This document discusses the development of the maxilla and its implications for prosthodontic treatment. It begins with definitions of growth, development, anatomy of the maxilla, and phases of development including prenatal and postnatal. Prenatal development includes the formation of the maxilla from embryonic processes. Postnatal development involves displacement, sutural growth, and surface remodeling. Prosthodontic implications are discussed for conditions like cleft lip and palate, maxillary hypoplasia, tumors and cysts. Management of these conditions may involve surgery, obturators, dentures or implants. Challenges in treating torus palatinus and conditions like Pierre Robin syndrome are also summarized.

1. DEVELOPMENT OF MAXILLA
AND ITS PROSTHODONTIC IMPLICATIONS
PRESENTED BY :- DR. GAURI PATIL (1ST MDS)

2. CONTENTS
• Introduction and Definition.
• Anatomy of maxilla.
• Development of maxilla – 1. Prenatal
2. Postnatal
• Prosthodontic implication of maxilla.
• Conclusion.
• References.

3. GROWTH
• Quantitative aspect of biologic development per unit of time- Moyers
• Growth refers to increase in size – Todd
• Increase in size and number – Profitt
• Change in any morphological parameter which is measurable- Moss
• The self multiplication of living substance- J.S.Huxley

4. DEVELOPMENT
• Refers to all the naturally occurring unidirectional changes in the life of an individual
from its existence as a single cell to its elaboration as a multifunctional unit
terminating in death. Thus, it encompasses the normal sequential events between
fertilization and death. -Moyers
• Development is progress towards maturity. - Todd
• It addresses the progressive evolution of a tissue. - Pinkham

5. ANATOMY OF MAXILLA

6. MAXILLA
Maxilla is the second largest bone of the
face, the first being the mandible. The two
maxillae form the whole of the upper jaw.
There is union of 2 maxillary processes at
the intermaxillary suture.
Each maxilla has a body and four processes,
the frontal, zygomatic, alveolar and palatine.
BD Human Anatomy - Head, Neck & Brain (Volume 3), fourth edition

7. BD Human Anatomy - Head, Neck & Brain (Volume 3), fourth edition

8. The body of maxilla is pyramidal in shape, with its base directed medially at the nasal surface,
and the apex directed laterally at the zygomatic process. It has four surfaces and encloses a large
cavity; the maxillary sinus.
BD Human Anatomy - Head, Neck & Brain (Volume 3), fourth edition

9. Maxillary sinus is first to develop. It appears as a shallow groove on the medial surface of maxilla
during fourth month of intrauterine life, grows rapidly during six to seven years, until it reaches
fill size.
Size is variable. Average height 3.7 cm; width, 2.5 cm; and depth, 3.7 cm.
Boundaries:- Roof- formed by the floor of orbit, and is traversed by the infraorbital canal.
Floor- formed by the alveolar process of maxilla
BD Human Anatomy - Head, Neck & Brain (Volume 3), fourth edition

10. PHASES OF DEVELOPMENT

11. PRENATAL
• The preimplantation period (first three weeks),
• The embryonic period (4th week to 8th week) -
• The fetal period (8th week until birth)
POSTNATAL
• Displacement
• Growth at sutures
• Surface remodelling
Orthodontics- The Art and Science, Bhalahi 5th Edition book

12. PRENATAL EMBRYOLOGY OF
MAXILLA

13. Orthodontics- The Art and Science, Bhalahi 5th Edition book
In the 4th week of
interuterine life-
prominent bulge
appears on the ventral
aspect of the embryo
Below the brain, a
shallow depression
called as
“STOMODEUM”.
The floor of the
STOMODEUM is formed
by the buccopharyngeal
membrane.

14. Around 4-5th week of inter-uterine life all the 5
branchial arches are formed. These branchial
arches form the future head and neck region
and thus give rise to various structures like the
connective tissue, vasculature, skeletal and
neural components.
Orthodontics- The Art and Science, Bhalahi 5th Edition book

15. Orthodontics- The Art and Science, Bhalahi 5th Edition book
Mesoderm proliferates and forms
the downward projection
FRONTONASAL PROCESS
Mandibular branchial arch gives
off a bud dorsally called as the
maxillary process

16. By the end of the
fourth week, the
nasal placodes.
Nasal placode
starts to sink
below the
surface as a nasal
groove.
First the lateral
nasal process
develops in the
early fifth week;
then the medial
nasal process
develops shortly
thereafter.
Together they
form a
downward-facing
“horseshoe” with
the open end
facing the
stomodeum.
Orthodontics- The Art and Science, Bhalahi 5th Edition book

