Maxillofacial prosthetics theory and practice 2011

MAXILLOFACIAL PROSTHETICS
THEORY AND PRACTICE
Mostafa Fayad
Assistant Lecturer of Removable Prosthodontic
Faculty Of Dental Medicine
Al-Azhar University
Cairo- Egypt
2010
1st ed

Table of contents
Subjects
1 intro Maxillofacial Prosthetics
2 Cleft Lip and Palate
3 mandibular defects
4 Maxillofacial Splints
5 Maxillofacial Stents
6 Radiation
7 Trismus
8 Immediate Denture
9 Snoring
10 Total and Partial Glossectomy
11 Extraoral Maxillofacial Prosthesis
12 Speech
13 Retention of Maxillofacial Prosthesis

Scope of Maxillofacial Prosthetics
Maxillofacial prosthetics is the art and science of anatomic, functional and
cosmetic reconstruction of missing or defective parts of the maxilla, mandible and/or face
by using a non living substitutes.
Maxillofacial prosthetics is the branch of Prosthodontics concerned with the
restoration and or replacement of intra-oral and associated facial structures by artificial
substitutes.
The structures may be missing or mutilated as a result of surgery, trauma, and congenital
or developmental defects.
Maxillofacial Prosthesis: any prosthesis used to replace part or all of any
stomatognathic and/or craniofacial structure.
Objectives of maxillofacial prosthetics
The most important objectives of maxillofacial prosthetics and rehabilitation include:
1 -Restoration of esthetics or cosmetic appearance of the patient.
2- Restoration of function and speech.
3- Protection of tissues.
4- Therapeutic or healing effect.
5- Psychologic therapy.
Types of maxillofacial deformities
1- Congenital : as cleft palate, cleft lip, facial cleft and missing ear.
2- Acquired: as accidents, surgery and pathology.
3- Developmental: as prognathism and retrognathism.

Classification of maxillofacial restorations according to its sits
1- Intra-oral restorations: e.g. obturators, stents and splints.
2- Extra-oral restorations: e.g. radium shield and restoration of missing eye, nose or ear.
3 - Combined intra-oral and extra-oral restoration.
4- Cranial and facial restorations:
a. cranial onlays and inlays used in cranioplasty to compensate for lost cranial
bone.
b. Intra- mandibular implants: Used to support or retain a restoration replacing
missing part of mandibular bone.
The maxillofacial team
The maxillofacial prothetist serves as a member of a team for planning rehabilitative
treatment for patients with maxillofacial defects.
These maxillofacial team including:-
1- Plastic surgeon.
2- Speech therapist.
3- Dental specialists:-
a- Prosthodontist.
b- Orthodontist.
c- Oral surgeon.
d- Dental technician.
4- Radiotherapist.
5- E.N.T (Ear, Nose and Throat) specialist.
6- Physical specialist.
7- The psychiatrist.

Cleft Lip and Palate
Mostafa Fayad 1
Cleft Lip and Palate prostheses
Normal Anatomy:
a- Maxilla is a pyramidal-shaped bone. It consists of a body which forms the mid face
and four processes. These processes are the frontal and zygomatic processes upwards and
the alveolar and palatine processes downwards. The alveolar process carries the anterior
and posterior teeth. The palatine process forms the anterior two thirds of the hard palate.
The maxilla has several distinct anatomical areas.
The nasal spine is the anterior projection of the maxilla and alveolus.
The alveolar process of the maxilla surrounds the palate and houses the teeth.
a- The palate is composed of the maxillary and palatine bony plates. The palatine
process of maxillary bone forms the anterior two thirds of the palate and the horizontal
maxillary plate of palatine bone constitutes the posterior third of the hard palate. They
are both divided into right and left by a longitudinal midline suture.
The anterior part of the palate is formed of the anterior alveolar process carrying the
anterior teeth and the premaxilla.
Blood vessels and nerves exit from the incisive foramen anteriorly and the greater
and lesser palatine foramina postero-laterally.
The incisive canal is located posterior to the incisors, and transmits the lesser palatine
artery, one of the distal branches of the internal maxillary artery.
Posteriorly and laterally along the palate is the greater palatine foramina, which
transmit the greater palatatine artery, a branch of the internal maxillary artery.
The palate itself is formed from the maxilla, the horizontal process of the palatine
bone and the pterygoid plates.
c- The soft palate is the unossified part of the palate. It attaches to the posterior rim of
the hard palate. Medially, a posterior extension, the uvula or the velum extends
downwards and acts as a valve for the pharyngeal cavity.
The soft palate contains a series of muscles , numerous minor salivary glands and
some lymphatic tissues and a dense network of elastic fibers which together with the
muscles of the pharynx form a sphincter that opens and closes the orifice between the
nasal cavities superiorly and the oro-pharyngeal cavity inferiorly.

Mostafa Fayad 2
The soft palate attaches to the posterior portion of the hard palate and
interdigitates with the lateral pharyngeal wall via several muscular attachments. From
the naso-pharyngeal to the oral cavity surface, the muscles of the soft palate consist of:
- the palatopharyngeus, - the salpingopharyngeus,
- the levator and tensor palatini, - the muscular uvula,
- the palatoglossus - the superior constrictor muscle.
The tensor veli palatini tenses the palate, but is not believed to play a major role in
palatal elevation.
The levator veli palatini is responsible for palatal elevation. Also may pull the lateral
pharyngeal walls down and back.
The salpingopharyngeus is a consistently small muscle with probable minimal effects
upon palatal and tubal function.
The superior constrictor muscle is the primary sphincter of the pharyngeal phase
(Velopharyngeal Closure) of swallowing and is responsible for preventing regurgitation
into the nasopharynx (velopharyngeal insufficiency, VPI) .
Muscle Origin Insertion Action
levator veli
palatini
temporal bone,
Eustachian tube
palatine aponeurosis elevates soft palate
tensor veli palatini
medial pterygoid plate of
the sphenoid bone
palatine aponeurosis tension of the soft palate
musculus uvulae hard palate palatine aponeurosis
palato glossus palatine aponeurosis tongue
raising the back part of the
tongue
palato pharyngeus
palatine aponeurosis and
hard palate
Upper border of thyroid
cartilage (blends with
constrictor fibers)
pulls pharynx and larynx

Mostafa Fayad 3
Structures of the Hard Palate:
-Premaxilla
- Incisive Foramen
-Palatine Processes
- Posterior Nasal Spine
Structures of the Soft Palate
-Velum (Soft Palate itself)
- Muscular Uvula
The Pharynx:
The pharynx is a simple, funnel shaped tube wide at the head and narrow at
esophageal end. The pharynx has three muscles superior, middle and inferior constrictors.
The action of the pharynx is complex but basically it contracts from side to side and its
posterior surface moves forwards. It is capable of local contractions at various levels,
which are mainly used in speech, and also peristaltic type of contractions which are
employed during swallowing.
The shape and action of the soft palate and pharynx in speech and swallowing are
different
Dark line illustrates position of soft palate and
posterior pharyngeal wall during speech. Dotted line
illustrate position of both when swallowing. Note
marked shift of pharyngeal wall in swallowing
position.

Mostafa Fayad 4
Palato (velo) pharyngeal mechanism (Palato (Velo) Pharyngeal Sphincter)
The velopharyngeal mechanism is a coordinated valve formed by the muscles of
the soft palate and pharynx.
Muscles forming the velo-pharyngeal sphincter
Muscles forming the velo-pharyngeal region are, (fig.3):
1-Muscles forming the palate, these are:
-Levator veli palatini muscle -Tensor veli palatini muscle
-Palato glossus muscle -Palato pharyngus muscle
-Uvula muscle, which is the intrinsic muscle of the velum
2-Muscles forming the pharynx, these are:
-Superior constrictor muscle -Salpingo pharynges muscle
-Palato pharyngus muscle which has two portions, the pharyngo palatal
portion and the thyro-palatal portion
The levator veli palatini muscle and the superior constrictor muscles play the
dominant role in velo-pharyngeal mechanism especially during closure of the nasal
cavity. The levator veli palatini muscle is a long muscle and provides a wide range of
movement necessary in moving the velum from the relaxed rest position to a fully
elevated position
Palato (Velo) Pharyngeal mechanism
The velum acquires three positions to perform the valve action required during
swallowing and speech, these are:
1-The relaxed position of the velum (uvula)
This is the relaxed position of the velum. It is required during normal breathing. The
velum is dropped downwards to keep the oro pharynx and naso pharynx opened to allow
for both oral and nasal breathing.

Mostafa Fayad 5
2-Closure of the nasal cavity
Velo pharyngeal mechanism is required for closure of the nasal cavity during
swallowing and for production of letters produced in the oral cavity. This mechanism is
achieved as follows:
-The middle third of the velum curves upwards and backwards in an attempt to contact
the posterior wall of the pharynx at or above the level of the plane of the palate at the
level of the atlas vertebra. This is done by the action of the levator veli palatini muscle.
This is aided by the contracted state of both the tensor veli palatine muscle and the uvulae
muscle that adds bulk to the nasal surface of the velum.
-However, this pull of the velum is not enough to achieve adequate closure between
soft palate and pharynx.
For this reason the pharynx shares in palato pharyngeal mechanism by:
*Movement of the posterior wall of the pharynx forwards. This is done by the action of
the superior constrictor muscle aided by the pharyngo palatalportion of the palato
pharyngus muscle.
*Movement of the lateral walls of the pharynx medially to close the last gap between the
lateral aspect of soft palate and lateral walls of pharynx. This is done by the action of the
salpingo pharynges muscle.
*The posterior pharyngeal muscles contracts strongly and produces a bunch-up forming a
prominent ridge or pad called “Ridge of Passavant”. This helps to approximate the soft
palate and pharynx,
Ridge of Passavant
The ridge of Passavant is a horizontal roll of muscles on the posterior wall of the
pharynx forming a bunching-up of the posterior pharyngeal wall. It is present at the level
of the palate which corresponds to the level of the atlas vertebra. It is usually more
evident in patients with soft palate defects as a compensating mechanism to aid in speech
and swallowing. It also serves as a guide for placement of soft palate prostheses

Mostafa Fayad 6
3-Closure of the oral cavity
Velo pharyngeal mechanism is required for closure of the oral cavity. This is required
to permit exit of air through the nasal cavity during sucking and pronunciation of sounds
as “M” and Ng as in sing. This mechanism is achieved as follows:
-The thyro-palatal portion of the palato pharyngus muscle pulls the soft palate downward
towards the tongue.
-The tensor veli palatini muscle flattens the dome-shape of the soft palate.
-The tongue is forced upward and backward.
-The palato glossus muscle contracts and completes the palate tongue approximation.
It function as follows:
1-Velopharyngeal closure: It is required for normal deglutition and the production of
some speech sounds such as plosives (e.g. P&D). This closure occurs by the following:
a-The middle of the soft palate curves upwards an backwards as an attempt to contact
the posterior wall of the pharynx. This action is done by the levator and tensor palatini
muscles.
b-The posterior wall of the pharynx moves forward by the action of the superior
constrictor and the palatopharyngeous muscles forming the ridge of passavant. This
ridge is a horizontal roll of tissues on the posterior wall of the pharynx corresponds to
level of the atlas vertebra. It occurs during speech and swallowing and serves as a
guide for placement of soft palate prosthesis.
c-The lateral walls of the pharynx move medially by the action of
the salpino pharyngeous muscle.
2-Velopharyngeal opening:
This occurs during normal breathing and for pronunciation of
vowels and nasal consonants in a varying degrees. It is a relaxed
position; the soft palate drops downward to keep the oropharynx and nasopharynx
opened.

