The document discusses maxillomandibular defects, focusing on maxillofacial prosthetics and the classifications of congenital and acquired defects. It outlines various treatment approaches, reconstruction algorithms, and material properties for prosthetic applications. Additionally, it describes the use of obturators to close palatal and alveolar defects resulting from surgical interventions or congenital conditions.

1. 1
Maxillomandibular defects
Dr Avneesh Saxena 2nd
year
resident
Guided by Dr Deeksha Gupta

2. 2
Table of content
• Introduction
• Anatomy of maxilla
• Classification of maxillary and mandibular defects
• Maxillary defect treatment part 1
• Mandibular defects

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Maxillofacial Prosthetics - The art and science of anatomic, functional,
or cosmetic reconstruction by means of nonliving 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 malformations.
Maxillofacial prosthetics is the branch of prosthodontics concerned with
the restoration and/ or replacement of stomatognathic and craniofacial
structures with prostheses that may or may not be removed on a regular
or elective basis. -GPT 9.

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Anatomy
• Roof - Floor of the orbit.
• Lateral walls - Lateral walls of the
maxillary sinuses zygomatic bone
• Central portion - Maxillary sinus.
• Anteriorly, it comprises the midface
supporting the nose and anterior teeth.
Overlying the posterior pterygoid
region of the maxilla is the cranial
base.

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6. 6
Congenital Defects:-
These defects most commonly occur because of two main reasons,
• when the mother during pregnancy is practicing pernicious habits like
smoking, alcoholism and drug abuse
or
• during the developmental phase of the fetus some obstruction
hampers the normal development of tissues.

7. 7
most accepted classifications of maxillary
and mandibular clefts
Davis and Ritchie (1922) classified the
congenital clefts and divided it into three
groups according to the position of the cleft
in relation to the alveolar process:
• Group I:- prealveolar clefts, unilateral,
median, or bilateral.
• Group II:- postalveolar clefts involving the
soft palate only, the soft and hard palate or
a submucous cleft.
• Group III:- alveolar clefts, unilateral,
bilateral, or median

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Spina (1974) gave the classification as follows:-
Group I:-. Pre-incisive foramen clefts (clefts lying anterior to the incisive
foramen). Clefts of the lip with or without an alveolar cleft-
a. Unilateral
b. Bilateral
c. Median
Group II:- Transincisive foramen clefts (clefts of the lip, alveolus, and
palate)-
a. Unilateral.
b. Bilateral.
Group III:- Postincisive foramen clefts.
Group IV:- Rare facial clefts.

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Veau’s Classification (1931):-
The Veau classification system divides the
cleft lip and palate into 4 groups, which are
Group I:- Defects of the soft palate only (A).
Group II:- Defects involving the hard palate
and soft palate (B).
Group III:- Defects involving the soft palate
to the alveolus, usually involving the lip (C).
Group IV:- Complete bilateral clefts (D).

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• Modified Kernahan and Stark Classification (1971):-

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Acquired defects
• Surgery is first choice for early cancers and for cancers that do not
respond to radiation and chemotherapy in the form of salvage.
Unfortunately surgery can result in cosmetic, functional and
psychological impairment greatly affecting the patient s quality of
‟
life.
• Such kind of ablative surgeries gives rise to a wide range of
maxillofacial defects; such defects are called as acquired defects of the
maxillofacial region

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Acquired palatal defects
• Lack of continuity of originally intact palatal structures through the
whole or part of its length.
Etiology
• Surgical e.g. tumor removal.
• Traumatic fracture of maxilla.
• Pathological conditions e.g. osteomyelitis, T. B., and syphilis and
mucormycosis

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Classification of maxillectomy defects
• Ohngren's classification system for maxillectomy defects in 1933

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• In its early stages, cancer originating in the anteroinferior quadrant
may irritate the middle or anterior branch of the superior alveolar
nerve and elicit pain in the incisors, canines, and premolare. Later, the
tumor causes bulging of the cheek, gingivolabial fold, or hard palate.
• Anterosuperior quadrant includes the infraorbital canal and the
anterior roof of the sinus. Cancer in this quadrant produces numbness
over the upper lip or cheek and pain or numbness in the incisors and
canines

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• Molar teeth may become loose or painful when cancer originates in
the posteroinferior quadrant
• Posterosuperior quadrant, the infraorbital canal may be separated from
the sinus cavity by a layer of relatively thick bone. Cancer originating
at this site usually remains asymptomatic until infraorbital symptoms
and bloody nasal discharge reveal far-advanced disease.

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Lederman’s classification
2 horizontal lines pass through
• floor of orbit and
• maxillary sinus producing
supra structure :ethmoid sphenoid,
frontal sinus, olfactory area of nose
Mesostructure: maxillary sinus
and respiratory part of nose
Infrastructure: alveolar processes

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Aramany’s Classification for Maxillectomy
Defects :-
categories based on the relationship of the defect with the abutment teeth.
• Class 1:- Resection is performed in the anterior midline of the maxilla, with
abutment teeth present on one side of the arch.
• Class 2:- The defect is unilateral, retaining the teeth on the contralateral side.
• Class 3:- Defect occurs in the central portion of the hard palate and may involve
part of the soft palate.
• Class 4:- Defect crosses the midline and involves both sides of the maxilla, with
abutment teeth present on one side.
• Class 5:- Defect is bilateral and lies posterior to abutment teeth.
• Class 6:- Anterior maxillary defect with abutment teeth present posterior to the
defect on either sides of the remaining maxilla.