17. By the late fifth week, these nasal pits
thrust back into the stomodeum,
forming the nasal sacs
In the fifth week, the oropharyngeal
membrane disintegrates, creating
communication between the foregut and
the outside
The ectoderm over the stomodeum
comes to abut the endoderm of the
developing foregut to form the
Oropharyngeal membrane.
Orthodontics- The Art and Science, Bhalahi 5th Edition book

18. In the sixth week, the
maxillary processes
grow medially. This
medial growth results in
medial displacement of
the nasal sacs.
Thus, by the seventh
week, each nasal cavity
opens to the outside
through a nostril and
communicates
posteriorly with the
pharynx.
In this 7th week of
interuterine life the
naso-medial processes
merge to form the
future philitrum of the
upper lip and the
primitive palate.
Orthodontics- The Art and Science, Bhalahi 5th Edition book

19. Forming the Upper Lip
• Ventrally, the fusion of the medial
nasal processes with the maxillary
processes will form most of the
upper lip and upper jaw on both
sides.
• The fusion of the 2 medial nasal
processes displaces the
frontonasal process superiorly and
posteriorly.
Orthodontics- The Art and Science, Bhalahi 5th Edition book

20. DEVELOPMENT OF PALATE
The palate is formed by:-
Frontonasal process forms the premaxilla
area whereas the palatal shelves forms the
rest of the maxilla.
1.Maxillary Process
Frontonasal Process
Palatal shelves given off by the maxillary
process
Orthodontics- The Art and Science, Bhalahi 5th Edition book

21. Intermaxillary Segment /
Primary palate.
• As a result of the medial growth of the
maxillary swellings, the two medial
nasal swellings merge not only at the
surface but also at the deeper level.
The structures formed by the two
merged swellings are together known
as intermaxillary segment.
• It is comprised of:
• 1. A labial component : forms the
philtrum of upper lip.
• 2. Upper jaw component : Which
carries 4 incisor teeth.
• 3. Palatal component : Which form
the triangular primary palate.
•
Orthodontics- The Art and Science, Bhalahi 5th Edition book

22. Ossification of palate
Ossification occurs from 8th week of I.U
life.
Intramembranous ossification  Hard
palate
No ossification  Soft palate
Mid-palatine suture ossifies by 12-14
years
Orthodontics- The Art and Science, Bhalahi 5th Edition book

23. Secondary palate
• Definitive palate is formed
by fusion of 2 shelf like
outgrowths from the
maxillary swellings at 6th
week i.u life.
• They attain horizontal
position at 7 week and fuse.
• By the 8 and half wk of inter-
uterine life the 2 palatal
shelves come in close
approximation.
• The development extends
from 7-10th week of
intrauterine life.
Orthodontics- The Art and Science, Bhalahi 5th Edition book

25. POSTNATAL DEVELOPMENT OF
MAXILLA

26. The growth of naso- maxillary complex is produced by following mechanism:
Displacement
Growth at
sutures
Surface
remodelling

27. PRIMARY DISPLACEMENT SECONDARY / PASSIVE DISPLACMENT
DISPLACEMENT

28. SUTURAL GROWTH • Maxilla is connected to the cranium by a number of
sutures-

29. SURFACE REMODELING

30. Expanding “V” principle
• Enlow’s expanding “V”
principle states that many
facial bones or part of the
bone follows a V pattern
of enlargement
• The overall growth
changes are the result of
downward and forward
translation of the maxilla
and simultaneous surface
remodelling

31. PROSTHODONTIC
MANAGEMENT

32. • Cleft lip and palate
• Vander woude syndrome
• Maxillary hypoplasia
• Developmental cyst
CONGENITAL
• Maxillary tumors
• Mucormycosis
ACQUIRED
Shafer'S Textbook Of Oral Pathology (6Th Edition) (2009) edited by R. Rajendran, B. Sivapathasundharam

33. • Oblique facial cleft: Failure of maxillary
swelling to merge with its corresponding
lateral nasal swelling results in this
deformity.
• Epstein’s pearls and Bohn’s nodules: The
entrapment of epithelial rests or pearls
in the line of fusion of the palatal
shelves may give rise to median palatal
rests cyst.