Mostafa Fayad 7
Velopharyngeal insufficiency:
Palato pharyngeal insufficiency is a condition characterized by abnormal anatomy
of the palate in the form of absence, short length or cleft in the tissues of the soft palate.
This could be congenital, or due to acquired causes as resection of soft
palate or lateral pharyngeal wall. This condition results in inability to
perform palato pharyngeal mechanism.
Prosthetic rehabilitation is achieved by palato-pharyngeal obturator
(speech bulb) or by meatle obturator.
Nasal sounds
Velopharyngeal incompetence:
Palato pharyngeal incompetence is a condition characterized by
normal anatomy but ineffective or absent motor function (tissues are
functionally impaired) resulting in impaired palato pharyngeal
mechanism. This usually results due to neurological disorders as
poliomyelitis affecting oro-pharyngeal structures through affection of
any of the nerves of the pharyngeal plexus which includes fibers from
the IX, X and XI cranial nerves. It could also be due to diseases as
multiple sclerosis or tumors, or due to traumatic head injuries. Oral sounds
Palato pharyngeal incompetence usually results in speech disorders in the form of
hyper nasality or reduced speech intelligibility.
Palato pharyngeal incompetence is diagnosed by easily lifting the soft palate by a tongue
depressor, by nasal endoscopy or by airflow pressure measurements.
Prosthetic rehabilitation is achieved by a palatal lift device.
Development of Palate
The development of the palate begins in the fifth week and is completed in the
twelfth week intrauterine. It develops from:
1-The primary palate is derived from the median nasal process and the maxillary
process and gives rise to:

Mostafa Fayad 8
a-The upper lip.
b-The premaxilla; the part of the hard palate in front of the incisive foramen
c- The anterior part of the alveolar process and the incisors.
2-The secondary palate: is derived from two horizontal lateral palatine (nasal)
processes or palatine shelves. It gives rise to:
a-Hard palate posterior to the incisive foramen.
b-Soft plate.
At about the end of the eighth gestational week, the shelves elevate, make contact,
and fuse with each other above the tongue Failure of union at any stage will result in a
cleft palate and or lip.
Because the secondary palate arises from the lateral palatine processes which fuse
in the midline, vascular, lymphatic, and neural elements are divided at the midline. This
phenomenon explains why unilateral palatal and paranasal sinus tumors rarely
demonstrate contralateral lymphatic spread. The midline also serves as an effective
anatomic barrier for resistance of local tumor extension and often serves as the medial
surgical margin in resection of palatal and paranasal sinus tumors.
Palatal cleft development
The union of the primary palate, the secondary palate and the nasal septum begins
at the meeting point of the premaxilla and the two lateral palatine processes (incisive
foramen). From this point of meeting union progress anteriorly and posteriorly in a Y –
shaped suture. Anteriorly, to form the premaxilla, anterior alveolar ridge and upper lip
and posteriorly to form hard and soft palate.
Congenital clefts occur during embryological growth due to arrest of development
and failure of fusion between the embryonic processes.
Incidence of cleft lip and palate
Cleft deformities of the palate are among the most common congenital
malformations. A cleft palate can be diagnosed as early as the 17th week of gestation by
means of ultra-sonography. Although many studies exist, the exact environmental and
genetic factors that play a role are still largely unknown. However, the following can be
concluded:

Mostafa Fayad 9
1- The incidence of clefting has a racial differences. However, the average incidence rate
is one in every 700 born has some form of clefting.
2-Unilateral clefts are more common than bilateral clefts of the lip and palate.
3-Left side cleft forms 70% of unilateral clefts.
4-The incidence of clefts in males is twice that in females.
Development of the palate, shown from beneath (left) and in coronal section (right).
(a) 7th week; (b) late 8th week; (c) 10 weeks. Swellings on the medial aspect of the maxillae grow
downwards either side of the tongue (a), then swing medially to form horizontal palatal shelves (b);
these fuse with each other and with the nasal septum by breakdown of the apposed epithelial seams
(c). e, eye; es, epithelial seam; hps, horizontal palatal shelf; mn, medial nasal swelling; mx,
maxillary process; nc, nasal conchae; ns, nasal septum; pp, primary palate; r, rugae; uv, uvula; vps,
vertical palatal shelf

Mostafa Fayad 10
Definition : A cleft palate may be defined as a lack of continuity of the roof of the
mouth. It may be congenital or acquired.
A] Congenital cleft palate
It is a lack of continuity of the roof of the mouth though the whole or part of its length in
the form of fissure extending anteroposteriorly.
Etiology : Congenital cleft palate results from lack of fusion of embryological processes
which would normally unite during the 6th
to 10th
weeks of embryonic development. The
exact cause of the clefts is unknown but it may be:
1- Abnormal position of the embryo,
2- Pressure from the amniotic fluid,
3- Failure of the tongue to drop,
4- Persistence of epithelium at the junction of the two palatal halves.
Hereditary and environmental factors influence the induction of the cleft palate:
1-Hereditary: There is widespread agreement that a hereditary bases exsists in about 20
to 30 % of all cases of clefts of lip and palate.
2- Environmental factors and teratogenic agents (predisposing factors):
Nutritional deficiency or cortisone administration has never been proved to be
teratogenic in humans. The principal environmental causes are:
1- Oxygen deprivation and glucose deprivation .
2- Nutritional deficiency e.g. Vitamin A and riboflavin deficiency.
3- Infectious diseases of the mother during pregnancy e.g. Acute virus infections as
German measles..
4- Cortisone therapy and hormonal disturbance as in pituitary dysfunction.
5- Radiotherpy and excessive X-ray exposure to the mother’s pelvic area during early
pregnancy.
6- Chemical irritation e.g. hypervitaminosis A and hypoxia to the pregnant mother.
7- Stress and anxiety during the first trimester of pregnancy, since these conditions result
in excessive production of adrenal hormons (cortisone) which has been shown to induce
clefting in mice.

Mostafa Fayad 11
The present of environmental factors together with the hereditary background may
increase the incedance of cleft lip and palate.
Types of Congenital cleft palate
Clefts may be isolated malformations or may be a part of a syndrome. Clefts of the
palate, alveolus and lip (CLAP) are:
Syndromic types are by definition associated with other malformations (At last
count, more than 300 syndromes were associated with CLAP).
Syndromic etiologies include:
- Single gene transmission such as trisomies.
- Teratogenic causes such as fetal alcohol syndrome; or
- Environmental causes such as maternal diabetes mellitus
Non-syndromic CLAP is a diagnosis of exclusion, and is considered to be of
multifactorial inheritance with known predicted rates of recurrence.
Syndrome: major malformations which appear unrelated but are frequently found
to have a common etiology.
Sequence: anomalies occur together the primary anomaly causes the first to
happen.
e.g., Pierre Robin Sequence - failure of mandible to grow in utero causes a u-shaped cleft
of the soft and hard palate but not the alveolar ridge.
Classification of cleft palate:
Victor Veau’ s classification
It is generally accepted and give more details of cleft palate.
class I. Clefts involving soft palate only.
Class II. Clefts involving soft and hard palates up to incisive foramen.
Class III. Clefts of soft and hard palates, right forwards through alveolar ridge and
continues into lip on one side.
Class IV. Same as Class III only associated with bilateral hare- lip.

Mostafa Fayad 12
Veau’s classification of cleft palate.
Olin's classification:
Group I. Cleft lip only: unilaterally or bilaterally with nasal deformity.
Group II. Cleft palate only: part of the soft palate, or the entire soft and hard palate may
be involved.
Group III. Clefts of lip and palate involve the alveolar ridge. Patient may have unilateral
or bilateral clefts
Group IV. Clefts of the lip and alveolar ridge not involve the palate (Rare occurrence).
Harkin's classification:
Patients are classified according to the degree of the cleft into:
 Bifid uvula.
 Cleft of the soft palate.
 Cleft of soft and hard palate extending through the palatal bones.
 Cleft of the soft and hard palates extending to the incisive foremen.
 Cleft of the soft and hard palates extending through the alveolar process and lip on
one side.
Davis classification: (1922) (Not used now) Classification depends on the extent of cleft
Group 1: all clefts of the lip
Group 2: All posterior alveolar clefts.
Group 3: complete cleft of alveolar ridge, palate & lip.
Stark's classification (1958) (The most widely used today).

Mostafa Fayad 13
Disabilities associated by the presence of cleft palate
The basic disability of a cleft palate results from inability to close well the
nasopharynx from the oropharynx. Patients with a cleft lip or palate have numerous
associated problems, such as the following:
1. Esthetic problem: due to
- Basic anatomic deformity - Deficient facial growth
Abnormal appearance of the child occurs due to the presence of labial cleft and facial
deformity due to improper or early surgical repair of palatal cleft. Trauma to the growth
center of bone during surgery leads to reduction of the forward growth and lateral
dimension of the maxilla.
2-Improper mastication: The masticatory function is impaired because babies cannot
suck due to lack of negative pressure, food escape through the nasal cavity and the
presence of missing teeth and malocclusion.
3-Swallowing: Swallowing is impaired when cleft occurs in both hard and soft palate.
The baby should be placed in upright position and a special nipple is used during feeding.
4. Dental problems
-Missing, malformed, and supernumerary teeth -Malocclusion
5. Speech problems (see speech & Palato (velo) pharyngeal mechanism)
-Velopharyngeal incompetence - Secondary articulation disorders
6. Otologic problems
- Eustachian tube dysfunction - Chronic ear disease
- Hearing loss
7-General health: The general health of the child is affected due to inadequate nutrition
and mouth breathing.
8-Psychological problems: Children with clefts have difficulty in adjusting with society.
They may withdraw or turn aggressive.
9- Additional congenital anomalies.

