
COPINGS OF THE REMAINING TEETH ARE MADE TO PREVENT
DECALCIFICATION AND CARIES. THE ABUTMENT ARE UTILIZED
ONLY TO SUPPORT THE PROSTHESIS, NOT FOR RETENTION.
THE PROSTHETIC SPEECH RESTORATION IS CONSTRUCTED IN THREE
STAGES, EACH STAGE REQUIRING A FUNCTIONAL IMPRESSION. AN
ACCURATE FUNCTIONAL IMPRESSION OF THE SPEECH BULB IS
OBTAINED AFTER THE PATIENT HAS ADJUSTED TO THE TEMPORARY
SPEECH BULB. www.indiandentalacademy.com

ALI ARAM (1959): CONDUCTED A STUDY ON
VELOPHARYNGEAL FUNCTION AND CLEFT PALATE
PROSTHESES. FOR THE PURPOSE OF THIS STUDY, 90
SUBJECTS, RANGING FROM 4 TO 20 YEARS IN AGE, WERE
STUDIED. THEY WERE DIVIDED INTO SIX AGE GROUPS:
GROUP I (4-5 YEARS OF AGE), GROUP II (6-8 YEARS OF
AGE), GROUP III (9-11 YEARS OF AGE), GROUP IV (12-14
YEARS OF AGE), GROUP V (15-17 YEARS OF AGE). AND
GROUP VI (18-20 YEARS OF AGE). FIFTEEN INDIVIDUALS
WERE INCLUDED IN EACH AGE GROUP.

THREE LATERAL CEPHALOMETRIC ROENTGENOGRAMS
WERE MADE OF EACH INDIVIDUAL. AND WE FOUND
THAT THE SIGHT OF VELOPHARYNGEAL CLOSURE
CHANGE WITH INCREMENT OF AGE. IN ALL AGE GROUPS
THE MEANS REVEALED THAT MID POINT OF CLOSURE
WAS ALWAYS ABOVE THE LEVEL OF THE ANTERIOR
TUBERCLE OF THE ATLAS.
MARK S. CHAMBERS (2004) PRESENTED A TECHNIQUE
FOR RECORDING THE CONTOURS OF PARTIAL SOFT
PALATE DEFECTS FOR PROSTHETIC OBTURATION.www.indiandentalacademy.com

DIAGNOSIS AND TREATMENT PLANNING:
THE FOLOWING PROCEDURES WILL FACILITATE DIAGNOSIS:
 CASE HISTORY AND RECORDING OF DEFECT
 STUDY CASTS AND PHOTOGRAPHS
 VARIOUS RADIOGRFAPHIC PROCEDURES
 MEDICAL,SURGICAL,SPEECH AND PSYCHO-SOCIAL
RECORDING
GENERAL CASE HISTORY:
HISTORY OF TREATMENT , SOCIO ECONOMIC STATUS
::

::
DENTAL HISTORY:
DENTAL ANOMOLIES SUCH AS THOSE INVOLVING
 NUMBER
 SHAPE
 FORM
 TEETH FORMATION

::
THE SHAPE OF THE ARCH
THE ARCH RELATIONSHIP
TOOTH RELATIONSHIP
TYPE OF MALOCCLUSION
ANY DENTAL CARIES
MISSING TEETH
THE CONDITION OF GINGIVAL AND
PERIODONTAL TISSUE, ANY PERIAPICAL
LESIONS. www.indiandentalacademy.com

::
IMPRESSION OF THE STUDY CAST:
FOR INFANTS: THE MAXILLARY IMPRESSION : 15
DEGREES
THE MANDIBULAR IMPRESSION:HEAD TILTED SLIGHTLY
UPWARD.
FOR OLDER CHILDREN AND ADULTS:
A STOCK TRAY OF ADEQUATE DIMENSIONS IS
SELECTED. IF THE REGISTRASTION OF THE ENTIRE CLEFT IS
DESIREABLE, THE STOCK TRAY IS MODIFIED WITH
MODELLING COMPOUND EXTENDING POSTERIORLY TO THE
PHARYNGEAL WALLS. THE FAST SETTINGT IREVERSIBLE
HYDROCOLLOID IS USED.www.indiandentalacademy.com

::
TIPS WHILE MAKING IMPRESSION:
IF THE PATIENT IS CHILD HE SHOULD BE GIVEN THE
OPPORTUNITY TO SEE AND EXAMINE THE TRAY AND
ALSO OCCUPY HIS MIND
THE PATIENT SHOULD HAVE AN EARLY MORNING
APPOINTMENT
A TOPICAL ANAESTHETIC-IF THE PATIENT SHOWS
GAGGING REFLEX
THE TRAY SHOULD NOT BE OVERLOADED
THE PATIENT SHOULD COME ON EMPTY STOMACH.