34. MANAGEMENT OF
ACQUIRED DEFECT
•Debulking surgery
High-dose radiotheraphy
Maxillectomy/palatectomy
Maxillary obturators
Removable or fixed prosthesis

35. MAXILLARY HYPOPLASIA

36. MAXILLARY HYPOPLASIA
AND ITS MANAGEMENT
• Hypodontia is attributed to
craniofacial dysplasia
• The treatment must include
• restoring the OVD,
• establishing masticatory function,
• improving the patient’s facial
appearance, and
• improving the patient’s
psychological well-being.
• Patients with maxillary hypoplasia
can be provided with prosthetic
treatment options such as complete
dentures, partial removable dental
prostheses, partial fixed dental
prostheses, and dental implants.
Kanghyun Kim et al. Prosthetic management of a growing patient with Russell-Silver syndrome: a clinical report. J Adv Prosthodont. 2015 Oct; 7(5): 406–410.

37. TORUS PALATINUS

38. The challenges faced while
treating a patient with palatal
tori could be overcome by
the modified tray and
denture design.

39. TORUS PALATINUS AND ITS
MANAGEMENT • Primary impression is made
using a stock tray modified with
modeling wax. The impression is
made with alginate
• Tray design consisted of a small
tray covering the tori for the
accurate recording of the extent
of tori and a complete palatal tray
over the small tray for recording
other areas of the palate without
defects near the tori. The special
tray is fabricated with light cure
acrylic resin
Rajeev V, Arunachalam R. Innovative Replication and Recuperation of Complex Torus Palatinus: A Prosthodontic Case Report. World J Dent 2016;7(4):208-212.

40. • Wax spacer is used inside both the trays
• The secondary cast is duplicated in die stone and is used for the fabrication of cast metal base for
the denture.

41. CLEFT LIP AND PALATE

42. A cleft lip and palate is a congenital defect of the middle
third of the face, characterized by the presence of oronasal
communication, malformation or agenesis of the teeth close
to the cleft, and deficient sagittal and transverse growth of
the maxilla.
Presurgical management of unilateral cleft lip and palate in a neonate: A clinical report. -Rajendra Avhad et al. Government Dental College and Hospital, Mumbai, Maharashtra(J Prosth et Den
2014)

43. FACTORS AFFECTING THE MANAGEMENT
Age
Socioeconomic status of the patient
Type and severity of the defect
Intraoral situation
Presurgical management of unilateral cleft lip and palate in a neonate: A clinical report. -Rajendra Avhad et al. Government Dental College and Hospital, Mumbai, Maharashtra(J Prosth et Dent
2014)

44. CLASSIFICATION OF CLEFT LIP AND PALATE

46. PIERRE ROBIN
SYNDROME
• Cleft palate, micrognathia, Glossoptosis.
• Characterized by glossoptosis and
mandibular hypoplasia with or
without cleft palate, this
ailment presents clinically with
severe upper airway obstruction (UAO),
obstructive sleep apnea, and feeding
complications.
Shafer'S Textbook Of Oral Pathology (6Th Edition) (2009) edited by R. Rajendran, B. Sivapathasundharam

47. Shafer'S Textbook Of Oral Pathology (6Th Edition) (2009) edited by R. Rajendran, B. Sivapathasundharam
Also called as Cleft lip syndrome, lip pit syndrome, dimpled
papillae of the lip.
Van der Woude syndrome is an autosomal dominant syndrome
typically consisting of a cleft lip or cleft palate and distinctive pits
of the lower lips.
VANDER WOUDE
SYNDROME

48. •Orofacial
examination
Examination and
genetic
counseling by a
pediatric
geneticist.
Surgical repair of
the cleft lip and
palate or other
anomalies may
be require.
Imaging studies
of affected
areas, such as CT
scan of
oropharynx, may
be appropriate.
Surgical excision
of lip pits is often
performed,
either to
alleviate
discomfort or for
cosmetic reasons

49. MANAGEMENT OF CLEFT LIP AND PALATE
Early intervention and
counselling
Feeding
Genetic evaluation
Team evaluation
Surgical approach
Prosthodontic approach

50. Anna Paradowska-Stolarz et al ,Current Concepts and Challenges in the Treatment of Cleft Lip and Palate Patients—A Comprehensive Review, J. Pers. Med. 2022, 12, 2089
•Early, Pre-Surgical Treatment –(presurgical naso alveolar
molding (PNAM also known as Figueroa’s NAM technique))
Lip and/or Palate Closure. Closure of other structures as
well.
Orthodontic management and Periodontal management (if
required)
Prosthetic management ( Fixed Partial Denture, Removable
partial denture, Complete Denture, Implant Supported
Prosthesis

51. RULE OF 10
coined by surgeons Wilhelmmesen and
Musgrave in 1969
According to them, the child should be at least
10 weeks of age; weighs at least 10 pounds, and
has at least 10g/dl hemoglobin
If the cleft is bilateral and extensive, two
surgeries may be required to close the cleft, one
side first, and the second side a few weeks later.
The most common procedure to repair a cleft lip
is the Millard procedure pioneered by Ralph
Millard.