Mostafa Fayad 14
Diagnosis and examination of cleft palate:
The patient should be examined by all maxillofacial specialists.
Maxillofacial team
The management of patients with acquired or congenital defects involves the
cooperation of the following team members:
1- Plastic surgeon: The role of plastic surgeon is important in treatment planning and
surgical reconstruction of deformities.
2-Prosthodontist: Prosthodontic treatment may be required in inoperable cases and in
case of failed surgery.
3-Speech therapist: The role of speech therapist is to correct defective speech
caused by the palatal defects.
4-Orthodontist: The orthodontist treat malocclusion associated with cleft lip and palate.
5-Psychologist: Help the patient to accept the problem, and to improve patient’s attitude
and cooperation in the course of treatment.
6-Social worker: Discusses the problem with parents, educate them about the problem
and guide the patient for his future life.
7-Dental technician: Construct the prosthetic appliance.
The following procedures facilitate the diagnosis:
1- General case history including all information about the cleft and anomalies.
2- Clinical examination and photographs.
3- Construction of study cast.
4- Radiographic procedures includs full mouth x-ray, bit wings, occlusal and
cephalometric x-rays.
5- Medical, surgical, speech, and psycological recording.
N.B. Study casts, photographs and radiographic data are recorded periodically to help the
dentist to study the growth and development patterns of oral-facial-cranial structures and
to observe the effects of surgical and orthopedic treatment.

Mostafa Fayad 15
Diagnosis and treatment planning are carried out through the maxillofacial team.
Full consideration should be given to the following:
1-Type and width of the cleft.
2-Position and relation of the maxillary segments to each other.
3-Form of the maxillary arch and its lateral and antero-posterior dimensions.
4-Length, thickness and mobility of the soft palate.
5-Perforations remaining in the hard and soft palate and labial sulcus after surgery.
6-Posterior and lateral pharyngeal wall activities size of naso-pharynx.
7-Floating premaxilla.
8-Number of missing teeth in line of cleft, malformed and malposed teeth and partially
erupted teeth.
9-Constricted maxilla.
10-Condition of tonsils and adenoids.
11-Growth and development of the child, mental attitude and general health must also be
considered.
12-Speech articulation of the patient, his voice quality and hearing acuity.
Treatment planning:
Any child born with cleft palate should be examined by the plastic surgeon,
orthodontist, the prosthetist and the speech therapist, in consultation and a combined plan
of treatment is formed .
I-Pre-surgical treatment phase
This phase starts at birth and may continue till surgical repair is performed.
Treatment in this phase includes:
-Psychological support to the parents provided by the social worker and the

Mostafa Fayad 16
nurse to encourage parents to correctly care for their child.
-Teaching parents how to care for and clean the defect.
-Teaching parents how to feed the infant to ensure proper nutrition necessary for
growth and development. Ensuring that feeding requires longer time and patience
compared to normal infants. Feeding devices could be selected from among the wide
variety present in the market.
Infants with cleft lip most often feed normally only slight milk leakage which
can be overcome by using a bottle with broad base nipple to seal the defect during
feeding. They can also be breast fed.
Infants with cleft palate are usually more difficult to feed due to their inability to
generate and maintain vacuum and loss of negative pressure required for sucking. This
may cause early fatigue and improper feeding. For this reason using squeezable bottles,
soft nipples with cross cut openings rather than tiny holes are recommended to allow for
easier flow of nutrients. Long nipples can also be used in order to be placed posterior to
the defect. Feeding spoons which are deep and with long pointed tips can also be used.
2- Surgical management of congenital cleft palate
The following should be taken into consideration:
1- Surgical closure is the treatment of choice for congenital defects.
2- Lip repair is usually performed 6-12 weeks after birth to facilitate feeding and improve
appearance if the infant’s physical health allows.
3- Repair of the cleft palate is performed after 1-4 years (usually 2 years). Early repair
of the cleft palate should be avoided to permit for the growth of the palate with narrowing
of the cleft and to permit for development of enough tissues for closure.
4- Surgical repair of the soft palate is superior to the fitting of a prosthesis. But if the cleft
is too wide and the muscular remnants poorly developed it is better to treat the cleft
entirely by prosthetic obturator.

Mostafa Fayad 17
If surgery can only produce a non-functional united soft palate, the prosthetic
obturator should be performed instead of surgery because the problem of fitting an
obturator in cases with repaired nonfunctional soft palate is greater than in those cases
which not surgically treated.
If a pharyngoplasty has been performed, a surgical repair of pharynx should be
performed before the end of the second year because the child commences to talk
between the second and third years and if repair is delayed beyond this time faulty habits
of speech will develop which are too difficult to eradicated.
If it is decided that surgery is unlikely to be successful the first obturator should be
fitted at the end of second year.
If the cleft of hard palate is too wide it is better to cover it by obturator because
surgiacal repair will certainly result in contraction of the dental arch and the orthodontic
treatment will reopen the cleft.
3- Prosthetic management of congenital cleft palate
Objectives of cleft palate prosthesis:
1- Restoration of masticatory apparatus.
2- Restoration of speech.
3-Prevent foods from enter the nose and prevent nasal secretion from enter the mouth.
4- Improve the esthetics of the patient by restoring the missing part of ridge and teeth.
5- Improve psychological condition of the patient.
Indication of maxillofacial prosthesis:
Generally, surgical correction of cleft palate is better than prosthetic treatment However,
there are some situations in which a prosthsis may be the treatment of choice as:
A-In unoperated cases:
1. A wide cleft with a deficient soft palate that cannot function properly after
surgery.

Mostafa Fayad 18
2. A wide bilateral hard palate cleft. In such cases surgical repair of the soft
palate can be performed and an obturators is constructed for the hard palate.
3. Partial or complete paralysis of the soft palate remnants.
4. In patients with neuromuscular disease affecting the soft palate and pharynx
resulting in velopharyngeal incompetence.
5. Absence of the premaxilla.
6. Patients with poor general health.
7. The cleft palate may be temporarily closed with speech aid, when surgery is
delayed.
8. When orthodontic appliance (e.g. expansion appliance or appliance to correct
teeth position) is indicated.
B- In operated cases:
1-Failure of surgery to close the defect completely.
2-When the soft palate movement is inactive or completely absent or the soft
palate is short causing incompetent palatopharyngeal closure.
3-A transitional prosthesis to provide certain function, e.g. feeding appliance or
appliance to activate the soft tissues of the pharynx for function.
Contra-indications for maxillofacial prosthesis
1- Easability of surgical repair
2- Uncooperative patient and parents.
3- Uncontrolled dental caries as rampant caries.
4- Mentally retarded patient.
5- Lack of dentist who has had training in cleft palate prosthodontics.

Mostafa Fayad 19
Prosthetic devices used in management of congenital cleft
palate
1-Obturators (discussed later)
An obturator is an appliance, which corrects openings in the hard palate, soft
palate or both. The prosthetic treatment consists of the construction of an obturator or an
artificial palate for closing the cleft and restoring the function of speech and swallowing.
2-Orthopedic treatment
Early orthopedic treatment of any patient should be underten on the basis of a joint
decision of the surgeon, the orthodontist, and the prosthodontist.
The orthopedic appliances are of two types:
a- The passive or holding type.
b- The active or expansion type.
The type of appliance will be determined by the configuration of the cleft.
1- If any degree of collapse is manifested, an expansion appliance is placed.
2- If the collapse is primarily in the anterior region, a fan type of split acrylic
appliance is used.
Splint acrylic appliance (Fan type) B. The cast before and after treatment .
3- If it appears that the arch is collapsed throughout its length, a straight Jack
screw appliance is used
Jack screw appliance.

Mostafa Fayad 20
4- If the cleft configuration is wide or if the segments appear in an ideal
relationship, a holding appliance is used. These case are operated on as soon
as the holding appliance is placed.
All appliances, whether active or passive, are fabricated and inserted prior to lip closure.
After the maxillary appliance has the segments is good alignment, the plastic surgeon
restores lip continuity.
Expansion type prosthesis
An expansion prosthesis may be used preoperatively for complete unilateral or
bilateral collapsed palate clefts. These prosthesis used to guide the maxillary segments
into proper spatial relations with each other and with the mandibular arch prior to
surgery. The segments can be gradually separated by an expansion prosthesis to create a
space for the premaxilla or to stabilize the parts in a normal position with or without bone
grafting.
In the period of expansion several successive prosthesis may be constructed
considering the growth and possible eruption of the teeth.
Indications:
1-In patients having complete unilateral or bilateral collapsed cleft, to align the
lateral segments of the palate before surgery.
2- To assess and diagnose the need and progress in speech that will be achieved by
surgery.
The expansion prosthesis is consists of palatal portion and pharyngeal portion.
a- The palatal portion composed of two separate lateral sections covering the hard
palate and united by expansion device. In the predental eruption period. The
prosthesis cover the alveolar ridge and extend to the mucobuccal fold. When the
teeth are erupted the prosthesis is extended to the lingual surface of the teeth and
retained by wire claspe.
b- The pharyngeal portion may be constructed in some cases to improve the speech
and deglutition.