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20. 20
Spiro’s Classification of Maxillary Defects-
Spiro et al reviewed 403 maxillectomies performed between 1983 and
1993. They suggested the following classification
1. Limited Maxillectomy- Any maxillectomy in which one wall of the
maxillary antrum is removed.
2. Subtotal Maxillectomy- Maxillectomy in which at least two walls of
the antrum are removed including the palatal wall.
3. Total Maxillectomy- Complete resection of the maxilla

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Liverpool Classification of Maxillectomy
Defects:-
Vertical Component-
Class 1:- Maxillectomy not causing oro-nasal fistula.
Class 2:- Maxillectomy not involving the orbit.
Class 3:- Maxillectomy involving the orbital adnexae with orbital retention.
Class 4:- Maxillectomy with orbital enucleation or exenteration.
Class 5:- Orbitomaxillary defect.
Class 6:- Nasomaxillary defect.
Horizontal Component-
Letter a:- Palatal defect only.
Letter b:- Less than or equal to half of the bilateral maxilla.
Letter c:- Less than or equal to half of unilateral maxilla.
Letter d-:-Greater than half of the maxillectomy.

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Cordeiro’s Classification of Maxillary
Defects
• Type 1:- Limited maxillectomy, one or two walls of maxilla resected with
preservation of palate.
• Type 2:- Sub-total maxillectomy, 5 out of 6 walls of maxilla are resected
preserving the orbital floor.
• Type 3:- Total maxillectomy, resection of all 6 walls of maxilla. This type
is further divided into two parts
• Type 3a:- Total maxillectomy with orbital contents preserved
• Type 3b:- Total maxillectomy with orbital exenteration.
• Type 4:- Orbito-maxillectomy, orbital exenteration with resection of 5
walls of maxilla, preserving the palate

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Reconstruction Algorithm:-
• Type 1 Defect:- Reconstruction with free non vascularized bone may be
required to replace bone in critical area. Further obliteration can be done
by using Radial Forearm Faciocutaneous Flap (RFFF).
• Type 2 Defect:- RFFF can be used to reconstruct missing palate. An
osseo-facio-cutaneous RFFF can be used to reconstruct anterior maxilla,
which will also provide good lip support.
• Type 3a Defect:- Free non vascularized bone can be used to reconstruct
the orbital floor and the remaining defect can be closed by using rectus
abdominus or temporalis flap.
• Type 3b Defect:- Reconstruction can be done by using rectus abdominus
flap with skin paddles to reconstruct palate, nasal wall or facial skin.
• Type 4 Defect:- Reconstruction can be done by using rectus abdominus
flap with or without skin paddles.

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Cantor and Curtis Classification of
Mandibular Defects
• Class I:- Radical alveolectomy with preservation of mandibular
continuity.
• Class II:- Lateral resection of the mandible distal to the cuspid area.
• Class III:- Lateral resection of the mandible to the midline.
• Class IV:- Lateral bone graft and surgical reconstruction.
• Class V:- Anterior bone graft and surgical reconstruction.
• Class VI:- Anterior mandibular resection without surgical
reconstruction

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Jewer’s and Boyd’s Classification of
Mandibular Defects:-
• H- Lateral defects of any length up to midline including condyle.
• C- Defects involve central segment containing 4 incisors and 2 canines.
• L- Lateral defects excluding the condyle
3 lower case letters describe soft tissue component
s– Skin.
m– Mucosa.
sm- Skin and mucosa

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Materials used in maxillofacial prosthetics
Ideal biological properties
• The cured material and any released materials should not irritate the
supporting tissues.
• Cured material and any released materials should be nonallergenic.
• Cured material and any released materials should be non-toxic. ·
• The cured material should not support the growth of microorganisms

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Ideal physical and mechanical properties of
maxillofacial prosthetic materials
• 1. Dynamic properties comparable
to tissues
• 2. High edge strength
• 3. High elongation
• 4. High resistance to abrasion
• 5. High tear strength
• 6. High tensile strength
• 7. Low coefficient of friction
• 8. Low glass transition temperature
• 9. Low specific gravity
• 10. Low surface tension
• 11. Low thermal conductivity
• 12. Odourless,
• 13. Non-inflammable
• 14. No water sorption
• 15. Softness compatible to tissue
• 16. Translucent

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Acrylic Resins.
• Acrylic resins are used in the fabrication of
both intra- and extraoral prostheses. In powder
form, these resins can be injection- and
compression- molded or, in dough form, they
can be molded in gypsum molds.
• Those resins obtained from acids, CH2
=CHCOOH, and methacrylic acids polymerize
by additional polymerization. Also, it is easily
repaired or relined with either a tissue
conditioner, or temporary denture reliner, and
it can be quickly and easily processed.

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Polymethyl Methacrylate.
• Polymethyl methacrylate is a transparent
resin of remarkable clarity; it transmits light
into the ultraviolet range to a wave length of
0.25. The resin is extremely stable; it will not
discolor in ultraviolet light, and it exhibits
remarkable aging properties.
• It will soften at 260°F (125°C), and it can be
molded as a thermoplastic material. Between
this temperature and 400°F (200°C),
depolymerization takes place.

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Silicone Elastomers
• Polydimethyl siloxane, commonly referred to as silicone, are a
combination of organic and inorganic compounds
• The long-chained polymers, when tied together at various points
(cross-linked), create a network that can be separated only with
difficulty. This network makes the silicones especially resistant to
degradation from ultraviolet light exposure.
• The process of cross-linking the polymers is referred to as
vulcanization. Vulcanization occurs both with and without heat and
depends on the catalytic or cross-linking agents utilized.

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Silicones are classified into 4 groups,
according to their applications
• 1.) The first classification is Implant Grade,
• 2.) The second classification is Medical Grade, which is approved for
external use only. This is the material most commonly used in
fabrication of maxillofacial prostheses
• 3.) Clean Grade.
• 4.) Industrial Grade, which is mostly used for industrial applications.

