Maxillofacial /orthodontic courses by Indian dental academy

“T āmso Mā J
yotirgāmāyā”
From Darkness Towards Light
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Maxillofacial Prosthetics : is the art & science of anatomic, functional or
cosmetic reconstruction by means of non-living substitutes of those regions in
the maxilla, mandible and face that are missing or defective because of surgical
intervention, trauma, pathology or developmental or congenital malformation.
Maxillofacial Prosthetics : The branch of prosthodontics concerned
with the restoration and/or replacement of the stomatognathic and
craniofacial structures with prostheses that may or may not be
removed on a regular or elective basis.(GPT-8)

Tycho Brahe (1600)
Medical Gazette (1832)
Ambroise pare
Peirre fauchard (1728)
Kingsley (1880)
Tetamore (1894)
American Academy (1953)

Esthetics
Function
Protection
Therapeutic
Psychological
Non irritating
Strong
Transparent
Light weight
Resistant to chemicals
Less Distortion
Easily washablewww.indiandentalacademy.com

Agnathia
Micrognathia
Etiology
Congenital
Developmental
Acquired
Commonest cause
Mal-development of 1st
mandibular & 2nd
hyoid branchial arches
Distinguishing b/w Retro & micrognathia
Posterior displacement of Angle
Decreased gonial Angle
Posteriorly located condyle
Size of Jaws

Macrognathia
Associated with –
Paget’s disease
Acromegaly
Leontasis ossea
Treatment
Ostectomy & Resection

Mandibular prognathism
Accompanied by class III malocclusion
Generally associated with Cleft lip & palate
Etiology
Developmental
Eg: Hapsburg jaw
Acquired
Eg: Tumor of anterior pituitary

Congenital double lip
Upper lip
Excess tissue – inner mucosa
Etiology – Embryonic developmental defect
Associated with Blepharochaliasis

Cheilitis Glandularis
Associated with lower lip
Etiology – sun / wind / dust
Tobacco
Emotional disturbances
C/F – Enlarged salivary glands,
Nodular ducts
Types –
Simple
Superficial suppurative
Deep suppurative

Cleft Lip And Cleft Palate

CARDIAC BULGE
Remains of FRONTONASAL
PROMINENCE after
development of nasal placodes
OPTIC PLACODE
NASAL PLACODE
MAXILLARY PROCESS
MANDIBULAR ARCH
HYOID ARCH
STOMODEUM
with perforating membrane
3-w/3.5mm EMBRYO Full-face
FACE

CARDIAC BULGE
9mm EMBRYO
OLFACTORY/NASAL PIT
EYE
NASOMEDIAL PROCESS
NASO-OPTIC GROOVE
MANDIBULAR ARCH
HYOID ARCH
MAXILLARY PROCESS
Stomodeum
FACE
GLOBULAR PROCESS

5-6-w/19mm EMBRYO
Primary palate consists of :
Nose ,Lips,&Prolabium
FACE
Median furrow

NARIS
INTER-MAXILLARY
SEGMENT
PALATE FROM BELOW
GUM
LATERAL PALATINE
PROCESS/SHELF
PRIMARY PALATE/
Median palatine process
NASAL SEPTUM
(mostly from median
nasal processes)
UPPER LIP
PALATE

LATERAL PALATINE
PROCESS/SHELF
PRIMARY PALATE/
Median palatine process
Once the primary palate is
fused in place, the lateral
shelves meet & fuse zipper-
like towards the rear
PALATE FROM BELOW
Fusion between
PALATE

PALATE FROM BELOW 12-w
GUM
SOFT PALATE
UPPER LIP
HARD PALATE
PALATE
Secondary
Palate

ETIOLOGY
Hereditary:
• Single Gene Transmission, Polygenic inheritance
– Trisomies 21, 13, 18
• Bixler
• Monogenic / syndromic cleft
Environmental :
• Nutritional deficiences – vit A
Streau &Peer – Emotional stress
• Defective vascular supply
• Size of tongue
• Drugs &toxins
• Infections
• Lack of development forcewww.indiandentalacademy.com

VEAU’S CLASSIFICATION
OF CLEFT LIP
Type I
Type II
Type III
Type IV

VEAU’S CLASSIFICATION OF CLEFT PALATE

Kernahan & Stark’s Classification of Cleft Lip
& Cleft Palate
• Unilateral incomplete cleft of the primary palate.
• Complete cleft of the primary palate ending at the
incisive foramen.
• Bilateral complete cleft of the primary palate.
• Incomplete isolated cleft of the secondary palate.
• Complete cleft of the secondary palate – soft &
Hard palate.
• Unilateral complete cleft of the primary &
secondary palate
• Bilateral Complete cleft of the primary &
secondary palate.
• Incomplete cleft of the primary palate and
incomplete cleft of the secondary palate

Examination & diagnosis
- case history & recording of defect
- study casts & photos
-radiographic features
-medical, surgical, speech & psychological recording
Dental anomalies – caries, missing teeth
Examination – infant
child
adolescent
adult phase