::
RADIOGRAPHS:
A CINERADIOGRAPHIC STUDY WITH SYNCHRONIZED
SOUND OF ORO- PHARYNGEAL STRUCTURES IN FUNCTION
CAN HELP THE DENTIST TO EVALUATE THE
VELOPHARYNGEAL FUNCTION AND TONGUE POSITION
ESPECIALLY IN VELOPHARYNGEALLY INCOMPETENT
INDIVIDUALS.
CEPHALOMETRY
SOUND SPECTROGRAM OF SPEECH
LAMINOGRAPHY
SPEECH RECORDING
PSYCHOLOGIC AND SOCIAL CONSIDERATIONSwww.indiandentalacademy.com

::
FACTORS CONCERNED WITH SOCIAL SERVICE :
 EVALUATING FINANCIAL ABILITY
 RELATIONSHIP BETWEEN THE CHILD,HIS FAMILY AND
THE COMMUNITY
 THE EFFECT OF PATIENT DISABILITY ON THE FAMILY

Disabilities occasioned by theDisabilities occasioned by the
presence of a cleft palate:presence of a cleft palate:
Individual is unable to
close the nasopharynx
from the oropharynx.

The action of swallowingThe action of swallowing

The problem of suckling inThe problem of suckling in
infant with cleft palateinfant with cleft palate

SPEECH - MECHANISM
Integrating centre
Resonating chamber
(oral & nasal)
Phonating organ
(vocal cords)
Respiratory organ
(lungs)
Articulating
organ

The technique of normalThe technique of normal
speech:speech:
Phase I Phase II
B B

G T

Treatment planTreatment plan
Requires careful planning as it should take
into account all factors involved in total
health care.
Cleft lip and palate requires a
multidisciplinary approach.

GENERAL REMARKS ON THE TREATMENT OFGENERAL REMARKS ON THE TREATMENT OF
CLEFT PALATE (IN RELATION TO SPEECH ANDCLEFT PALATE (IN RELATION TO SPEECH AND
SWALLOWING FAULTS):SWALLOWING FAULTS):
The surgeon’s main problem will be to
repair the lip.
Next is the repair of palate.
If surgical repair is decided it should be
performed before the end of second year.

VELOPHARYNGEAL FUNCTIONVELOPHARYNGEAL FUNCTION
The synergetic behaviour of velar and pharyngeal
musculature creates a sphincteric type of constriction,
commonly called velopharyngeal closure.
The adequate velopharyngeal closure prevents the passage
of air from the oropharynx into the nasopharynx during
function.
Functional valving cannot be attained if a soft palate is
short, limited in mobility or cleft.

INSPITE OF THE SURGICAL ADVANTAGES
AVAILABLE TO THE CLEFT PALATE PATIENT,THERE HAS
BEEN A NEED FOR CLEFT PALATE PROSTHESIS.THE
PROSTHODONTIST CAN ASSISST BOTH SURGEON AND
PATIENT , AND THE MUTUAL UNDERSTANDING AMONG
THE SPECIALISTS IN A WELL ORGANIZED TEAM IS OF
GREAT BENEFIT TO THE PATIENT.
INDICATIONS FOR PROSTHESIS IN
UNOPERATED PALATES

SOME SITUATIONS …………
WIDE CLEFT WITH DEFICIENT SOFT PALATE
WIDE CLEFT OF HARD PALATE:
IN BILATERAL CLEFTS,THE VOMER MAY BE HIGH
AND THE CLEFT OF HARD PALATE IS WIDE SO THAT
SURGICAL REPAIR MAY PRODUCE A LOW VAULTED
PALATE.

NEUROMUSCULAR DEFICIENCY OF SOFT PALATE AND THE
PHARYNX
IT IS DIFFICULT TO CREATE AND MAINTAIN A
PHARYNGEAL FLAP LARGE ENOUGH TO PRODUCE
COMPETENT PALATOPHARYNGEAL VALVING WITHOUT
OBSTRUCTING THE AIRWAY IN THE PRESENCE OF
NEUROGENIC DEFICIENCY OF THE CRITICAL MUSCLES.