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HTV silicones
• Designed for higher tear resistance in engineering applications, this
type of polymer requires more intense mechanical milling of the solid
HTV stock elastomer compared with the soft putty RTV silicone,
especially for incorporating the required catalyst for cross-linking, and
for pigmentation.

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Types of HTV Silicones
• Silastic 4-4514, 4-4515
• Q7-4635, Q7-4650, Q7-4735, SE-45240

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Advantages
• They have improved physical
and mechanical properties
compared to RTV silicone
• single component system with
unlimited shelf life.
Disadvantages
• they do not possess sufficient
elasticity to function in movable
tissue beds. Polydimethylsiloxane
oligomer may be added to reduce
the stiffness and hardness
• Opaque, difficulty in intrinsic
colouration, high superficial
surface hardness, and difficulty in
processing

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RTV SILICONES
• Designed for rapid room temperature curing, the RTV silicones
continue to serve the needs of maxillofacial restorations but with some
limiting aspects. With some grades, internal colouring is difficult.
• elastomer with the catalyst for the curing (vulcanizing), air entrapment
persists in the finished cured prosthesis, which tends to initiate tear
and accumulation of skin exudates

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Types of RTV silicones
• MDX4-4210:
• Cosmesil
• A-2186
• A-2000 and A-2006
• Chlorinated polyethylene
• Polyphosphazenes

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Metals for framework of definitive obturators
• Metal frameworks for obturator prosthesis are typically made of Co-Cr
alloy; however, Ni, Co or Cr may sometimes cause sensitivity,
including not only local responses such as gingivitis and stomatitis but
also generalized manifestations like eczema or dermatitis with or
without mucosal lesions
• Titanium and its alloys have very high biocompatibility and excellent
corrosion resistance in the oral cavity as titanium oxide that is formed
on its surface is highly stable and inert.

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• Titanium is less dense than conventional alloys, which is of key
importance in view of the large size of obturator prostheses.
• Titanium frameworks have been reported to be 40 % lighter than Co-
Cr frameworks and 60 % lighter than Ni-Cr frameworks.
• The use of visible light-polymerized (VLP) resins not only reduces
weight but also improves oral hygiene since these resins demonstrate a
much lower porosity than autopolymerized resins

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MANAGEMENT OF MAXILLARY
DEFECTS
• Resection of the hard and soft palate and related structures result in a variety
of anatomic and functional defects in the oral cavity and Oropharynx.
Methods of Resection:
• Palatectomy –
The mucosal incisions are outlined to give appropriate margin around the
tumour, depending upon the histopathology observed in the biopsy
If the soft palate is also involved a generous margin or the entire soft palate is
resected.

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• If the lesion approaches the greater palatine foramen, then the
posterior alveolar ridge and the pterygoid plates should also be
resected.
• After resection, the bony edges are smoothened and contoured, then
covered with the periosteum and mucosa. Packing is placed in the
defect and an immediate surgical obturator is inserted and wired to the
teeth or alveolar ridge
Maxillectomy:
• It is required if the tumour is very malignant and invades the nasal
cavity or paranasal sinuses.

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• Complete exposure of the maxilla is
obtained by the Weber- Fergusson
Incision in which the lip is split and
the incision extended around the nose
up to the orbit and along the eyelid.
• The orbital rim is spared if the orbital
contents have not been invaded
• The pterygoid plates and the soft
tissues of the pterygomaxillary space
are resected at the base of the skull
using a curved osteotome
• The wound is packed, the immediate
surgical obturator is placed and the
Weber- Fergusson incision closed.

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‘Obturator'.
• The most common of all intraoral defects of the maxilla are in the
form of an opening into the nasopharynx. The prosthesis needed to
repair the defect is termed as an 'obturator’
• Definition: According to Glossary of Prosthodontic Terms, obturator is
a prosthesis used to close a congenital or acquired tissue opening
primarily of the hard palate and/or contiguous alveolar/soft tissue
structures

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• Chalian in 1971 described an obturator as a disc or plate, natural or
artificial which closes an opening or defect of the maxilla as a result of
cleft palate or partial or total removal of the maxilla for a tumor mass.
• Obturator is a maxillofacial prosthesis used to close, cover, or
maintain the integrity of the oral and nasal compartments resulting
from a congenital, acquired, or developmental disease process, i.e.
cancer, cleft palate, osteoradionecrosis of the palate. It helps to restore
the continuity of the hard palate and oral cavity from nasal cavity,
maxillary sinus, and orbit from the oral cavity

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Ideal requirements for maxillary obturator
• 1. To carry out natural functions such as phonation, deglutition, and
mastication
• 2. Life-like appearance to aid function
• 3. The design of the prosthesis should easily & swiftly be placed in
position both comfortably and securely
• 4. The prosthesis should be durable for a reasonable period of time,
retain its polish and finish
• 5. Should be easy to clean to maintain hygiene.

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Functions of obturator
• 1. To close the defect
• 2. For feeding purpose
• 3. To keep wound or defective area clean, thus enhance healing of
traumatic or postsurgical defects.
• 4. As a stent to hold dressings or packs post surgically
• 5. To reduce the postoperative hemorrhage
• 6. Help to reshape and reconstruct the palatal contour and/or soft
palate
• 7. Improve speech

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Classification of obturator
A) The origin of discrepancy:
• a) Congenital defect obturator.
• b) Acquired defect obturator.
B) The location of the defect
• a) Labial or buccal reflex obturator.
• b) Alveolar obturator
• c) Hard palate obturator
• d) Soft palate obturator
• e) Pharyngeal obturator

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C) The type of obturator attachment to the basic maxillary prosthesis
• a) Fixed obturator
• b) Hinged or movable obturator
• c) Detachable obturator
D) The physiologic movement of the oral, nasal & pharyngeal tissues adjacent
or functioning against the obturator
• a) Static obturator
• b) Functional obturator
E). Depending on the material used
• a). Metal obturator
• b). Resin obturator
• c). Silicon obturator

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General Outline For Prosthetic Rehabilitation
Of Hard Palate Defects
• Patient is rehabilitated in three phases by an obturator prosthesis that
supports the patients through various stages of healing.
It involves three phases of treatment
• a. Immediate surgical obturator
• b. Transitional obturator
• c. Definitive obturator

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Immediate surgical obturator or maxillary
surgical prosthesis
• Surgical obturator is defined as a temporary prosthesis used to restore
the continuity of the hard palate immediately after surgery or traumatic
loss of a portion or all of the hard palate and/or contiguous alveolar
structure – GPT
• Objective-To restore and maintain oral functions at reasonable levels
during the postoperative period until healing is substantially
completed.