Mostafa Fayad 21
3- Combined prothesis and orthodontic appliance:
In case of malposed teeth an orthodontic appliance may be combined with a
prosthesis to move malposed teeth into a more favorable alignment. A speech appliance
prosthesis could be designed for patient receiving full band orthodontic treatment.
Obturators used for treatment of congenital cleft palate
1- Preoperative devices for children:
- Feeding devices
- Expansion prosthesis.
2- Cleft palate prosthesis for adolescent:
Fixed pharyngeal obturator.
3- Cleft palate prosthesis for adult (definitive obturator)
I-Prosthetic rehabilitation of congenital cleft palate (in children)
1- Feeding devices:
In case of cleft lip the infant can feed normally with a bottle or breast. To prevent
milk leakage the finger is placed over the lip cleft or a broad base nipple is used.
In case of unilateral alveolar cleft the nipple should be pointed toward the
unaffected side.
For cleft palate the infant cannot suck. A syringe is used or a specially designed
bottle and nipples, while the infant in a semi-upright position. Soft nipples, crosscut
nipples, or long nipples and squeeze bottles can be used. In some cases an obturators
attached to the nipple is used.
The importance of feeding appliances:
1- Most infants with cleft lip and palate are unable to nurse from the breast
or bottle. Since normal suckling is impossible, a more upright position
of the baby, and a bottle with large hole nipple may compensate for the

Mostafa Fayad 22
slow flow of milk or fluid associated with defective suckling.
Sometimes Nasogastric tube is used for feeding.
2- The repeated pressure of the tongue on the nipple forces it upwards
against the edges of the cleft and tends to increase the width of the cleft.
All these difficult conditions make the construction of the feeding device
essential to separate the oral cavity from the nasal cavity and thus , facilitate food
intake and reduce irritation prior to surgical closure.
Construction:
The feeding devices consists of an acrylic plate, constructed from a low fusing
compound impression.
A mass of softened compound is placed on suitable tray or on the convex surface
of the spatula and mould it to the shape of block of the needed size. Then compound is
inserted into the baby’ s mouth to the back of the pharynx and with light upward and
forward movement, so that the edges of the cleft leaves their marks on the block.
The compound impression is taken out by moving the spatula from the front to
back and then downward and forward. The impression is poured in stone and allowed to
set before separation. A plate of softened wax is adapted on the lingopalatine surface of
the model formed the palatine wings of the obturator. The wax is replaced by acrylic
resin using the routine method of flasking, then finishing and polishing are done.
The plate can be designed to be attached to the neck of feeding bottle to cover
the cleft during bottle feeding. Or the acrylic plate can be made with a wire or acrylic
handle to be held by the mother to cover the cleft during breast feeding.
2-Expansion prosthesis
The expansion prosthesis (described before) may be constructed with pharyngeal
portion to improve the speech and deglutition.
II-Prosthetic rehabilitation of congenital cleft palate for adolescents
Dental considerations for adult cleft patients

Mostafa Fayad 23
Oral disfigurement is not gross nowadays due to advances in the management of
newborns and infants. Problems associated with rehabilitation of cleft adult or adolescent
patients
-Missing or malformed incisors is the most common dental defect associated with cleft.
-High smile line exposing residual soft tissues which become unaesthetic if
bridges are to be constructed. Hence, removable partial dentures are constructed.
-Cleft alveolus that is unreconstructed by bone grafts results in movement of the two
segments of maxilla which results in break of cementing cement if fixed bridges are
constructed. Hence, removable partial dentures are constructed.
-Early surgeries lead to scarring which hinders growth of maxilla leading to discrepancy
in size of maxilla and its relation to the mandible.
-Lack of early orthodontic treatment.
-Dental neglect and poor oral hygiene.
-Inadequate vertical dimension of occlusion.
Proper dental care, oral hygiene measures, osteotomy to reposition maxilla in a
downward and forward position and interim dentures to restore vertical dimension are
lines of treatment that may precede prosthetic rehabilitation.
Temporary appliances are usually constructed for adolescents till they reach complete
growth. A temporary appliance is a great aid to the prosthodontist to assess and determine
the best design providing an esthetics, mechanical and functional prosthesis. It is also
considered an educational tool for the patient.
However, it may sometimes be required to construct metal removable partial dentures
for patients between 11 and 20 years where esthetics and retention are primary demands.
In this case a self-cleansing restoration with margins ending as far as possible from the
gingival margin and natural teeth should be designed.
Definitive appliances are usually constructed at the age of 20 after complete growth
and bone grafts if present, are mature.
Definitive appliances to obdurate clefts may be attached to a partial denture, a
complete denture or an overdenture depending on the condition and number of teeth.

Mostafa Fayad 24
For partially edentulous patients with surgically repaired clefts removable partial
dentures with similar designs as non-cleft patients are constructed. However, patients
with palato pharyngeal deficiencies, the partial denture will be extended to the
pharyngeal cavity as a speech aid which may in turn exerts a long lever arm especially in
free end saddle cases. Thus, the design of partial denture needs to be altered to provide
additional direct and indirect retention.
For completely edentulous patients, several problems may arise during complete
denture construction as the maxilla of these patients tends to be smaller in size compared
to the normal sized mandible. This is usually due to reduced forward and downward
growth of maxilla. These problems are:
1-Reduced bony support due to small maxilla.
2-Increased inter arch space.
3-Lack of adequate denture support and stability.
4-Inadequate retention due to ineffective posterior palatal seal due to scar
issue if surgery was previously performed.
5-Scarring of lip tissues which may affect anterior border seal and exerts a
backward push on the denture, thus affecting denture retention.
Appliances for habilitation of congenital cleft palate (for adolescents):
1-Fixed pharyngeal obturator (speech aid)
The fixed pharyngeal obturator is an extension of a denture projecting into the
pharynx to the level of the anterior arch of the atlas bone or Passavant’ s ridge. The
obturator is shaped so that it can be gripped by the pharyngeal walls.
They are temporary appliances usually constructed for adolescents (between 11-20
years) till they reach complete growth.
Normal lateral growth of the palatal bones necessitates replacement of this
prosthesis occasionally. Intermittent revisions of the obturator section can assist in
maintenance of palatopharyngeal closure.

Mostafa Fayad 25
It is a space filling prosthesis, designed to be held in the lower region of the
nasopharynx to compensate for the tissue deficiency. It acts as a core against which
palatopharyngeal musculature can form a seal.
N.B. Passavant's ridge is a horizontal ridge or cushion around the lateral and posterior
walls of the pharynx at the horizontal level of the hard palate coinside with the anterior
tubercle of the atlas vertebra. It is a compensatory factor associated with cleft palate that
help in reducing the diameter of palatopharyngeal orifice.
The passavant’s ridge is present in few cases and used as a reference point to place
the pharyngeal section of the fixed pharyngeal obturator.
Objectives:
The prosthesis must establish a competent naso-oral separation to satisfy the
following objectives:
1-Socially acceptable speech.
The prosthesis must help the patient to acquire normal speech pattern. For
reasonable speech articulation and resonance there must be adequate dental
relation together with adequate oronasal separation.
2-Restoration of masticating apparatus.
Help in mastication and increases the efficiency of chewing and confine the
food material in the oral cavity. Help in deglutition and prevent the seepage of
fluids to the nasal cavity during the act of swallowing.
3-Prevent the seepage of nasal secretion into the oral cavity.
4-Facial esthetics and dental harmony.
Improve the esthetics of the patient.
Restoring the missing, malposed and improve the articulation of the teeth to
establish dental esthetics.
5-Improve psychological condition of the patient.

Mostafa Fayad 26
Fixed pharyngeal obturator requirements:
1- The prosthesis must be designed to suit the patient regarding his oral and facial
condition, masticatory function, and speech.
2- The prosthesis must preserve the remaining structures wrong design of the
maxillary portion will result in premature loss of the hard and soft tissues and
further complicating prosthetic habilitation.
3- The prosthesis requires greater retention and support. In adult cases, crowing and
splinting of the abutment teeth increases retention and, support.
4- Closed vertical dimension in more suitable in the cleft palate patients.
5- Minimum weight should be kept. The material used should be easily repaired and
altered.
6- Soft tissue pressure in the velar and naso–pharyngeal areas by the appliance must
be avoided.
7- The prosthesis must not be displaced by velum, lateral and posterior pharyngeal
wall muscle activities or tongue movement during swallowing and speech
production.
8- Pharyngeal section should be properly placed. The superior surface of the
pharyngeal section must be at the level of the palatal plane.
Preparation of the patient for prosthetic treatment:
The oral cavity should be prepared before the construction of the speech aid
prosthesis as follow:
1-Decayed teeth are preferably restored with full coverage to prevent recurrence of
decay and to shape the teeth in the desirable form to support and retain the speech
aid in position.
2-Every tooth in the cleft palate patient should be saved to avoid problems of
retention.
3-Teeth needing extraction or other surgical treatment should be preferably done
before the construction of the speech aid.

Mostafa Fayad 27
4-Orthodontic treatment to expand the arch or approximate the two segments and
correct malposed teeth are done at this stage if possible.
5-Gingivectomy for partially erupted teeth is recommended to expose the clinical
crown to be used for retention.
Sections of speech aid: The speech aid consists of three sections; palatomaxillary
section, palatovelar section and pharyngeal section.
a-The palatomaxillary section:It covers the cleft of the hard palate, and may
be constructed in the form of partial or complete denture. In general the
number of retainers is increased.
b- The palatovelar section or tailpiece: It supplements the palatal cleft and
must remain in lateral contact with the soft palatal muscles during function or
rest.
c- The pharyngeal section (speech bulb): It extends posteriorly into the
pharyngeal cavity to be surrounded by the sphincteric action of the
pharyngeal muscles during swallowing and speech.
Sections of speech and (a) Palatomaxillary, (b) Palatovelar, ( c) Pharyngeal.
Construction:
Preliminary impression:
Prior to taking the impression the undercuts in the palatal cleft is packed with
vaseline gauze. An alginate impression is taken in a suitable stock tray and cast is poured.
Final impression:
An acrylic special tray is constructed and the final impression is taken with rubber
base or alginate impression material. The deep undercuts in the hard palatal cleft should
be packed with vaseline gauze prior to taking impression.