Infant
Proper assistance & lighting
Visualization & palpation
Extent of cleft
Nasal deformity – esthetics
Lip contour & position of premaxiila
Width of palatal & alveolar cleft
Position of maxillary segments

Child & Adolescent
• Growth & dev – optimum
•Asymmetry of face
•Hypertelorism , malformed ears
•Lips – symmetry…
•Intra oral examination – soft & hard tissues
•Exam. Of teeth – no., Size…..
•Vertical dimension
•Oro-nasal fistulae
•Exam of vault

ADULT:
Extensive prosthetic treatment
Integrity of repaired cleft
Position of tongue
Intra oral examination
Facial symmetries, profile…

Other diagnostic modalities
impressions – 2 yrs.
cephalograms
Photo
IOPA
PANTOMOGRAPHYwww.indiandentalacademy.com

Sound spectrographic recording
Cineradiographic study
Laminography
Speech recording
Measurement of nasal & oral pressure Spectrographywww.indiandentalacademy.com

Assessment of function
Movement of mandible Rest
Less vertical growth of maxilla
Forward shift with overclosure of mandible
For restorative procedures – centric should
be properly recorded
at occlusion

Principles of treatment
The Neonatal Period :
• Difficulty in swallowing laryngospasm
• Paedtrician
– directs care
– establishes feeding
 a soft, large bottle with large
hole is required
 a palatal prosthesis may be
required (obturator)
Advantages of obturator:
Reduces feeding diificulty
Cross arch stabilization
Orthopaedic moulding

Presurgical Orthodontics
(Baby Plates)
– Molds palate into
more anatomically
correct position
– decreases tension
– may improve facial
growth
– Grayson,
presurgical nasal
alveolar molding
(PSNAM)

Primary lip closure
• Lip surgery (cheiloplasty)
– “the rule of tens” - 10 wks, 10 lbs, Hgb 10
Primary palatal closure .

PRIMARY DENTITION
Bilateral cleft – premaxilla is prominent
Treatment – prevention protrusion of incisors
Decidous dentition - normal
Lateral incisors malpositioned
Dental care
Surgical closure - Palatal fistula
Treatment – simple palatal prosthesis
Dental Care

Mixed dentition
Stable position of maxilla
Normal tongue position
Lateral commonly missing
Presence of supernumerary teeth

Adolescence & Adults
•Orthodontic treatment performed
position of maxilla
adequate vertical development
alignment of teeth - occlusion
•Later phase - Prosthodontic measurement
•Mandible permanent stabilised
•Bony grafts
•Raustad (1973)
•Treatment - Full crowns www.indiandentalacademy.com

Median cleft face syndrome
- De Meyer
C/ F :
hair line
cranium bifidum occultum
telecanthus
cleft lip
Cleft of premaxilla
cleft palate
- Hypertelorism
Transverse or lateral cleft
- Seen in macrostomia
- Etiology – eradicatio of dev. Furrow
- Asoc. with mandibulofacial dysostosis
- Extension of furrow…

Hereditary Intestinal Polyposis
k/a Peutz Jegher’s Syndrome
Simple Mendelian dominant trait
Pleiotropic gene
Common – buccal mucosa

Fordyce’s granules
Etiology – inclusion of ectoderm of
skin
no functional significance
Heck’s Disease
k/a Focal epithelial hyperplasia
Multiple nodular lesions – buccal
mucosa, commisures, upper lip & tongue

Fibromatosis ginginva
k/a Elephantiasis gingiva, Congential
macro gingiva
Etiology – Dominant autosomal gene
Present – eruption of incisors
Overgrowth of tissues – nearly hidden
crowns
Treatment – surgical excision

Macroglossia
Congenital / Secondary in type
C/F : Displacement of teeth
malocclusion
No treatment / surgical treatment
Fissured tongue
Commonest
Scrotal Tongue
Halperin – Associated with chronic trauma
or vitamin deficiencies

Hairy tongue
Hypertrophy of filiform papillae
Unknown etiology
Predisposing factors – fungi, drugs ( Sod. Perborate, Sod. Peroxide)
Treatment - empirical

Median Rhomboid Glossitis
K/a Central papillary atrophy of tongue
Cooke – associated with chronic fungal
infection,devoid of filiform papillae
No specific treatment
Geographic tongue
K/a benign Migratory glossitis, Wanderin,
rash or Erythema migrans
Emotional causes – stress in children

Aplasia
Unknown etiology
Associated with – emotional reaction,
blockage of duct by calculus,
infection of salivary glands,
Sjogren syndrome
C/F : Xerostomia
Cracking of lips,Fissuring of Commisures
Rampant Caries
Treatment – maintain oral hygiene
Milk - Salivary Substitute
Sailogogues
Artificial saliva