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Advantages of immediate surgical obturator
• Provides a matrix on which the surgical packing can be placed.
• -The prosthesis reduces oral contamination of the wound during the
immediate post-surgical period.
• -Enables the patient to speak more effectively postoperatively by
reproducing normal palatal contours and by covering the defect.
• -The prosthesis permits deglutition, thus the nasogastric tube may be
removed at an earlier stage.
• -The prosthesis lessens the psychological impact of surgery by making
the postoperative course easier to bear.
• -The prosthesis may reduce the period of hospitalization,

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Procedure of fabrication of surgical obturator
in edentulous patients
• Alginate impression is made, and cast is obtained
• If any tumor bulk is present that area of the cast is reduced to normal
contour.
• Avoid extent of the surgical peripheries, especially in soft palate and
pterygoid area.
• Surgical packing will close discrepancies in surgical defect margin &
prosthesis margin.
• Prosthesis can be fabricated with heat-cure resin or autopolymerizing
resin (clear resin) to facilitate visualization of the underlying tissues at
the time of placement and during initial healing period.

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Surgical obturator in dentulous patients
• Fabrication of the obturator should be according to a conservative line of
resection still allowing the obturator to be used for larger resections. This
method allows the surgeon to utilize the obturator regardless of the size of
the defect to perform intraoperative adjustments to the obturator.
• Fabricate the surgical obturator for the most extreme surgical resection,
making it fit best even in a difficult situation. The prosthodontist can guide at
the time of surgery to perform the modifications & able to modify the
obturator to accommodate the teeth that are not resected.

57. 57
Transitional or Interim Obturator
• Definition: Prosthesis that is made several weeks or months following
the surgical resection of a portion of one or both maxilla including
replacement of teeth in the defect area. This prosthesis when used
replaces the surgical obturator that is placed immediately following
the resection & subsequently replaced with a definitive obturator –
GPT

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• Interim obturator is placed when surgical obturator is removed on
which surgical dressing is supported.
• Interim obturator constructed from the postsurgical master cast serves
the patient for 4–6months till the maxillary defect heals and matures.
• Patient should routinely be taught about home care procedures for the
regular cleaning of the residual defect, remaining teeth, and the
prosthesis.

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-----------------------------------to be continued-------------------------------

60. 60
Definitive obturators
• It is defined as a prosthesis that artificially replaces part or all of the
maxilla and the associated teeth lost due to surgery or trauma – GPT
• Timing will vary depending on
• -i. Size of the defect
• -ii. Progress of healing
• -iii. Prognosis for tumor control
• -iv. Effectiveness of the present obturator
• -v. Presence or absence of teeth.

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Reasons for fabrication of a new prosthesis.
• Periodic edition of interim lining material increases the bulk and the
weight of the prosthesis and this temporary material may become
rough and unhygienic
• if anterior teeth are resected, addition can be of psychological benefit
• if retention and stability are inadequate occlusion contact on the
defects side may result in improvement

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Types of obturators
• Hollow bulb (Closed).
• Roofless (Open bulb)

63. 63
If the obturator is left open-
• nasal secretions accumulate leading to odour and added weight, if
secretion occurs then ,small diagonal opening may be for drainage.
• -Dificulty in polishing and cleaning the internal surface, from saliva,
mucous crusts, food accumulation ,inability to obtain support from the
superior aspect in the defect area.

64. 64
Advantages of a hollow bulb obturator
•  Weight of the obturator is reduced, comfortable and efficient.
•  No excessive atrophy & physiological changes in muscle balance.
•  Reduces the self-consciousness of wearing a denture
•  Improves retention & increases physiological function so that teeth
and supporting tissues are not stressed unnecessarily.
•  Decrease, in pressure- aids in deglutition and encourages the
regeneration of tissue

65. 65
Movement of the obturator prostheses
• Degree of movement will vary with number and position of teeth
available for retention, the size and configuration of the defect, the
amount & contour of the remaining palatal shelf, height of the residual
alveolar ridge, the size, contour, and lining mucosa of the defect and
the availability of undercuts.
• Lack of retention, stability and support are common prosthodontic
treatment problems for patients who have had a maxillectomy.

66. 66
• Retention
Retention is the resistance to vertical displacement of the
prostheses
1. Teeth:
The number, position, and periodontal status of the remaining teeth are
the most critical factors in evaluating the amount of stress that the
remaining teeth absorb.
Fixed splinting of all remaining teeth indicated to provide dissipation of
the stresses directed to primary abutment teeth.
If the defect is small & remaining teeth stable- intracoronal retainers
might be considered .
If the defect is large & some or all remaining teeth are weak-
extracoronal retainers should be used

67. 67
2. Alveolar ridge
A large ridge with a broad crest is more retentive than a small or
tapering ridge crest. Broad palate is more retentive than the high
tapering palate. Square arch form is more conducive to retention than
the tapering or ovoid arch form.
Within the defect retention
3. Residual soft palate: It provides a posterior palatal seal which will
minimize the passage of food and liquids above the obturator prosthesis.
Extension of the obturator prosthesis onto the nasopharyngeal side of
the soft palate will help in this purpose and will also provide retention.