52. PROSTHESES FOR CHILDREN
Nasoalveolar moulding (NAM)
Obturator prostheses
•Feeding obturator
•Pharyngeal obturator (speech bulb prosthesis)
•Anterior prosthesis which contours the upper lip and improves the anterior occlusion.
PROSTHESES FOR ADULT CLEFT LIP AND PALATE PATIENTS
Removable prosthesis
Fixed prosthesis
Implants
PROSTHETIC TREATMENT OPTIONS

53. PNAM

54. • Presurgical naso-alveolar molding
(PNAM) provides
• improved foundation to repair the
defect.
• It reduces the size of the intraoral
alveolar cleft through the molding of
the bony segments, and the active
molding and positioning of the
surrounding soft tissues affected by
the cleft.
• PNAM depends on the inherent
plasticity and moldability of the
neonatal cartilaginous tissues. So, it
provides excellent results when
started early after birth.
Anna Paradowska-Stolarz et al ,Current Concepts and Challenges in the Treatment of Cleft Lip and Palate Patients—A Comprehensive Review, J. Pers. Med. 2022, 12, 2089

55. It is an acrylic orthodontic device to
stimulate the maxillary growth and
change the growth pattern of the patient
with cleft.
PNAM plate is helpful with rotation of
the premaxilla and reducing the amount
of cleft fissure.
Anna Paradowska-Stolarz et al ,Current Concepts and Challenges in the Treatment of Cleft Lip and Palate Patients—A Comprehensive Review, J. Pers. Med. 2022, 12, 2089

56. • Additions and Subtractions are
generally in the order of 1mm. This
process continues at weekly intervals
until the cleft segments are in close
apposition to one another.

57. UNILATERAL CLEFTS

58. Commences
soon after birth
and is usually
completed in 1
week itself
Natal teeth are
removed
Multiple oral
impression
made with
silicone putty
Multiple casts
made- 1 for the
tray and other
for the record
Appropriate size
acrylic tray is
prepared
Small button is
created anteriorly
to retain the elastic
band –tape
retention
apparatus

59. Tapes and elastics hold the NAM device in position. The anterior
band tape has been modified to retain the elastic band apparatus

60. BILATERAL CLEFTS

61. B
A
C
Prolabial band(acrylic resin strip) is secured between
2 nasal extension.
3. Lengthen the columella.
2. Apices of flattened alar cartilages are repositioned
superiorly towards nasal tip
1. Posterior palatal segments are repositioned and
premaxilla is rotated back into a proper midline
position
Molding of bilateral clefts consists of 3 stages:

62. If it is decided the surgery will be unsuccessful for the treatment of cleft
soft palate then the first obturator is given at 2 years
• Cleft palate – Feeding plate is given immediately after birth.
Obturator is given later
Obturator
• Prosthesis is required for the patients who have undergone tumor
resection of hard palate and maxillary sinus.
Cleft palate –
• There are 3 types of obturators: • Surgical obturator. • Interim obturator. •
Definitive obturator.
• Cleft lip – Missing lateral incisors are replaced with RPD or FPD or
Implants.

63. OBTURATORS

64. CASES INCLUDED
CLEFTS CONFINED
TO SECONDARY
PALATE
PATIENTS WHO
SHOW
HYPERNASALITY
AND INADEQUATE
SPEECH
VELOPHARYNGEAL
DEFICIENCIES

65. FEEDING
OBTURATORS
•
Ruta Jadhav et al,Flexible feeding obturator for early intervention in infants with Pierre Robin sequence, J Prosthet Dent 2017

67. Putty viscosity elastomeric impression material used to
take the initial impression.
Make diagnostic cast using type 2 dental plaster.
Prepare a custom tray and paint it with tray adhesive.
Load light body elastomeric impression material over
the flexible custom tray.
Box the impression and pour it with die stone and
prepare the cast.
Adapt 2mm thermoplastic sheet using vacuum forming
machine. And shape it to provide 5-6mm extension.
Ruta Jadhav et al,Flexible feeding obturator for early intervention in infants with Pierre Robin sequence, J Prosthet Dent 2017