 DELAYED SURGERY
 EXPANSION PROSTHESIS TO IMPROVE SPATIAL
RELATIONS
 COMBINED PROSTHESIS :
ORTHODONTIC APPLIANCE
+
PROSTHESIS

INDICATIONS FOR PROSTHESIS IN
OPERATED PALATES
AN INCOMPETENT PALATOPHARYNGEAL MECHANISM :
IF THE CLINICAL AND CINE RADIOGRAPHIC
ANALYSIS SUGGEST THAT PATIENT IS CLOSE TO
FUNCTIONAL CLOSURE, A PROSTHESIS MAY SERVE AS A
PHYSICAL THERAPY MODALITY.
WHEN A PATIENT PRESENTS A LARGE
VELOPHARYNGEAL GAP ASSOCIATED WITH A NUROGENIC
DEFICIENCY THE SPEECH AID PROSTHESIS MUST BE
COSIDERED AS A PERMANENT TYPE OF TREATMENT.
 SURGICAL FAILURES:
PROSTHESIS SHOULD BE CONSIDERED IN
FOLLOWING CONDITIONS:LOW
VAULTED,SCARRED,CONTRACTED PALATES OR THOSE WITHwww.indiandentalacademy.com

SPEECH APPLIANCE
REQUIREMENTS:
THE PROSTHESIS MUST BE DESIGNED FOR THE
INDIVIDUAL PATIENT IN RELATION TO HIS ORAL AND
FACIAL BALANCE,MASTICATORY FUNCTION AND SPEECH.
KNOWLEDGE RELATED TO REMOVABLE PARTIAL
DENTURE AND COMPLETE DENTURES SHOULD BE USED IN
DESIGNING THE MAXILLARY PART OF THE CLEFT PALATE
PROSTHESIS.
THE PROSTHETIC SPEECH APPLIANCE SHOULD HAVE
MORE RETENTION AND SUPPORT THAN MOST OTHER
RESTORATIONS. THE CROWNING AND SPLINTING OF
ABUTMENT TEETH IN ADULT PATIENTS MAY INCREASE
RETENTION AND SUPPORT OF THE PROSTHESIS AND MAY
EXTEND THE LIFE EXPECTANCY OF ABUTMENT TEETH.www.indiandentalacademy.com

. THE LOCATION AND THE CHANGES OF THE SPEECH BULB
INCLUDE CONSIDERATION OF THE FOLLOWING FACTORS:
 SPEECH BULB SHOULD BE POSITIONED IN LOCATION OF
GREATEST PHARYNGEAL AND LATERAL PHARYNGEAL
WALL ACTIVITY SINCE VOICE QUALITY IS JUDGED BEST
WHEN SPEECH IS AT THESE POSITIONS.
THE INFERIOR –SUPERIOR DIMENSION AND WEIGHT OF
SPEECH BULB MAY BE REDUCED WITHOUT APPERENT
EFFECT ON NASAL RESONANCE. THE SUPERIOR PORTION OF
THE PHARYNGEAL SECTION SHOULD BE SLOPED LATERALLY
TO ELIMINATE THE COLLECTION OF NASAL SECRETIONS.
THE INFERIOR PORTION OF THE PHARYNGEAL SECTION
SHOULD BE SLIGHTLY CONCAVE TO ALLOW FOR FREEDOM
OF TONGUE MOVEMENT

THE SPEECH BULB SHOULD BE PLACED ON OR ABOVE
THE PALATAL PLANE WHEN POSTERIOR AND LATERAL
PHARYNGEAL ACTIVITIES ARE NOT PRESENT OR WHEN
VISUAL OBSERVATION OF THE BULB IS NOT POSSIBLE
BECAUSE OF A LONG SOFT PALATE.

PROSTHETIC REHABILITATION FOR
CLEFT PATIENTS
PROSTHETIC TREATMENT OF THE CLEFT LIP AND PALATE
CONDITION IS SO WIDE IN SCOPE THAT ONE MIGHT
GENERALIZE BY SAYING THAT IT STARTS AT BIRTH AND
ENDS WITH DEATH.
THE CLEF PALATE REHABILITATION IS A TEAM
WORK.THE PROSHODONTIST HAS THE SAME GOALS AS ANY
OTHER PROFESSIONAL PERSON WORKING IN THIS
HABILITATION AREA THAT IS:
TO IMPROVE APPEARANCE.
TO PROVIDE ADEQUATE FUNCTION INCLUDING AN
ADEQUATE SPEECH MECHANISM.