68. 68
4. Residual hard palate: Depending on the location of the line of palatal
resection, there will be varied degrees of undercut along this line into
the nasal or paranasal cavity. The objective of prosthesis extension is to
provide resistance to vertical and horizontal displacement.
5. Lateral scar band: A scar band results after surgical resection at about
mucobuccal fold. the lateral scar band also tends to stretch with
continued use which may necessitate sequential additions to the
prosthesis
6. Height of lateral wall: Utilized for indirect retention. A high lateral
wall of an obturator will undergo less vertical displacement with a given
defect wall flexure than will a shorter prosthesis lateral wall.

69. 69
• Stability
Resistance to prosthesis displacement by functional forces.
1. Residual maxillary stability: Bracing components of the prosthesis
framework can be used to minimize movement in all three directions.
2. Stability within the defect - Maximal extension of the prosthesis in all
lateral directions must be provided. Contact of the obturator portion of
the prosthesis with these structures like medial line of resection, the
anterior and lateral walls of the defect, the pterygoid plates, and the
residual soft palate minimizes anteroposterior, mediolateral and
rotational movement of the prostheses

70. 70
3. Occlusion: The most important aspect of stability is occlusion.
Maximal distribution of occlusal force in centric and eccentric jaw
positions is imperative to minimize the prostheses' movement by
correctly selecting an occlusal scheme and eliminating premature
occlusal contacts. Acrylic resin teeth with a reduced occlusal contact
area may be indicated. Altering the cusp angle of posterior teeth may
influence the stability of the prosthesis.

71. 71
• Support
Resistance to movement of a prosthesis towards the tissue.
• Residual maxilla In the residual maxilla, the primary areas available
for support are the residual sound teeth, the alveolar ridge, and the
residual hard palate.
• Only sound teeth should be selected to provide support in the
remaining segment for a large prosthesis.

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73. 73

74. 74

75. 75

76. 76

77. 77

78. 78
REHABILITATION OF SOFT PALATE
DEFECTS
• The term velum is often used interchangeably with the preferred soft
palate. Abnormalities of the soft palate can occur in different ways.
The resultant defects can be grouped into three categories: congenital,
acquired, or developmental.
• When some or all anatomic structure of the soft palate is absent, the
term palatopharyngeal insufficiency is applied. When the soft palate is
of adequate dimensions but lacks movement because of disease or
trauma affecting muscular and/or neurologic capacity, the term
palatopharyngeal incompetence applies.

79. 79
• The term palatopharyngeal inadequacy includes incompetence and/or
insufficiency but may also suggest a reduction or absence of
pharyngeal wall function.
• A pharyngeal obturator prosthesis, which may also be called a speech
aid or speech bulb prosthesis, extends beyond the residual soft palate
to create separation between the oropharynx and nasopharynx helps to
provides a fixed structure against which the pharyngeal muscles can
function to effect palatopharyngeal closure

80. 80
PROSTHEIS
PALATAL
OBTURATOR
PALATAL
LIFT
PROSTHESIS
SPEECH
BULB
PROSTHESIS

81. 81
Palatal lift prostheses.
• The prosthetic management of VP insufficiency is carried out by
means of a pharyngeal obturator, whereas VP incompetence is
traditionally managed by a palatal lift prosthesis
• A palatal lift prosthesis addresses palatopharyngeal incompetence by
physically displacing the dysfunctional soft palate in the hope of
closing the palatopharyngeal part enough to mitigate hypernasal
speech and/or prevent nasopharyngeal regurgitation of liquids or
solids during the pharyngeal phase of swallowing.

82. 82
Advantages of palatal lift prostheses
• The gag response is minimized because of the superior position and
the sustained pressure of the lift portion of the prosthesis against the
soft palate.
• The physiology of the tongue is not compromised because of the more
superior position of the palatal extension.
• The access to the nasopharynx for the obturator is facilitated.
• The lift portion may be developed sequentially to aid patient
adaptation to the prosthesis. - Application to a diverse patient
population.

83. 83
Fabrication of Prosthesis:
• Surgical treatment is not considered as an option,
• Upper and lower perforated stock trays are selected. Upper trays are
modified with orthodontic wire, and wax extension is made into the
defect to record the defect.
• Upper & lower preliminary impressions are made with irreversible
hydrocolloids. The upper impression also recorded the defect and
diagnostic casts are fabricated

84. 84

85. 85
• Autopolymerizing acrylic resin having pharyngeal extension with
following factors are to be kept in mind that 5 mm gap between the
bulb and posterior pharyngeal wall is kept and angle of the bulb is
kept approximately 20° relative to the palatal plane.

86. 86
• Border molding with low-fusing impression compound - by recording
all the functional movements of the soft palate, by asking the patient to
perform side to side movement, bend head in front and back direction
following a circular path.
• Patient is asked to swallow which helps to record the anterior and
posterior tonsillar pillars, Passavant’s ridge, and the anterior tubercle
of the atlas

87. 87
• Upper final impression was made with medium body polyvinyl
siloxane and lower with ZnOE

88. 88

89. 89
SPEECH BULB PROSTHESIS
• A speech bulb obturator, also known as a speech aid appliance, is also
a removable device that is used for the treatment of VP insufficiency .
• When the velum is short relative to the depth of the posterior
pharyngeal wall, resulting in a VP opening during the speech, the bulb
serves to fill in the pharyngeal space.
• The bulb sits in the nasopharynx to occlude the VP port during the
speech. This improves the speech and can also improve swallowing
because it eliminates nasal regurgitation.
• It can also be combined with partial or complete dentures.