68. A training appliance is used to promote increased muscular
activity so that the coordinated movement of the soft palate
and the posterior pharyngeal wall will achieve
velopharyngeal closure during speech.
OBTURATOR FOR
VELOPHARNYGEAL
DEFIENCIES

69. STEPS FOR RECORDING IMPRESSION FOR
PHARYNGEAL OBTURATOR
Impression is taken in patient’s mouth by starting with a small
bulb about the size of a pea with each addition of compound.
The child is asked to bend his head down as far as he can.
The child next moves his head from side to side.
After enough material has been added, a thermoplastic wax
is added to the compound bulb, and the patient goes
through the same motions.
Laboratory procedure are carried out and the prosthesis is
fabricated.

70. PROSTHESES FOR ADULT CLEFT LIP
AND PALATE PATIENTS

71. Dental finding in cleft patients after
years
• Medial collapse of the cleft segment.
• Crossbite of the canine w/o crossbite of molars.
• Premature loss or removal of teeth.
• Supernumery teeth may be present on the cleft margin.
• Increased incidence of anterior crossbite due to medial displacement
of alveolar process.
• Congenital missing teeth ( lateral incisors are most frequent and then
premolars)
• Crowded or maligned arch.
Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John Beumer

72. Removable
prosthesis
Fixed
prothesis
Implants

73. Teenaged patient after completion of orthodontic treatment. A removable partial dentre
restores the missing dentition until DEFINITIVE PROSTHESIS is given.
Definitive prothesis may include:- 1. Porcelain fused to metal(PFM) or Maryland bridge
can be fabricated.
2. Implant.
INTERIM PROSTHESIS
Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John Beumer

74. REMOVABLE PARTIAL DENTURE
Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John Beumer

75. CHALLENGES THAT ARE FACED IN THESE CASES
•The reduced size of the cleft maxilla
•Excessive inter-arch space
•Lack of a bony palate
•Poor alveolar ridge development and shallow depth of
the palate
•Scarring from lip closure
COMPLETE DENTURES
Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John Beumer

76. • Edentulous patient with a repaired cleft and anterior
fistula.
• Prosthesis with soft palate obturate is fabricated.
Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John Beumer
COMPLETE
DENTURE

77. • Bilateral cleft lip and palate with anterior open bite and
reduced VDO case.
• Overdenture with internal chrome-cobalt framework with
retainers is fabricated.
Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John Beumer
OVERDENTURE

78. FIXED PARTIAL DENTURES
• In the past, porcelain fused to metal prosthesis were used.
• Nowadays, composite resins, dentin bonding and porcelain veneers
are upcoming.
• Size and colour discrepancies can be managed ith the help of esthetic
veneers whereas missing teeth can be replaced by resin bonded fixed
partial dentures.
Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John Beumer

79. IMPLANT
PROSTHESIS
• Edentulous patients with repaired bilateral cefts.
Four implants have been placed in the maxilla.
Finally prosthesis with obturator extension is placed.
Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John Beumer

80. CONGENITALLY
MISSING LATERAL
INCISOR IMPLANT
• Implant placed in a previously grafted site
Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John Beumer

81. • P.M. Som and T.P. Naidich et al, Illustrated Review of the Embryology and Development of the
Facial Region, Part 1: Early Face and Lateral Nasal Cavities, American Journal of
Neuroradiology December 2013, 34 (12) 2233-2240
• Anna Paradowska-Stolarz et al ,Current Concepts and Challenges in the Treatment of Cleft Lip
and Palate Patients—A Comprehensive Review, J. Pers. Med. 2022, 12, 2089
• Orthodontics- The Art and Science, Bhalahi 5th Edition book
• Maxillofacial_Rehabilitation,_Prosthodontic_and_Surgical_Management. Third edition by John
Beumer.
• CHALIAN Maxillofacial_Prosthetics_Multidisciplinary,
• BD Human Anatomy - Head, Neck & Brain (Volume 3), fourth edition.
• Shafer'S Textbook Of Oral Pathology (6Th Edition) (2009) edited by R. Rajendran, B.
Sivapathasundharam
• Ruta Jadhav et al,Flexible feeding obturator for early intervention in infants with Pierre Robin
sequence, J Prosthet Dent 2017.
REFERENCES

82. THANK YOU