Mostafa Fayad 28
Recording jaw relation:
If the patient is edentulous the upper denture should has an upward extension that
engages undercuts in the cleft to help retention.
If the patient is dentulous the working model is surveyed and the cleft in the hard
palate filled in with plaster of paris to reproduce the contour of a normal palate. On this
prepared model a record block is constructed. Jaw relation is recorded in the usual
manner and the casts are articulated.
The artificial teeth are set in positions demanded by appearance and occlusion.
At the try-in the usual points are checked and a wire loop made of German silver
or stainless steel is bent and attached with sticky wax to the base of the trial denture. This
loop should be adjusted by bending and altering its position in the wax until it lie along
the center of the cleft of the soft palate, without contact with its remnants or with the
posterior pharyngeal wall when a prolonged “ah” is sounded. If the loop is made of
German silver wire, it will be more easily adjusted than if made of stainless steel.
In some cases where difficulty to the wearing of the denture is
anticipated it is desirable to leave the wire loop off the denture and
allowing the patient to wear the denture for few weeks until it is quite
comfortable. The wire loop may than be added to the denture with cold
cure resin to avoid the induce of extra strains in the acrylic by a second
processing.
Denture with wire loop
After the denture has been completed and fitted, a tailpiece must be made and
attached to the back edge of the denture and positioned at a level just below the soft
palate when assumes fully relaxation. If the tailpiece is positioned at higher level,
discomfort and pressure sores will occure when the soft palate relaxes. If on the other
hand the level of the tailpiece is much below that assumed by the relaxed soft palate, then
it will cause discomfort by obstructing the movements of the tongue.
For locating the plane of the tailpiece a piece of pink base plate wax is attached
to the back edge of the denture with sticky wax, this wax should be wide and long enough
to cross the soft palate into the pharynx.
The denture carrying the wax is then inserted into the mouth and the patient is
instructed to relax and breath through the nose. After few minutes the wax will be

Mostafa Fayad 29
moulded by the relaxed soft palate above and the tongue below to conform to the plane
and contour of the relaxed palate. The denture is removed and the wax is chilled
thoroughly. The denture is then replaced into the mouth and the plane of wax in relation
to the relaxed soft palate is checked with the mouth open.
If there is any appearance of the wax supporting the soft palate, the shaping
technique as previously described should be repeated. When the plane and contour of the
wax is satisfactory, a plaster model is cast under the palatal side of the wax and extending
under the denture to enable it to be located. After the plaster set, the wax is removed, and
replaced by thin mix of cold cure resin. The back of the denture should be roughened to
ensure a firm union between the denture and the cold cure resin.
The velar section can also be constructed after few weeks from using the denture
by attaching a piece of base plate, which act as a tray, to the posterior part of the upper
denture with suitable relief for the zinc oxide impression paste. During taking the
impression the patient should hold his head in a vertical position to prevent the escape of
the material into the naso-pharynx.
Construction of speech bulb
A piece of soft modeling compund is added on the wire loop that attached to the
end of the velar section. The denture with the soft compound is inserted into the mouth
and the patient is requested to swallow, say “ah” move his head up and down and then
from side to side while the compound is still soft. A drink of warm water or hot tea will
facilitate swallowing. The denture is removed, cleaned, dried and the compound is
inspected and reheated then reinserted in the mouth and the patient is asked to do the
same previously described movements using stick compound to correct the impression
section by section .
Impression wax softened in water bath maintained at 51 - 64 C painted over the
green compound with a brush. The denture carrying the compound and wax is inserted to
the patient s mouth and the same previously described movements are performed. The
prosthesis is removed and reinseted several times with gradual adjustment to the speech
bulb until a satisfactory functional impression is made. The impression wax has the
advantage that it can stay soft in the mouth for relatively long period for better
regestration of the functional movement. The size of the bulb should be adjusted until the
patient can breath clearly through the nose and produce acceptable nasal sounds. If the
patient is sensitive enough to produce a gag reflex, the speech bulb should be made
underextended using self curing resin, allowing the patient to wear the denture for few

Mostafa Fayad 30
weeks until he is accustomed to the underextended bulb, then the final impression of the
speech bulb is taken.
The black gutta-percha can also be used to make impression for the speech bulb.
This material can be fully adjusted to fit the movements of the pharynx and palatal
remnants before being processed in acrylic resin. The
black gutta-percha has the advantage of remaining
soft enough to be moulded by the pharyngeal
musculature for about 5 minutes after each heating,
while at the same time remaining sufficiently viscous
to support its own weight. It is therefore deformed by
muscular pressure and then retaines the shape
impressed on it by that pressure. The final details
should be register by zinc oxide paste. Speech bulb moulded in gutta-percha
A special large flask is used for curing the tailpiece into clear acrylic, resine.
If the speech bulb is not too large and the deture is well retained, the speech bulb
can be made of solid acrylic. If however, the speech bulb is large ,or if the denture is
poorly retained due to there being only a few nature teeth present in the upper jaw or if it
is a full upper denture, then the speech bulb should be made hollow to reduce the weight
of the appliance.
Correction of the speech bulb
If the speech bulb need correction, the tissue conditioning or functional material is
applied to the bulb portion and the prosthesis is inserted into the mouth. The patient can
use the speech aid at home under normal conditions. The advantage of this is that at home
the patient can make the normal phisiologic movement without stress. While in the clinic
the patients are usually exaggerate there movement which may lead to inaccurate
impression.
when the palate is cleft a problem of how a fixed obturator which can fit the cleft in
both the functions of speaking and swallowing will developed.
The solution of this problem may include the following. In relation to the function of an
obturator it is suggested that :-
- The patient must learn new speech habits.

Mostafa Fayad 31
- The gripping of the bulb during swallowing is a basic principle which must be
mastered
- The action in producing the palatal consonants is horizontal instead of vertical
and involves the gripping of the pulb as in swallowing.
The plane of location of the obturator must be in the plane of action of the
palatopharyngeal sphincter or bulge of passavant so the individual can gripping it with
his ring or sphincter mechanism and squeezing the remnants of the soft palate against it.
In practice an obturator is shaped by luting a piece of softened gutta-percha to a wire loop
or tail piece extending from the posterior border of the denture along the midline of the
cleft into the pharynx. The gutta-percha is then shaped by the muscles as they function.
Special Obturator Prostheses:
1- Hinged pharyngeal obturator
2- The palatal lift prosthesis
3- The meatal obturator
1- Movable (Hinged) pharyngeal obturator
The hinged pharyngeal obturator is similar to
the speech aid, it consists of three sections. However
the velar portion is attached to the posterior border of
the denture by a hinge and its lateral borders are shaped
to be gripped be the ruminants of the soft palate and
moved with them. The pharyngeal section is activated
by lateral pharyngeal musculature.
Delabarre (1820) emphasized the importance of the normal soft palatal movement
during biologic and activities and constructed a prosthesis a soft rubber velar as in the
more simple hinged type obturator. Although these prosthesis were mobile under
influence of the cleft soft palate, the movement was more similar to mechanical
movements than to physiologic function.

Mostafa Fayad 32
Disadvantages
a- The hinged obturator fail to achieve noraml physiologic soft palate movement.
b-The hinge is a source of weakness and frequently gets out of adjustment.
The mobile rubber prosthesis:
This prosthesis was constructed with a soft rubber velar section. The movement was more
similar to mechanical movements than to normal physiologic function.
2-The Palatal Lift Prosthesis
This type of prosthesis is designed to displace the soft palate superiorly and
posteriorly to assist the soft palate to close with the peripheral pharyngeal tissues.
Indications
a-Neurologic diseases as myssthenia gravis, cerebrovascular accidents, traumatic
brain injuries, and bulbar poliomyelitis.
b-Injuries to the soft palate as following adenoidectomy, tonsillectomy, or maxillary
resections.
c- Postsurgical cleft palate with insufficient length and movement.
Contraindications
1- If adequate retention is not available.
2- If the palate is not displaceable.
3- Uncooperative patients.
The objective of the palatal lift prosthesis
-To displace the soft palate to the level of normal palatal elevation enabling closure by
pharyngeal wall action
-In cases where the length of the soft palate is unsufficient to effect closure after
maximal displacement, the addition of an obturator behined the displaced soft palate
may be necessary.

Mostafa Fayad 33
This prosthesis may used as a diagnostic aid to assess the possible improvement in
speech. Some clinicians believe that the use of a palatal lift on an interim basis may
stimulate flaccid soft palate to increase functional activity.
A Anatomically normal but
paralyzed soft palate,
B Palatal lift prosthesis in
position elevating soft palate to
produce palatopharyngeal
closure.
A Congenital anatomic
insufficiency of palatopharyngeal
region,
B Palatal lift obturator in position
elevating soft palate and obturating
palatopharyngeal space.
The advantages of palatal lift prosthesis
a-The gag response is minimized (because of the superior position and the sustained
pressure of the lift portion against the soft palate.
b-The tongue is not changed (because of the superior position of the palatal
extension.
c- The access to the nasopharynx for the obturator (if necessary)becomes easier.
d-The lift portion of the prosthesis may be extended gradually to help patient
adaptation.
e-Useful treatment for surgically risky patients.
Construction
The impression is taken using custom tray that extended with baseplate wax to
record and displace the soft palate superiorly. A suitable partial denture framework is

Mostafa Fayad 34
fabricated and verified. The retentive meshwork or wire loop is extended to cover the
anterior two thirds of the soft palate. Modeling plastic is added to the retentive meshwork
until the appropriate displacement of the soft palate is achieved. Then a thermoplastic
wax is used to record tissue detail. If displacement of the soft palate does not achieve
adequate obturation the obturator can be extended behind the deficient soft palate.
It is important to insure that the lifting force does not create soreness and the force of
displacement does not have an adverse effect on the supporting dentition.
3- Meatal obturator prosthesis
Meatus obturator has extension of the posterior border of maxillary section
upward and backward to close the posterior openings of the nose. It is used when there is
very large cleft to reduce the resonance of the nasopharynx.
The meatal obturator establishes closure with nasal structures diagonally above
the hard palate terminus. The obturator extends superiorly and slightly posteriorly from
the hard palate border and separates the oral and nasal cavities at this level
There are no movable tissues in this area and closure is established against the
turbinates, the residual vomer (if present) and the roof of the nasal cavity.
The position of meatal and conventional obturators in relation to palate plane.
Indications
a-This type of obturator may be indicated for patients with extensive defects of the
soft palate with a very active gag reflex.
b- For edentulous patients when retention is a problem.( when horizontally extended
speech aid is thought to be result in prosthesis displacement by leverage action.

Mostafa Fayad 35
A meatus obturator should be considered when the posterior extension of fixed
obturator prosthesis is likely to result in prosthesis displacement. Since the vertical
extension is closer to the palatal portion of the prosthesis, less torque is placed on the
palatal portion, thus decreasing the tendency to dislodge.
Advantages
a- Lesser in weight comparing to the conventional obturator.
b-The downward displacement force from the obturator extension is closer to the
supporting tissues of the parent prosthesis. This result is less lever action.
Disadvantages
a- The obturator does not enable the patient to control nasal air emission because it
is positioned in an area devoid of muscle function.
b-Distortions in nasal resonance occar, because the oral cavity and oral pharynx are
increased in size and the nasal cavity is proportionally reduced.
Construction
The definitive maxillary prosthesis is constructed first, and a wire loop is attached
to the palatal end of the prosthesis. Modeling plastic is added to the wire loop to mold the
obturator. Head, speech, and swallowing movements are unnecessary because there are
no movable tissues in this area. The obturator is reduced 1mm and refined by
thermoplastic wax.
Over extension should be avoided because nasal mucosa is delicate and will not
withstand stress. After processing two small holes or hole approximately 5mm in
diameter should be drilled through the obturator to permit nasal breathing. An alternate
method is to reduce the lateral dimensions of the obturator until nasal breathing is
restored.
4- Silicone retentive obturator:
Indications:
a) Congenital clefts.