90. 90

91. 91
MEATAL OBTURATOR
• It is special type of obturator that extends up to nasal meatus.
• It establishes closure with nasal structures at a level posterior &
superior to posterior border of hard palate.
• The closure is established against the conchae & roof of nasal cavity.
• It separates oral & nasal cavities.
• Indicated in patients with extensive soft palate defects

92. 92

93. 93

94. 94
DISADVANTAGES OF MEATAL
OBTURATORS
• Nasal air emission cannot be controlled because it is in an area where
there is no muscle function.
• Nasal resonance will be altered.

95. 95
Prosthetic management of Cleft lip and
palate
A. Surgical closure
It is the treatment of choice for palatal cleft closure. It superior to prosthetic closure by
obturator. If cleft involves the lip, it is advisable to repair it as early as possible (6 wks. after
birth) to facilitate feeding and improve appearance. Surgical closure of palatal cleft is better to
be done before the end of the second year of age.
B. Prosthetic restoration
• feeding appliance
• Simple palatal plate to close cleft.
• Speech aid obturator.
C. Orthodontic treatment and arch expansion.

96. 96
Time consideration in treatment of cleft
palate

97. 97

98. 98
FEEDING OBTURATOR
• Neonates born with a cleft palate have difficulty in feeding, which
leads to failure to thrive
• Oro-nasal communication diminishes negative pressure, makes
suckling difficult & causes nasal regurgitation.
• Orogastric and nasogastric tubes can be effective but should be used
only for a limited length of time.

99. 99
Advantages
• It helps in feeding
• Reduces nasal regurgitation
• Prevents tongue from entering the defect
• Allows spontaneous growth of palatal shelves
• Contribute to speech development
• Reduces incidence of otitis media and other
• pharyngeal infections

100. 100

101. 101
Presurgical naso alveolar moulding
• As the clefts are deficient in hard and soft tissue elements, they present
a significant surgical challenge to achieve a functional and cosmetic
outcome.
• Even a mild incomplete unilateral cleft lip in the absence of a cleft
palate can be associated with a nasal deformity.
• The primary aim of PNAM is a reduction in the soft tissue and
cartilaginous cleft deformity to facilitate surgical soft tissue repair in
optimal conditions under minimum tension to minimize scar
formation.

102. 102
• It allows stimulation and redirection of growth for the controlled
predictable repositioning of the alveolar segments and gives the ideal
arch form, normalizes the tongue position, aids in speech
development, improves appearance and gives a psychosocial boost,
and improves feeding and bone contour.

103. 103
Objectives of presurgical nasoalveolar
molding
• To provide symmetry to severely deformed nasal cartilages
• To achieve projection of the flattened nasal tip
• To provide nonsurgical elongation of the columella
• To improve the alignment of the alveolar ridges and reduce the
distance between the cleft lip segments.

104. 104

105. 105
Treatment of congenital defects
Effects of cleft palate and lip
• 1. Speech – lack of valvopharyngeal closure leads to escape of air
through the nose (nasal speech)
• 2. Deglutition – greatly impede the feeding, regurgitation and escape
of fluids through the nose takes place .
• 3. Mastication – impaired due to escape of food through the nasal
cavity and due to missing teeth and malocclusion .
• 4. Esthetics is affected seriously especially in cleft palate/lip.
• 5. Deterioration of the general health
• 6. Psychological trauma .
• 7. Recurrent infection of the air ways and middle ear .

106. 106
----------------------------------To be continued---------------------------------

107. 107
Cantor and Curtis Classification of
Mandibular Defects
• Class I:- Radical alveolectomy with preservation of mandibular
continuity.
• Class II:- Lateral resection of the mandible distal to the cuspid area.
• Class III:- Lateral resection of the mandible to the midline.
• Class IV:- Lateral bone graft and surgical reconstruction.
• Class V:- Anterior bone graft and surgical reconstruction.
• Class VI:- Anterior mandibular resection without surgical
reconstruction

108. 108
Class 1 defect
TISSUES RESECTED
• Portion of alveolar process and body of mandible
• Lingual and buccal sulcus mucosa
• Portion of base of tongue and mylohyoid muscle
• Lingual and inferior alveolar nerves
• Sublingual and Sub maxillary salivary glands
• Sometimes anterior part of digastric muscle

109. 109
FEATURES
• Least debilitating.
• Can raise the floor of the mouth causing reduction in tongue mobility.
• Ability to shape and control the tongue may be lost due to loss of
some intrinsic muscles.

110. 110
Class 2 defect
TISSUE RESECTED
• condyle, ramus and body of mandible distal to canine
• mylohyoid, hypoglossal, ant belly of digastric,
• Internal pterygoid,masseter, external pterygoid,
• Pharangoglossal & palatoglossal muscles, most of intrinsic
• muscles of tongue.
• hypoglossal , lingual and inferior alveolar nerves
• adjacent buccal and lingual mucosa

111. 111
• FEATURES
• Speech, swallowing, saliva control, manipulation of food impaired.
• Facial disfigurement
• Disarticulation and loss of muscles of mastication which will hamper
mandibular movements
• Taste ,sensory and motor losses more extensive as compared to class
1

112. 112
Class 3 defect
TISSUE RESECTED
• all those described in class 2
additionally
• anterior portion of the mandible,
• geniohyoid,
• genioglossus, remaining portion of mylohyoid
• muscle with lingual and buccal mucosa.

113. 113
FEATURES
• Restricted tongue mobility due to loss of the tip of tongue and
genioglossus muscle
• Speech, swallowing, saliva control, and manipulation of food severely
restricted.
• Facial disfigurement is worse due to loss of the anterior part of the
mandible
• Disarticulation and reduction in the amount of basal bone reduce
prosthodontic prognosis.

114. 114
Class 4 defect
• Lateral bone and split-thickness skin or
pedicle graft can be performed on patients
who have had:
• radical alveolectomies
• resection of mandible distal to cuspid
• with or without disarticulation.