Artificial saliva
Composition (mg/l) :
NH4CL – 233
CaCl2 - 210
MgCl2 - 43
KCl - 1162
Pott dihydrogenortho. phosp-354
Pott thiocyanate – 222
Sod citrate – 13
NaHCo3 - 535
Disod hydrogen orthophospate-375
pH – 6.8

Microdontia
Types – true generalized
relative generalized
Involving a single tooth (Peg lateral)
Macrodontia
Types – true generalized
relative generalized
Involving a single tooth

Gemination
attempt for division –
incomplete formation
hereditary tendency
Fusion
Depending upon development
of teeth complete
incomplete
C/F : appearance, spacing ,
periodontal conditions
Eg: mesiodens, distomolar

Concresence
Fusion occurs after root formation
etiology – trauma, crowding
Dilaceration
etiology
trauma – during tooth development
Change of tooth calcified portion
Difficult extraction

Talon’s cusp
resembles eagle’s talon
associated with Rubinstein Tayabi syndrome
Dens in dente
k/a Dens invaginatus or dilated composite odontome
Etiology – invagination before calcification
increased localized internal pressure
focal growth retardation / stimulation
Food debris – infection
Treatment – early prophylaxis

Dens evaginatus
• k/a leong’s premolar, evaginated odontome,
occlusal enamel pearl
• Etiology – proliferation and evagination of
IEE & odontogenic mesenchyme
• Extra cusp – incomplete eruption , displaced
teeth , pulp exposure
•Taurodontism
•Etiology – mendelian recessive trait
•Atavistic feature
•Mutation resulting from odontoblastic
deficiency
during dentinogenesis
•Failure of HERS
•Large pulp chamber with greater apico-occlusal
height
•Pulp lacks usual constriction

Amelogenesis Imperfecta
k/a Hereditary enamel dysplasia ,Hereditary brown
enamel , Hereditary brown opalescent dentin
Types:
Hypoplastic - Defective formation of matrix
Hypocalcification - Defective mineralization
Hypomaturation - Immature enamel
Treatment - laminates ,crowns

Mottled enamel :
1st
described by – G.V.Black & Fredrick S.
Fluoride content > 0.9 – 1 Mottling
Level of fluoride :
Questionable changes
Mild changes
Moderate & Severe
Corroded app.
Treatment – cosmetic reasons –
Vital bleaching –
36% HCl
30% H2O2
An. ether Mc Minn’s sol.
Non – vital bleaching –
Superoxol & sod peborate

Dentinogenesis Imperfecta:
-Autosomal dominant also k/a – Hereditary opalescent dentine
-Types :
I -assoc. with osteogenesis imperfecta
II- never assoc. with osteogenesis imperfecta
III- k/a Brandywine type
-Gray or brownish violet
-Smooth DEJ – Enamel lost early
I&II- Obliterated pulp chambers
III - Shell teeth ,thin & enormous pulp ch.
Treatment – prevent loss of enamel & dentine attrition

Dentine Dysplasia:
- Autosomal dominant
-k/a Rootless teeth
- Types
Radicular dentine / type I
Coronal dentine / type II
- Amber coloured , transparent
- Extreme mobile – Early exfoliation – Short roots
- Yellow opalescent
Type II - Decidous teeth – obliteration pulp ch.
Type I – Permanent teeth – Thistle tube pulp ch.
No treatment , prognosis depends upon
periapical lesions
Missing teeth – replaced by TPD

Regional Odontodysplasia:
K/A – Odontogenesis Imperfecta,Odontogenic dysplasia,Ghost teeth
C/F - Teeth delayed or show faiure to erupt
- Reduction in density – Ghost teeth
Treatment – Poor cosmetic apearance- ext. with restoration

Hereditary Hypohidrotic Ectodermal
Dysplasia
Etiology – X – linked recessive
C/F – absence of sweat glands ,
hyperpyrexia , defective hair follicles.
Oral manifestations – anodontia /
oligodontia
impaired alveolar but normal jaw
growth
xerostomia , cracked & dry lips
Treatment:
• Prosthodontic intervention – 2-3 yrs.
• Mature child
• Stabilized Growth
• Overdentures

Microtia :
- only remanants of ear present
Treatment – reconstructive surgery or Prosthetic rehabilitation
Bat ear / Lop ear :
- malformed ear with downward folding of helix

Cup ear :
- helix is swung anteriorly
- wide helical margin
Macrotia :
- Excessively large pinna

List of references:
1. Maxillofacial Rehabilitation – John Beumer
2. Maxillofacial Prosthetics – Chalian
3. Maxillofacial Prosthetics – William R Laney
4. Human Embryology – Inderbir Singh
5. Prosthodontic Treatment – Bouchers
6. BDJ 1988 : 165 ; 91 – 4
7. JPD 2001 : 86 ; 364 – 8
8. JPD 2001 : 86 ; 574 – 7
9. JPD 2001 : 86 ; 342 – 7

Maxillofacial /orthodontic courses by Indian dental academy

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