Mostafa Fayad 36
b) Acquired defects.
c) More retention is required.
Material: Silicone or rubber latex.
Technique of construction.
5- Fixed Prostesis (Stabilize Premaxilla).
6- Snap-on Prosthesis:
Types:
a) with speech pulp. b) without speech pulp.
8- Unconventional speech aid prosthesis:
Two sections: Nasal portion – Denture.
9- Titanium self tapping implants:
Position: Alveolus – Ptrygoid plates.
10- Root coping (attachments) Telescopic crown with rest.
II-Prosthetic rehabilitation of congenital cleft palate for adults
Definitive obturators for adults
Definitive appliances are usually constructed at the age of 20 years, when growth
and development is complete and bone graft, if present, is mature.
A definitive prosthesis is usually made for a patient whose experience with a
diagnostic one has been successful and surgery is contraindicated.
Obturators are attached to a partial denture, complete denture or an overdenture.
A- Partially edentulous patients
The design of the partially edentulous patients in cleft patients is similar to partial
dentures in normal patients. However, the partial denture is extended to the pharynx in

Mostafa Fayad 37
cleft patients. This extension exerts a long lever arm, which call for additional direct and
indirect retainers.
In the presence of scar tissue on the palate, the borders of major connectors should
follow the scar tissue rather than crossing them, with minimal beading.
The center of rotation of the partial denture.
B- Completely edentulous patients
The problems associated with completely edentulous cleft patients are:
1-The size of the maxilla is reduced due to reduced downward and forward growth
of the maxilla.
2-Increased inter-arch space also occurs as a result of maxillary growth reduction.
3-Lack of adequate support, retention and stability; due to lack of adequate bony
palate, lack of effective posterior palatal seal due to scarring, shallow depth of the
palate and poor alveolar ridge development.
4-Scarring in labial vestibule, in case of lip closure, affects peripheral seal and
denture retention.
B. Acquired palatal defects
While congenital clefts are confiend to the lines of union of the different
embryonic processes of the palate, the acquired defect may occur any where in the palate.
The cleft may involve the alveolar process, tuberosity, the hard palate and/or the soft
palate, half the upper jaw or more. Nasal and adjacent tissues may be involved.
Causes of acquired defects
1-The commonest cause is radical surgical removal of tumors (malignant or benign)
of the palate and paranasal sinuses.

Mostafa Fayad 38
2-Trauma by accidents from pencil, gunshot, severe compound comminuted
fracture.
3-Pathalogical conditions, like osteomyelitis of the palatal bone, syphilis,
tuberculosis and radium burns.
Disabilities associated with acquired maxillary defect
I- Function:
a-Speech: It is markedly changed after surgery by increased hypernasal speech.
These patients do not require speech therapy after prosthetic treatment because they
had a learned speech pattern.
b- Swallowing: Swallowing may be difficult, foods and fluids regurgitates into the
nasal cavity.
II- Appearance:
Disfigurement of the face and Diplopia may occur if the surgery extends to the
inferior border of the orbit.
III- Psychological Trauma:
The psychological impact of loss of part of the face is very severe on these
patients.
Rehabilitation of acquired maxillary defects
I- Surgical rehabilitation:
It is the best line of treatment, but it is limited to the following cases:
1- If the defect is the result of trauma.
2- In small size defects.
3- Tumors unsusceptible to recurrence.
II- Prosthetic rehabilitation:

Mostafa Fayad 39
It is indicated in the following cases:
1-Large defects which is difficult to be corrected surgically.
2-Tumors with susceptibility to recurrence.
Phases of prosthetic treatment:-
1- Initial phase (surgical obturation):
The prosthesis should be placed at surgery or immediately thereafter. It restores and
maintains oral function at reasonable levels during the post-operative period until
healing is completed.
2- Second phase starts 3-4 months after surgery when the surgical site becomes stable
dimensionally thus permitting construction of the definitive prosthesis.
Obturators used for treatment of aquired cleft palate
1- Immediate surgical obturator.
2- Delayed surgical obturator.
3- Definitive obturator..
1- Immediate surgical obturator:
This obturator is constructed presurgically and inserted immediatelly after surgery
in the operating room. It is in the form of simple acrylic plate with retaining clasps or
holes in the flanges for wiring to remaining teeth or to available bony structures.
This obturator is particularly suitable for dentulous patients requiring a partial or
total maxillectomy as the remaining teeth used to help retention of the prosthesis. It must
not be removed before 7-10 days after surgery.
Advantages of immediate obturator
I- Functional:

Mostafa Fayad 40
1- The prosthesis provides a matrix on which the surgical packing can be placed.
2- Permits the patient to speak and swallow more normally by reproducing
normal palatal contour and by covering the defect.
3- Allows earlier removal of the nasogastric tube.
4-It can carry a skin graft or medicaments in the proper relationship to the
surgical cavity.
II- Hygienic:
The prosthesis reduces oral contamination of the wound during the immediate post
surgical period, reducing the incidence of local infection.
III- Psychological:
1-It decreases the psychologic impact of surgery by reproducing the contours of
the lost oral structures and maintain the function.
2-It helps to reduce the hospitalization period and thus reduce the costs of
hospitalization..
3- Restores the patient's self-image by reproducing the contours of the lost oral
structures and allows the patient to function in social environment.
Principals relative to the design of immediate surgical obturators
1- If it is possible the surgeon should leave the posterior edge of the hard palate &
tuberosity. Otherwise the soft palate will be flabby and often drop inferiorly.
2- The obturator should terminate short of the skin graft-mucosal junction. As
soon as the surgical packing is removed., extension into the defect may be
accomplished with tissue conditioning or interim soft lining materials.
3- The prosthesis should be simple and light in weight.
4-The prosthesis for dentulous patients should be perforated at the interproximal
extension to allow the prosthesis to be wired to the teeth at the time of surgery.

Mostafa Fayad 41
5-Normal palatal contours should be reproduced to facilitate postoperative speech
and deglutition.
6- A couple of wire loops is attached to the fitting surface in cases of big tumor.
7- Posterior occlusion should not be established on the defect side until the surgical
wound is well organized. If the three maxillary anterior teeth included in the
resection, they may be added to the prosthesis to improve esthetics.
8- The existing complete or partial denture may be modified for use us an
immediate surgical obturator. The flange at the defect should be reduced and the
posterior teeth removed prior to surgery. Tissue conditioning material may be
used to improve adaptation at the time of surgery.
The technique of construction
First, the abutment teeth should be surveyed and if there retentive undercuts do
not appear to be adequate., tooth modification should be made, which may include re
contouring. ”dimpling“ or placement of restorations.
Upper and lower alginate impressions are made in a perforated stock trays. The
maxillary impression tray must be modified to allow for the size of the tumor so it
should extended posteriorly with baseplate to record a significant portion of the soft
palate in the impression. The patient should be placed in an upright position so that the
soft palate assumes a relatively normal and relaxed position. If the patient has an active
gag reflex, it is useful to use topical anesthetics and fast-setting alginate.
It is important to make an accurate impression of the vestibular depth .on the
resected side so that the approximate position of the skin graft mucosal junction can be
determined.
The upper and lower impressions are poured in stone and the maxillary cast is
dublicated for future reference. The casts are mounted on a suitable articulator with the
aid of a jaw relation record.
The surgeon and prosthodontist should discuss the surgery together and outline
the proposed surgical margins on the upper cast. The lateral boundary is usually the
labial and buccal reflex and the medial boundary is the midline of the palate. The
questionable extensions are the anterior and posterior margins.

Mostafa Fayad 42
Try to persuade the surgeon to leave the posterior edge of the hard palate and
tuberosity. It is better to encouraged the surgeon to make the anterior incision through the
socket of an extracted tooth instead of between adjacent teeth.
A- Margins of proposed surgical resection are outlined on the cast. B- Teeth included in the resection are
removed and cast is trimmed for fabrication of immediate surgical obturator.
The maxillary cast is altered to conform to the proposed surgical resection. Teeth
on the area involved are cut away from the cast, but alveolar height is maintained. Any
elevation on the cast representing the palatal swelling should be removed to give a
normal palatal contour. The residual alveolar ridge is trimmed moderately on the labial
and buccal surface to reduce the stress on the soft tissue closure.
If the pterygoid hamulus is removed during the maxillectomy procedure, the
attachment and/or function of the tensor veli palatine, buccinator, and superior constrictor
muscles can be compromised due to the medial collapse of the distolateral portion of the
defect. In this case the cast should be reduced 2 to 3 mm medially.
The wire retainers are adapted and the prosthesis is waxed, invested and
processed in clear acrylic resin , then finished and polished in the normal manner.
A couple of wire loops is added at the fitting surface to hold the lining material.
Clear resin is preferred because the extensions and possible pressure areas can be
easily seen at surgery.
Holes are drilled in the buccal flanges when it is supposed to wire the obturator to
the zygomatic arches and/or anterior nasal spine.
Prior to surgery the obturator is immersed in a disinfectant solution, the required
instruments are autoclaved, and the dental material are sterilized with gas.

Mostafa Fayad 43
In most cases the obturator is easily fitted and secured. The lateral extension of
the obturator should be adjusted short of the skin graft-mucosal junction to avoid pressure
to this area. The lateral and anterio aspects of the obturator should be reduced until
correct facial contours are abtained without creating tension during closure.
The surgical packing will accommodate for most discrepancies. However, if the
surgery was more extensive than planned it is preferable to add a thick mix of soft
denture liner to the obturator. If the deficiencies are modest, a thinner mix of the soft liner
or tissue conditioning material is used.
In the past autopolymerizing acrylic resin or impression compound were used for
major additions to the obturator at surgery. However, resin is difficult to manipulate and
the free monomer has adverse effect on raw tissue surfaces. Impression compound
deteriorates easily intraorally, especially if used in conjunction with tissue-conditioning
materials.
If a weber-Fergusson exposure is used, the prosthesis should be inserted before
closing the cheek flap then the defect is packed with gauze and the cheek flap is closed. If
a transoral surgical approach is used, the defect should be packed prior to inserting the
prosthesis.
Retention can be obtained in dentulous patients by wiring the prosthesis to
existing teeth. In edentulous patients the obturator is wired or pinned to the alveolar ridge
and zygomatic arches and /or anterior nasal spine.
After 7 to 10 days postsurgically
 The prosthesis and packing are removed. The obturator is cleansed; the
wire retainers and minor occlusal discrepancies are adjusted.
 A new application of tissue conditioning material may be made to improve
adaptation , seal and comfort.
 The patient is dismissed for one week with the instruction regarding the
irrigation and cleaning of the surgical defect properly.
 Usually the patient is seen every 2 weeks and the tissue conditioning
material changed to suite for tissue contracture. It is better to remove and