115. 115
Class 5 defect.
TISSUE RESECTED
• anterior portion of the mandible
• large bilateral portions of mylohyoid, geniohyoid
• genioglossus and anterior digastric muscles
• bilateral lingual and inferior alveolar nerves
• bilateral submaxillary and sublingual salivary
• glands
• mucosa of lower lip
• anterior floor of mouth
• ventral surface of tongue

116. 116
Class 6 defect
• It is similar to a class V patient, but the continuity of the mandible
has
not been restored surgically.
• Because each lateral fragment moves independently, the prognosis for
a removable prosthesis is poor and fabrication is not recommended

117. 117
• With only one-half or two-thirds of the mandible remaining, the
stability, support, and retention of the mandibular denture are
compromised.
• Due to radiation therapy either prior to or after surgery, the oral
mucosa is atrophic and fragile, predisposing to soft tissue irritation
and ulceration.
• The reduction in saliva output, and the thick mucinous nature of the
saliva that remains after therapeutic levels of radiation, impairs
retention and stability of the future prosthesis.

118. 118
• The angular pathway of mandibular closure induces lateral forces
upon the dentures which dislodge them.
• The deviation of the mandible creates abnormal jaw relationship
which prevent ideal placement of the denture teeth over their
supporting structures
• The impairment of motor and sensory control of the tongue, lips and
cheek impairs the ability of the prosthesis to stay in its original
position

119. 119
Factors affecting
treatment of
mandibulectomy patients

120. 120
1.Location & Extent of Mandibular Defect
• Marginal defects have better prognosis than discontinuity defects.
• Marginal alveolectomy
• -Least debilitating
• Main problems – loss of vertical ridge
height and vestibular depth

121. 121
• The farther anterior the defect, the more disfiguring and functionally
debilitating it is likely to be.
• Reason: Loss of key muscle attachments(genioglossus and
geniohyoid) located in anterior mandible that control tongue function
and mobility.
• Defects of the symphyseal region are most debilitating and difficult to
treat.

122. 122
2. Presence of remaining natural teeth/pre-
existing implants
• Greater the number of teeth ,better the prognosis
Remaining natural teeth in linear relationship are unlikely to provide
adequate abutments for prosthesis than teeth arranged in two
dimensions

123. 123
3.Degree of post mandibulectomy rotation
and deviation
• Mandible deviates towards the defect and rotation of mandibular occlusal
plane inferiorly
• During mandibular closure, mandible rotates around occlusal contacts on un-
resected side, and remaining teeth on resected side drop further out of
occlusion. This movement is called
FRONTAL PLANE ROTATION.

124. 124
• Deviation: Due to Primarily due to loss of tissue involved in surgical
resection.
• Rotation: Due to Pull of the suprahyoid muscles on the residual
fragment causing inferior displacement and rotation around the
fulcrum of the remaining condyle.
And Gravity.

125. 125
5.Available mouth opening
• Trismus –due to surgical trauma Physical therapy should be started
immediately. Scar tissue formation will further reduce mouth opening

126. 126
6.Functional limitation of tongue
• Frequently the surgical wound is closed by suturing the remaining
tissues of the floor of the mouth
or
• tongue to the remaining buccal tissues

127. 127
This compromises: -
• Speech
• - Swallowing
• - Mastication
• - Control of food bolus
• - Ability to control removable prosthesis
• In such cases consideration is given to lowering the anterior occlusal
plane or arranging the teeth slightly lingually.

128. 128
7.Compromised vestibular extensions
• Vestibular depth is critical for stability and peripheral seal
• It is also critical when mandibular continuity is restored with bone
grafting and implants are

129. 129
8.Skin grafting
• Skin grafts are used for surgical reconstruction either as lining for the
surface of resected soft tissue or as part of skin and connective tissue grafts
such as pedicle flaps, free flaps etc.
Advantages
• 1. Effective load-bearing tissue.
• 2. Can withstand pressure and chafing from the prosthesis.
• 3. Protects underlying bone and connective tissue well due to rapid
turnover of keratin-producing cells.
Disadvantages
• 1. No sensory innervations.
• 2. Full-thickness grafts may incorporate hair

130. 130
9.Radiation therapy
• Irradiated tissue is fragile ,sensitive to manipulation, desiccated, slow
to heal, prone to infection and at risk of osteoradionecrosis

131. 131
10. Altered anatomic relationships following
restoration of mandibular continuity
Reconstruction of anterior defects
• grafting frequently results in a graft that is deficient anteriorly.
- Results in a severe Class 2 like situation.
• The prosthodontic difficulties seen in rehabilitating such a patient are:-
- Inability to provide proper lip support.
- Speech problems associated with mandibular dentition placed too far
lingually.
- Inability to control food bolus due to lack of motor control

132. 132
• Excessive display of mandibular teeth due to patients inability to
maintain normal lip posture.
• Difficulty gaining adequate space for prosthesis placement without
encroaching on function of tongue.
• Misalignment of remaining un resected mandibular fragments and
resultant relationship between maxillary and mandibular teeth.

133. 133
Reconstruction of posterior defects
- More predictable from prosthodontic point of view as compared to
anterior defects.

134. 134
11. Previous experience with removable
prosthesis
• Indicator of how successful rehabilitation will be, particularly
edentulous patients

135. 135
Prosthodontic rehabilitation

136. 136
• All basic principles of complete denture construction must be
considered and modified because of the unusual anatomic and
functional situation.
• TREATMENT PLAN
•  Exercise regimen
•  Reconstruction
•  Definitive Guidance Prosthesis

137. 137
Impressions
• Maximum extension and tissue coverage should be recorded with the
preliminary impression
• Irreversible hydrocolloid is used with an altered/sectional stock tray.
• Conventional border molding and Master impression is used to
achieve better peripheral seal.