MAXILLARY ORTHOPEDICS
McNEIL AND OTHERS PROVIDED GENERAL GUIDELINES
FOR MAXILLARY ORTHOPEDIC APPLIANCES AND
PRESURGICAL TREATMENT.
FACTORS THAT INFLUENCE THE RESULTS OBTAINED :
CONFIGURATION AND EXTENT OF THE CLEFT
GROWTH POTENTIAL OF THE PATIENT
PARENTAL COOPERATION AND
APPLIANCE DESIGN.www.indiandentalacademy.com

TYPES OF APPLIANCES
THE PASSIVE OR HOLDING TYPE
ACTIVE OR EXPANSION TYPE
 THE APPLIANCE DESIGN IS DETERMINED BY THE
CONFIGURATION OF THE CLEFT.
GENERALLY IF ANY DEGREE OF COLLAPSE IS MANIFESTED
AN EXPANSION APPLIANCE IS PLACED.
IF THE COLLAPSE APPEARS IN THE ANTERIOR REGION, A
FAN TYPE OF SPLIT HOLDING APPLIANCE IS USED.
IN CASE OF ARCH COLLAPSE, SURGICAL CLOSURE OF THE
LIP IS DELAYED UNTIL THE EXPANSION APPLIANCE HAS
ACHIEVED AN IDEAL ARCH CONFIGURATION.

CASES PRESENTING INITIALLY WITH AN IDEAL ARCH
ALIGNMENT OR A WIDE CLEFT CONFIGURATION ARE
OPERATED AS SOON AS THE HOLDING APPLIANCE IS
PLACED.
IN EITHER SITUATION , THE CLEFT LIP IS SURGICALLY
CLOSED BETWEEN 1 AND 10 MONTHS.
IT SHOULD BE STRESSED THAT PRIMARY PURPOSE OF THE
APPLIANCE PRIOR TO LIP CLOSURE IS NOT TO PROLIFERATE
OR INITIATE GROWTH, BUT TO GUIDE THE MAXILLARY
SEGEMENTS INTO PROPER SPATIAL POSITION WITH EACH
OTHER AND WITH THE MANDIBULAR ARCH.
AFTER THE MAXILLARY ARCH HAS THE SEGMENTS IN
GOOD ALIGNMENT, THE PLASTIC SURGEON RESTORES LIP
CONTINUITY.

THE MOLDING PRESSURE OF THE SURGICALLY CLOSED LIP
ALONG WITH THE APPLIANCE WILL HELP TO CREATE AN
IDEAL ARCH FORM.
SUCCESS IN ACHIVING AND MAINTAING A GOOD ARCH
ALIGNMENT IS CONSIDERABLY GREATER IN PATIENTS
WHOSE INITIAL ARCH CONFIGURATION IS WIDE.
WHEN THE INITIAL ARCH CONFIGURATION
DEMONSTRATES SOME DEGREE OF COLLAPSE, EVEN
THOUGH THE SEGEMENTS MAY BE EXPANDED UNTIL IDEAL
REALTIONSHIP,THE END RESULTS ARE LESS THAN
SATISFACTORY.
THE ANTEROPOSTERIOR GROWTH OF THE PALATAL ARCH
IS INDEPENDENT OF THE APPLIANCE WHICH IS MAINLY
CONCERENED WITH THE LATERAL GROWTH.

MOUTH PREPARATIONS MUST BE COMPLETED BEFORE
MAKING FINAL IMPRESSIONS WHICH INCLUDE
GINGIVECTOMY TO EXPOSE CLINICAL CROWNS(TO MAKE
THEM USABLE)AND THE PLACEMENT OF COPINGS ON
REMAINING TEETH TO PREVEBT DECALCIFICATION AND
CARIES.
WEIGHT AND SIZE OF THE PROSTHODONTIC APPLIANCE
SHOULD BE KEPT TO A MINIMUM.
SOFT TISSUE DISPLACEMENT IN VELAR AND
NASOPHARYNGEAL AREAS BY THE PROSTHESIS SHOULD
BE AVOIDED.
VELAR AND PHARYNGEAL PORTIONS OF THE
PROSTHESIS SHOULD NEVER BE DISPLACED BY LATERAL
AND POSTERIOR PHARYNGEAL WALL MUSCLE
ACTIVITIES OR TONGUE MOVEMENT DURING
SWALLOWING AND SPEECHwww.indiandentalacademy.com