Mostafa Fayad 44
change all of the lining material to reduce bacterial contamination and
mucosal irritation.
2-Delayed surgical obturator:
It is an alternative to immediate surgical obturator that placed 7 to 10 days
postsurgically. It is the treatment of choice for edentulous patients with extensive surgical
defect.
The technique of construction
I- Tray selection and modification:-
1- The surgical packing is removed.
2- A soft metal stock tray with short flanges and clearance of 1/4 inch exists in all
dimensions is selected.
3- In the area of the defect, much of the flange may be removed or bent medially.
4- All flanges are covered with peripheral beading wax and additional wax is added
in the area of the defect to provide support for the impression material.
II- Impression making:
Major medial undercuts and other sensitive areas should be blocked-out with
Vaseline gauze. The gauze is used to limit the extension of the impression material
into the defect. An impression is carried out using alginate impression material in
the modified ray. The impression should be removed gently to avoid pain during
removal.
IV- Prosthesis fabrication:
In dentulous patients: -
1-The prosthesis will be fabricated as the immediate obturator, from acrylic resin
base with wrought wire clasp.
2-Anterior teeth, if missing, can be included for esthetic reason.
3- Posterior occlusion should be avoided to reduce the movement of the acrylic
resin extension against tissue, but as healing proceeds, posterior occlusal ramps

Mostafa Fayad 45
can be established with addition of self-curing resin to help the patient to retain the
prosthesis in position.
4- The prosthesis is delivered and adjusted using pressure indicating paste and
articulating paper. If it fits well and is well retained, it is not necessary to add
temporary lining material.
In edentulous patient: -
It is preferable to use the patient own maxillary denture as a delayed surgical
obturator, with the following modifications: -
1- The labial and/or buccal flanges of the denture are shortened on the side of
defect.
2- The existing denture is inspected to insure that it well adequately obturates the
surgical defect.
3- Self-cure acrylic resin may be added to the denture to cover the margin of
resection on the soft palate.
4- After adjustment of the denture the obturator should be lined with relining
material.
Instructions to the patient:
1- The patient should not remove the obturator at nights. The obturator remains in
place except for brief periods while cleaning the defect and the prosthesis. If the
obturator is removed for extended periods of time, the patient may have difficulty
reinserting it.
2-Patients are instructed to use a soft toothbrush and hand soap to clean the
prosthesis. Effervescent types of denture cleansers should be avoided, as they will
cause blistering of the soft lining materials of the post-surgical prosthesis.
3- The patient should visit the prosthodontist monthly for evaluation of the fitting of
the prosthesis and cleaning of the maxillary sinus.
3-Definitive obturator:
It is constructed 3-4 months after surgery. The timing will very depending on
many factors. The timing will vary depending on:

Mostafa Fayad 46
1- The size of the defect.
2- The progress of healing.
3- The prognosis for the tumor.
4- The effectiveness of the present
obturator.
5- The presence or absence of teeth.
The prognosis of definitive obturator depends on (Treatment concepts):
1- Defects classification : Maxillary defects have been conveniently classified according
to the defect location and its relation to the remaining teeth by Aramany, 1978.
Aramany classification of maxillary defect
2- Movement of the prosthesis: If the maxillary alveolar ridge and teeth are involved in
the resection the obturator will displaced superiorly with the stress of mastication and
will tend to drop without occlusal contact.
3-Tissue changes: Dimensional changes will occur specially during the first year after
scar contracture. The obturator portion should be made of acrylic resin to facilitate
rebasing if required.
4- Extension into the defect: The degree of extension of the prosthesis into the defect
will depend on the requirements of retention, stability and support. If the remaining
maxillary structures give adequate retention, stability and support, a lettel extension into
the defect will be required. The presence of teeth enhances the retention, stability and

Mostafa Fayad 47
support so generally the use of the defect in edentulous patients is more extensive than
dentulous patient.
5-The weight of the prosthesis: Bulky areas should be hollowed to reduce weight to
avoid unnecessary stress to the teeth and supporting tissues. The hollowing is done during
packing the acrylic resin, by placing a sand bag between the acrylic resin in the middle of
the defect. After currying a small hole is made on the fitting surface to empty the
obturator from the sand. Then the hole is closed with self cure acrylic resin.
The construction of the definitive obturator will vary with the type of resection
and the presence or absence of teeth. Techniques for both edentulous and dentulous
patients with total or partial maxillactomy defects will be described
The superior surface may be closed to avoid accumulation of the nasal secretions
leading to odor and added weight, or left open to decrease the weight and is easier to
adjust. In the open type if secretions do tend to accumulate, a small diagonal opening
may be made between the inferior-lateral floors of the obturator through to the cheek
surface for drainage. If the skin graft lining the cheek surface has no secretory potential,
an open top is acceptable.
6- The presence of teeth: As with all maxillofacial prostheses the presence of teeth
enhances the prosthetic prognosis. The teeth will assist retention, stability, and support
for the prosthesis.
7- Covering prostheses: The obturators are basically covering prostheses serving
primarily to reestablish the oral-nasal partition.
1- Edentulous patient with total maxillectomy defects
With any palatal perforation, retention in the classical sense of complete denture is
impossible, so that the residual palatal structures and the defect must be used more
extensively to improve retention, stability and support. In most cases acceptable retention
can be gained from:
1-Remaining palatal structures: The arch form and the amount of palatal shelf
remaining influence the stability and support. A square or ovoid arch will exhibit
relatively more palatal shelf area following a total maxillectomy.

Mostafa Fayad 48
The surgeon should be encouraged to resect only enough hard- palate to allow adequate
tumor margins. Especially important is ipsi-lateral palate preservation, which will allow
a tripoding effect. If the anterior alveolus can be maintained, the patient will have better
facial and less contracture postoperatively.
2-Engagement of the skin graft superiolaterally above the skin graft mucosal scar
band. The thick squamous epithelium of a split-thickness skin graft will resist the wear
and tear applied by the obturator. Engagement of the skin graft and the scar band formed
at the skin graft-mucosal junction will significantly improve retention. The scar band is
flexible and will permit the prosthesis to be inserted but will tend to resist dislodging
forces.
3-Extending the prosthesis along the oral surface of the soft palate
Junction of oral mucosa and skin graft lining.
4- Additional retention may be gained by extending the obturator along the nasal
surface of the soft palate and or anteriorly into the nasal aperture. If the vomer was
surgically removed, an undercut may exist superiorly along the medial margin. However,
this is a bony undercut lined with respiratory mucose. Therefore, this area is limited for
use unless a resilint material is used to engage the undercuts.
The support and stability can be improved by engagement of key portions of the
defect. Stability is enhanced by engaging the superuolateral portion of the defect and the
medial margin of the defect when it is lined with keratinized epithelium.
Some support can be obtained from the oral side of the skin graft-mucosal junction and
from the oral surface of the soft palate.
Technique of construction
Impression technique:
The skin graft-
mucosal junction
Nasa
Oral

Mostafa Fayad 49
An edentulous soft metal tray is selected and ultered according to the
configuration of the remaining maxilla. The medial and anterior undercuts are blocked
out with vaselineated gauze.
Adhesive is applied to the tray and alginate is mixed and loaded in the tray. Prior
to seating the tray, impression material is wiped or injected into posterior and lateral
undercuts. Cast is poured, and the undesirable undercuts are blocked out with wax.
shim is provided and a special tray are made from acrylic resin. Extension of the
tray are verified in the mouth. Several perforations are made for escape of the
impression material with at least three perforations being along the medial palatal margin.
Border molding using modeling plastic is carried out initially on the unresected side to
stabilize and orient the tray to the defect. The modeling plastic is relieved approximately
1 mm in all the areas. The tray and modeling plastic are painted with adhesive. Saline
irrigation is performed to remove excess nasal secretions .
Elastomaric impression material is prepared and injected into desirable undercut
areas and the loaded tray is seated into position. The lips and cheek are manipulated and
the patient is instructed to perform eccentric mandibular movements to account for the
movement of the anterior border of the ramus and the coronoid process of the mandible.
After the material has set, the impression is removed with a gentle teasing action.
Obturaror should maintain contact with soft palate during elevation
otherwise fluid leakage may occur.
If the anterior margin of the soft palate exhibits marked elevation during
swallowing and speech, the portion of the impression that engages the superior and
inferior part of the soft palate is cut away with a scalpel and a functional impression is
advocated using thermoplastic wax. To reinsert the impression, it may be necessary to
trim some of the impression material that has engaged undesirable undercuts.
If the patient exhibits extreme trismus, an alternative impression techniques is
suggested by using the surgical obturator after making necessary adjustment. A new
application of tissue conditioning material (or impression material ) is used for tacking
final impression.

Mostafa Fayad 50
Recording of jaw relationship
Two methods are suggested for construction of record bases.
1- If the defect is large and stability and support are difficult to obtain with a
conventional record base, the definitive base is fabricated from the master cast. This base
is used in recording jaw relation and at a later time the denture teeth are added with self
curing acrylic resin.
2- If stability and support are adequate, a conventional self curing acrylic base is
constructed after blocking of all undercuts and the rugae area to protect the master cast.
The vertical dimension of occlusion is determined in the usual manner using wax
rims on the record bases. An arbitrary face bow transfer is obtained and centric relation is
recorded.
Trismus is common in patients received radiation therapy. If trismus is extreme,
the vertical dimension of occlusion is reduced to allow passage of the food between the
denture teeth.
Care must be taken to prevent displacement of the maxillary record base during
the registration. Even in acceptable stable maxillary base, pressure on the defect side will
result in superior displacement into the defect. Soft wax, zinc oxide or plaster are the
material of choice for recording jaw relation.
The use of tracing devices to record centric relation are contraindicated.
Nonanatomic posterior teeth are preferred and adjusted to eliminate lateral
deflective occlusal contact. The trial denture are tried in the mouth and changes are made
to accommodate the esthetic desires of the patient and the prosthodontist.
Processing, delivery and follow up:
The obturator with the denture are processed in heat-cured acrylic resin. On
delivery, the resin extensions into undercut areas may require considerable relief to
permit seating of the parosthesis.
The superior surface of the obturator should be slightly convex and well polished.
Any sharp projection on the lateral surface of the obturatot should be rounded and
polished with pumice. Polishing improve cleansibility and reduce the friction between the
prosthesis and soft tissue during functional movements.