138. 138
Jaw relations
• Centric relation does not exist in partially mandibulectomy patients
with discontinuity defects because there is only one condyle to guide
the mandible.
• Interestingly they do have proprioception for a repeatable area but not
a repeatable point contact when asked to open wide and close the
mandible

139. 139
• In the maxilla, the wax rim used to record the centric occlusion
registration record is widened on the un resected side towards the
palatal side in order to account for deviation of the mandible.
• Vertical dimension of occlusion is difficult to determine due to
mandibular deviation and impaired motor and sensory function.
• Traditional methods are contraindicated hence VDO is recorded with
mandible closing as much as possible.
• VDO determination should rely on lip competence, facial appearance
and speaking space parameters.

140. 140
• The patient is instructed to move the mandible as far as possible
toward the untreated side. Then patient was asked to close with his
own muscular force when the mandible was manually guided. This
records a functional maxillo mandibular relationship which the patient
can attain.

141. 141
Teeth selection and arrangement
• Artificial denture teeth of zero degree cuspal angulations are selected
and arranged to achieve monoplane occlusion and to allow for lateral
freedom of mandibular movements.
• With the lingual inclination of the residual mandible, and with elevation
of the buccal shelf, placement of posterior teeth to the buccal of the
residual alveolar ridge centers the forces of occlusion more favorably
• After all the mandibular teeth and the maxillary teeth have been
arranged, ramps are developed for the maxillary prosthesis in base plate
wax. These ramps usually 5-10mm wide and should provide 2-4mm
horizontal overlap with the mandibular posterior teeth.

142. 142
• Depending upon severity of deviation, the ramp on the nonsurgical
side usually extends palatal to the maxillary alveolar ridge, and the
ramp on the surgical side extends buccal to the alveolar ridge

143. 143
Cast partial denture
• Indicated for patients with marginal mandibulectomies
• Ideal prosthesis bearing surface is split thickness graft ; it is thin,
firmly attached to the mandible and will not move with movement of
tongue, floor of mouth or cheek.

144. 144
Management of mandibular deviation
• Use of skin grafts and flaps for wound closure
• Inter maxillary fixation at time of surgery
• Intense physiotherapy to minimize deviation
• Mandibular Guidance Prosthesis

145. 145
IMF
• This type of fixation maintains the residual mandible in the proper
maxillo mandibular position and permits healing of the defect and the
associated scar formation with the teeth in occlusion.
If Inter maxillary fixation is used in immediate postoperative period,
very little muscle retraining may be needed.
• The degree of deviation seems to be inversely proportional to
the length of time the imf has been done.

146. 146
MANDIBULAR GUIDANCE PROSTHESIS
• In discontinuity defects mandibular guidance therapy can be instituted
to retrain the patient’s neuromuscular system to provide an acceptable
maxillo-mandibular relationship of the residual portion of the
mandible which permits occlusion of the remaining natural teeth

147. 147
Classification.
1) Palatal-based guidance prosthesis
• Maxillary inclined plane prosthesis.
• Positioning prosthesis with palatal flange
• Widened maxillary occlusal table
2) Mandibular-based guidance prosthesis

148. 148
Maxillary inclined plane prosthesis
• The prosthesis is retained using inter proximal ball clasps or adam’s
clasps.
• Mandibular closure results in the progressive sliding of the remaining
mandibular teeth up the incline in a superior and lateral direction until
the occlusal contact is reached.

149. 149
Positioning prosthesis with palatal flange
• Patients who are able to use their presurgical inter cuspal position after
mandibular resection often complain of mandible deviating towards
the defect side during sleep.
• On awakening they have difficulty reestablishing normal occlusal
contact and also muscle pain.
Flage extending from palate inferiorly into the lingual vestibule between
lateral border of tongue & lingual surface of the mandible can be
formed in the mouth with auto polymerizing acrylic resin.

150. 150
• Prevent medial deviation of un resected mandible even when the
mouth is open.
The flange should contact only the lingual surfaces of mandibular teeth
and it should not impinge on the lingual mucosa of the mandible
throughout the opening and closing movements.

151. 151
Widened maxillary occlusal table
• Patients who cannot attain the ideal medio lateral position of the
remaining segment and an acceptable occlusal contact of the teeth, in
spite of the use of various guidance prostheses, a palatal ramp or a
widened maxillary occlusal table using double row of teeth may be
used.
This provides a surface against which the remaining mandibular teeth
occlude against the maxillary teeth

152. 152

153. 153

154. 154
Mandibular lateral guide flange prosthesis
• Used in patients who can achieve proper medio lateral position of the
mandible but cannot hold that position for adequate mastication

155. 155
• The guide flange is attached to a cast mandibular removable partial
denture.
• It can be either molded in wax at the try-in stage and processed in
clear acrylic resin or a heavy wire loop may be used.
• The guide flange is extended into maxillary muco-buccal fold
superiorly & diagonally on non defect side without impinging on the
muco-buccal fold.

156. 156
CONCLUSION

157. 157
Reference.
• Ackerman AJ The prosthodontic management of oral and facial defects J
Prosthet Dent,1955;5:413-432
• Scannel JB Practical considerations in dental treatment of patients with head
and neck cancer J Prosthet Dent,1965;15:764-778
• Kelly EK Partial denture design applicable to the maxillofacial patient J
Prosthet Dent,1965;15:168-173
• Swoope CC Prosthetic management of resected edentulous mandibles J
Prosthet Dent,1969;21:197-201
• Cantor R and Curtis TA Prosthetic management of edentulous
mandibulectomy patients Part 1 J Prosthet Dent,1971;25:447-455, Part 2 J
Prosthet Dent,1971;25:547-555, Part 3 JProsthet Dent,1971;25:671-78.