RATIONALE OF PHARYNGEAL BULB
THE CONSTRUCTION OF A PHARYNGEAL BULB PROSTHESIS
MUST BE APPROACHED FROM A PHYSIOLOGIC VIEWPOINT
RATHER AN A PURELY MECHANICAL ONE.WHATEVER THE
MATERIAL USED IN OBTAINING THE IMPRESSION THE
OBJECTIVE IS SAME
THE COMPLETED BULB MUST ALLOW COMPLETE
VELOPHARYNGEAL CLOSURE DURING SPEECH AND YET
PRESENT AN OPEN VELOPHARYNGEAL PORT FOR
BREATHING.
THE GROSS FUNCTIONAL ANOTOMY OF THE STRUCTURES
SHOULD BE APPRAISED IN DETAIL.SIZE,EXACT LOCATION
AND ITS ASSOCIATED MUSCLES SHOULD BE VISUALIZED.:

LEVATOR PALATI
PALATOPHARYNGEOUS
SALPINGOPHARYNGEOUS
PALATOGLOSSUS
SUPERIOR PHARYNGEAL
CONSTRICTOR
TENSOR PALATI
MUSCULUS UVULAE

SPEECH APPLIANCE
REQUIREMENTS:
THE PROSTHESIS MUST BE DESIGNED FOR THE
INDIVIDUAL PATIENT IN RELATION TO HIS ORAL AND
FACIAL BALANCE,MASTICATORY FUNCTION AND SPEECH.
KNOWLEDGE RELATED TO REMOVABLE PARTIAL
DENTURE AND COMPLETE DENTURES SHOULD BE USED IN
DESIGNING THE MAXILLARY PART OF THE CLEFT PALATE
PROSTHESIS.
THE PROSTHETIC SPEECH APPLIANCE SHOULD HAVE
MORE RETENTION AND SUPPORT THAN MOST OTHER
RESTORATIONS. THE CROWNING AND SPLINTING OF
ABUTMENT TEETH IN ADULT PATIENTS MAY INCREASE
RETENTION AND SUPPORT OF THE PROSTHESIS AND MAY
EXTEND THE LIFE EXPECTANCY OF ABUTMENT TEETHwww.indiandentalacademy.com

TYPES OF OBTURATOR
FIXED PHARYNGEAL
HINGED PHARYNGEAL
MEATAL
THE FIXED VARIETY IS AN EXTENSION OF A DENTURE
PROJECTING INTO THE PHARYNX AT ABOUT THE LEVEL OF
THE ANTERIOR ARCH OF THE ATLAS AND SO SHAPED THAT
IT CAN BE GRIPPED BY THE PHARYNGEAL WALLS.
THE HINGED VARIETY IS ATTACHED TO THE
POSTERIOR BORDER OF A DENTURE BY A HINGE AND ITS
LATERAL BORDERS ARE SHAPED SO THAT THEY MAY BE
GRIPPED BY THE REMNANTS OF THE SOFT PALATE AND BE
RAISED AND LOWERED WITH THEM.

THE MEATAL OBTURATOR IS AN EXTENSION OF
THE DENTURE UPWARDS AT RIGHT ANGLES TO IT SO THAT
IT OCCLUDES THE OPENING OF POSTERIOR NARES.
PRESENTLY ONLY THE FIXED PHARYNGEAL
OBTURATOR IS USED . ?

PHARYNGEAL IMPRESSION

HEAD POSITION – BORDER MOULDING

IMPRESSION MAKING FOR
PHARYNGEAL OBTURATORS

PHARYNGEAL OBTURATOR IMPRESSION

FABRICATION OF IMPRESSION TRAYFABRICATION OF IMPRESSION TRAY
WITH THE AID OF AN EXISTINGWITH THE AID OF AN EXISTING
PROSTHESISPROSTHESIS

CASE REPORTSCASE REPORTS

NASAL STENOSISNASAL STENOSIS

COMMON ERRORS IN THE MANAGEMENT OF
CONGENITAL DEFECTS
MOUTH PREPARATION
TEETH THAT ARE TO BE USED AS ABUTMENT OR OVERLAY
MUST BE ADEQUATELY PROTECTED
MALPOSED OR SUPERNUMERARY TEETH THAT MAY
UNDUELY COMPLICATE PROSTHESIS DESIGN AND
COMPROMISE THE MAINTANANCE OF GOOD ORAL HYGINE
SHOULD BE CONSIDERED FOR REMOVAL
VETICAL DIMENSION OF OCCLUSION
IN COMPLETE CLEFT LIP AND PALATE PATIENT WILL HAVE
AN ACCEPTABLE VERTICAL DIMENSION.IF THERE IS A
DOUBT………………………………..