Mostafa Fayad 51
If more retention in necessary, soft silicon material is used for the obturator
segment to engage undercuts more profoundly.
Home care instructions are reviewed and recall appointments are arranged. Most
maxillary obturator will require rebasing within the first year because of dimentional
changes of the defect.
Modifications over the next years are often performed if the prosthesis becomes
intolerable to the patient or a warning signs are encountered. The warning signs that the
obturator is no longer functioning are, liquid reflux into the nasal cavity, change in the
quality or nasality of the voice.
To obtain hollow bulb: During backing of acrylic
resin a small cellophane bag filled with sand is backed
within the bulb. After processing, a hole is drilled
throughout the bulb and sand drained away. The opening is
then closed with self-curing resin.
Superior surface of the obturator should be slightly
convex and well polished to decrease friction during
functional movement.
To gain better retention, soft material allows the obturator to engage the undercut
in the defect more aggressively.
2- Edentulous patient with partial maxillectomy defects:
In this defects, more of the hard palate remains and thus the stability and support
are increased. However, retention may be reduced. Soft silicone materials may be used to
improve retention by engage bony undercuts .
Fabrication of definitive obturator for partial resections of the edentulous maxilla
are similar to the prosthesis for total maxillectomy resection. However , rebasing is not
necessary as frequently.
3- Dentulous patients with maxillectomy defects:

Mostafa Fayad 52
The presence of teeth assist retention, stability and support of the removable prosthesis.
Treatment Concepts:
1- Location of the defect. The distal portion of the maxilla are usually included
in the surgical resection and the distal abutment is rarely remain. Therefore for
most patients, a Kennedy class II partial denture with extensive lever arm is
required.
2- Movement of the prosthesis: The defect must be used to minimize the
movement of the prosthesis to reduce the stress on the abutment teeth.
3- Length of the lever arm. Considerably longer lever arms are encountered in
patients with intraoral surgical defects.
4- Arch form: Square or ovoid arch forms provides more bearing surface
perpendicular to occlusal stress resulting in more stabe prosthesis during
function. Tapering arch form gives less palatal shelf area and therefore support
is compromised.
5- Teeth: Preservation of the remaining teeth is important for retention and
esthetics. The partial denture design must prevent the natural teeth from any
pathologic stresses during functional. Maximum retention, stability and support
should be obtained from the defect.
Aramany’s classification of maxillary defects:
Maxillary defects have been classified according to the defect location and its
relation to the remaining teeth.
Class I: lateral defect with anterior margin approaching the midline.
Class II: Lateral defect with anterior margin away from the midline.
Class III: Middle defects surrounded by remaining dentition.
Class IV: Lateral defect with anterior margin crossing the midline.

Mostafa Fayad 53
Class V: Defect with anterior teeth remaining.
Class VI: Defect with posterior teeth remaining.
Partial denture design:
Diagnostic casts are surveyed carefully to locate the undercuts, the contour of
guide planes, and selection of the path of insertion. Often a compound path of insertion
must be employed to use the undercut in the defect. For example, if lateral and posterior
undercuts will be used, the obturator is inserted into the defect first and then rotated into
position onto the teeth.
The basic principals of partial denture design should be followed :
-Major connectors should be rigid,
- Occlusal rests should direct occlusal forces along the bony axis of the teeth,
- Guide planes should be designed to facilitate stability and bracing,
- Retention should be within the physiologic limits of the periodontal ligaments. The
clasp arms should be passive when not functionally stressed and provide minimal
retention needed to resist displacement.
- Maximum support should be gained from the residual soft tissues.
- Indirect retainer should be distributed as even as possible.
 Aramany classes 1, II & IV ”
These defects are considered together because they share the same cantilever stress
patterns. A Kennedy class II partial denture with an extensive lever arm is required for these
patients.
Defferent partial denture designs were suggested to achieve adequate retention
and to ensure proper orientation of the prosthesis. A rest and retainer should be placed on

Mostafa Fayad 54
the tooth closely adjacent to the anterior margin of the defect. If this concept is not
employed, the prosthesis will tend to rotate out of retentive areas posteriorly.
Often the bony support for the tooth adjacent to the defect is compromised and
does not permit its use as abutment. Other adjacent tooth should be used for this purpose.
This compromised abutment can be treated endodontically with amputation of the crown
and the root serves as an ”overdenture“ abutment.
Different suggested partial denture designs. Note fulcrum line in relation to defects.
Multiple occlusal rests may be used to improve stability and support. The fulcrum
line is determined by the position of the occlusal, incisal or cingulum rests.
Sometimes lingual retentive clasp arms with buccal reciprocating arms are used
depending on the angulation of the abutment teeth.
Since there is no cross-arch reciprocation of either buccal or lingual retention, this
partial denture must be viewed as a unilateral partial denture and both buccal and lingual
retentive arms may be considered to obtain cross-tooth retention and reciprocation.
Dentulous patients with partial maxillectomy defects ” Aramany class II“
In Aramany class II the prosthodontic consideration are similar to the total
maxillectomy except that the prosthetic prognosis improves as the margin of the resection
moves posteriorly.
If the maxillary cuspid of the defect side remains. The prosthetic prognosis
improves dramatically. Even the presence of a central or lateral incisor on the defect side
will enhance the stability and support of the prosthesis. The fulcrum line is dependent on
the placement of occlusal rest. As more teeth are retained on the defect side, the fulcrum
line shifts posteriorly. If bicuspid teeth remain the fulcrum line will be similar to a
conventional Kennedy class II partial denture .

Mostafa Fayad 55
Indirect retainers should be placed as far anterior as possible from the fulcrum
line. If adequate retention, stability, and support can be
obtained from the residual dentition and soft tissues, no need
to engage the defect aggressively.
The partial denture designs of Aramany Class II defect is similar to
Kennedy Class II partial denture.
Class I design: The design can be either tripodal or linear.
Tripodal design: Two or three anterior teeth are splinted. Retention and bracing
(labial and buccal retention and palatal bracing) and support are derived from the central
incisor and the most posterior abutment tooth. Indirect retention is utilized by the location
of a rest on the canine, or on the distal surface of the first premolar.
The linear design: If the anterior teeth are not included in the design, a linear
design is recommended. Where the unilateral design requires bilateral retention and
stabilization (diagonally placed on the posterior teeth).
Class I. Left; tripodal design. Right; linear design.
Class II design
The triangle formed by the fulcrum and lines through the anterior and posterior
teeth with the canine as an apex serves as a reference. As this triangle flattens and
diminishes in area, the stresses on the posterior teeth increase,
leading to more difficult considerations of retention and stress

Mostafa Fayad 56
distribution. Based on this principle class IV is the most critical, followed by class I and
finally class II is the least.
canine (apex, A), the distal abutment B and anterior abutment (C, or D, or E).
In Class II design, the teeth next to the defect are splinted. Retention is placed
buccally on all abutment teeth, and indirect retention is located on the opposite side of the
defect. Guiding planes are on the proximal surfaces of the second molar and the tooth
next to the defect.
Class IV design:
Cross tooth reciprocating retention (lingual retention on the molars and buccal
retention on the premolars) are used. Guiding planes are placed on proximal surface of
the tooth next to the defect and the posterior terminal tooth. It is indicated to use only
light wires in an acrylic resin base for class IV definitive obturation if the remaining
dentition is not optimal.
linear design for metal frameworks for a Class IV maxillectomy is indicated. Retention and
bracing are diagonally opposed
Prosthetic procedures:
The mouth preparation is completed as outlined and master impression is
performed to construct the partial denture framework. The master cast is made and the
framework is designed and fabricated. The frame work is adjusted to the abutment teeth
in the patient s mouth using disclosing medium. The undercuts within the defect are

Mostafa Fayad 57
blocked out on the cast and relief is placed over the scar band and lateral wall of the
defect . Acrylic resin is molded to the framework and the defect in preparation for the
altered cast impression.
The extension of the prosthesis is adjusted using modeling plastics. The extension
is relieved and holes are made along the finish line to escape excess material. Adhesive is
applied and an elastic impression material is used to complete the altered cast
impression. While the impression is tacking the patient is directed to make eccentric
mandibular movements. After setting , the impression is removed and examined. The
master cast is segmented , the framework and altered cast impression are seated on the
tooth segment, and the impression is boxed and poured in dental stone. Conventional
methods are followed to complete the prosthesis.
The obturator portion is made hollow and constructed from acrylic resin to allow
for adjustment and rebasing. Slight pressure against the cheek is desirable to ensure
maximum retention, stability and support.
Dentulous patients with partial maxillectomy defects which not involve the
alveolar ridge and teeth .“Aramany class III”
This is essentially a tooth supported partial denture with central obturator
extension. Conventional clasping elements are selected according to the position and
condition of remaining dentition.
The partial denture design of Aramany Class III is essentially a tooth- supported partial denture
with central obturator extention.
The Class III defect can be treated by tooth supported partial denture with central
obturator extension.

Mostafa Fayad 58
Class III: retention, bracing and support are derived from four widely separated abutment teeth.
It is unreasonable to make any support from extension into the defect space,
although soft liner extensions above the lateral palatal shelves may be useful. If the
junction of the hard and soft palates is involved, construction of an obturator for this type
of defect is more difficult than it appears, as the obturator must maintain contact
posteriorly and laterally during soft palate elevation.
Thermoplastic is used to record the functional impressions of the tissue bordering
the defect. Speech is usually normal after delivery of the prosthesis. However the patient
will note excessive fluid leakage when swallowing . To alleviate this problem 5-10 mm
extension is placed across the intact soft palate. During function the soft palate will lift
from this extension, but this shield will serve to direct food and liquids into the oral
pharynx. Extension into the defect with contact with the nasal side of the soft palate
during elevation also is suggested.
Patients with bilateral total maxillectomy defects ”Aramany class V”
Class V design:
The design for Class V maxillary defect. Splinting of the anterior teeth is
recommended. Tripodal design calls for buccal retention and palatal bracing. Support is
derived from the splinted components, and indirect retention is located on the central
incisors.
When both maxillae have been excised, the prosthetic prognosis is quite guarded.
Prostheses constructed for these patients are primarily for speech and esthetics. However,
without bony support the prosthesis will exhibit considerable movement during
mastication and swallowing and placed tremendous stress on the remaining anterior

Maxillofacial prosthetics theory and practice 2011

Maxillofacial prosthetics theory and practice 2011

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Maxillofacial prosthetics theory and practice 2011

Similar to Maxillofacial prosthetics theory and practice 2011 (20)

Recently uploaded

Recently uploaded (20)

Maxillofacial prosthetics theory and practice 2011