PROSTHESIS CONTOURS:
OFTEN WHEN A PROSTHESIS HAS A
PHARYNGEAL EXTENSION THE PARENT PROSTHESIS IS
OVERLOOKED.
VELAR EXTENSION DESIGN:
VELAR PORTION OF AN OBTURATOR OR LIFT
IS THE PORTION THAT CONNECTS THE PALATAL WITH THE
PHARYNGEAL PORTION.THE MOST COMMON FORM IS THE
WIRE OR THE CAST METAL RETENTYIVE LOOP.IT MUST
HAVE SUFICIENT STRENGTH AND BE PASSIVE.

PROSTHESIS CONTOURS:
OFTEN WHEN A PROSTHESIS HAS A
PHARYNGEAL EXTENSION THE PARENT PROSTHESIS IS
OVERLOOKED.
VELAR EXTENSION DESIGN:
VELAR PORTION OF AN OBTURATOR OR
LIFT IS THE PORTION THAT CONNECTS THE PALATAL
WITH THE PHARYNGEAL PORTION.THE MOST COMMON
FORM IS THE WIRE OR THE CAST METAL RETENTYIVE
LOOP.IT MUST HAVE SUFICIENT STRENGTH AND BE
PASSIVE.

INDICATIONS FOR DIFFERENT
DESIGNS:
 SHORT, IMMOBILE SOFT PALATE---A SINGLE HALF
ROUNDED WROUGHT OR CAST METAL BAR
 WHEN THE UVULA IS PRESENT IN THE MIDLINE—
A SPLIT BAR CONFIGURATION SHOULD BE
CONSIDERED
 OBTURATOR PLACEMENT

SUMMARY AND CONCLUSION
WHEN NATURE HAS PROVIDED INSUFFICIENT TISSUE FOR
SUCCESSFUL SURGICAL CLOSURE, THE PROSTHESIS BECOMES
THE METHOD OF CHOICE.
MANY CLEFT PATIENTS WITH DEFICIENT MAXILLARY
DEVELOPMENT FIND THAT THE SPEECH APPLIANCE COMBINED
WITH AN ANTERIOR DENTURE ALONG WITH THE PLASTIC
SURGEON’S ADJUSTMENT IN THE UPPER LIP AND NASAL
STRUCTURE ENABLES THEM FOR THE FIRST TIME IN THEIR
LIVES TO SPEAK INTELLIGENTLY,TO EAT NORMALLY AND TO
HAVE AN ESTHETICALLY ACCEPTABLE APPEARANCEwww.indiandentalacademy.com

REFERENCES
VAROUJAN.A.CHALIAN:MAXILLOFACIAL PROSTHETICS
MULTIDISCIPLINARY PRACTICE
WILLIAM.R.LANY:MAXILLOFACIAL PROSTHESIS
MOHAMMED MAZHAHERI:CINERADIOGRAPHY IN
PROSTHETIC SPEECH APPLIANCE CONSTRUCTION.J
PROSTHET DENT 1962;12:571-875
MOHAMMAD MAZHAHERI:PROSTHETIC TREATMENT OF
CLOSED VERTICAL DIMENSIONOF OCCLUSION IN THE CLEFT
PALATE PATIENT.J PROSTHET DENT 1961;11:187-194
ALI ARAM:VELOPHARYNGEAL FUNCTION AND CLEFT
PALATE PROSTHESIS
M.S.RAVI:TWO PIECE PALATAL PROSTHESIS IN
REHABILITATION OF CLEFT PALATE AND PALATE.www.indiandentalacademy.com

MARK.S.CHAMBERS:OBTURATION OF THE PARTIAL SOFT
PALATE DEFECT .J PROSTHET DENT:2004;91:75-79
JOSEPH.R.CAIN:A CUSTOM IMPRESSION TRAY MADE WITH
THE AID OF AN EXISTING PROSTHESIS:A CLINICAL
TECHNIQUE .J PROSTHET DENT 2001;86:382-385
McCRACKEN’S:REMOVABLE PARTIAL PROSTHODONTICS
10TH
EDITION.

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