http://theoptimalsmile.wix.com/dentistry By : Ahmed Ali Abbas

1. Removal partial denture
considerations in maxillofacial
prosthetics. (Part -1)
theoptimalsmile.wix.com

2. Index
1. Maxilofacial prosthetics
Definition
Classification
2. Timing of dental and maxillofacial
prosthetic care for acquired defects
Post operative and intraoperative care
Interim care
Potential complications
Defect and oral hygiene
Definitive care

3. Index
3. Intraoral prostheses design
considerations.
4. Surgical preservation for prostheses
benefit
Maxillary defects
Mandibular defects
Mandibular reconstruction-bone grafts

4. 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”

5. Classification
• Acquired
• Congenital
• Developmental
• Acquired defect – trauma or disease-RX
Soft/hardpalate defect-squamous cell carcinoma.
• Congenital defect – craniofacial defects - birth.
• Developmental defect – genetic predisposition-
growth and development.

6. Classification
Type of prostheisis under consideration-
• Extra-oral (cranial or facial replacement)
• Intra-oral (oral cavity)
• Interim (short periods)
• Definitive (more permanent)
• Treatment prosthesis (splint or stent)

7. • Major distinguishing feature-tooth supported or
tooth and tissue supported.
• Maxillofacial patient can experience unique
alterations in normal oral/craniofacial environment
which are the results of surgical resections.
• (maxillofacial trauma,congenital
defects,developmental anomalies or
neuromuscular disease.)
• Not only tooth and tissue support considerations-
design.

8. Timing of dental and maxillofacial
prosthetic care for acquired
defects
• Preoperative and intrao-perative care
• Interim care
• Definitive care

9. Preoperative and intraoperative
care
• Planning of prosthetic treatment for acquired oral
defects-before surgery.
• Pt-head and neck surgery-dental needs.
• Dental objectives-preoperative and intraoperative
care stage-potential dental postoperative
complications-subsequent prosthetic Rx.

10. Preoperative and intraoperative
care
• Preoperative consultation-pt clinician
relationship-surgery.
• Benefit from a prosthesis standpoint view-
strategically important teeth-interim or
definitive prosthesis use-discussed
surigical team-rx plan –preservation.

11. Preoperative and intraoperative
care
• Immediate postoperative period-challenging.
• Large carious lesion-endodontic therapy.
• Acute periodontal disease – treated-post pain.
• Nonrestorable tooth-interim care-removed-before/at
time of surgical resection.

12. Preoperative and intraoperative
care
• Impressions –max and mand arches-immediate
or interim prostheses.
• To assess need for both immediate and delayed
modification of teeth or adjacent structures to
optimize prosthetic care.
• Planning-definitive prosthesis.

13. Interim care
• Major empahasis-surgical mangement need of pt.
• When discontinuity defects in mandible results-interim
prosthetic care-not indicated.
• Typical maxillary acquired defect results in oral
communication with the nose/max sinus.

14. Interim care
• Creates physiological and functional
deficiencies in mastication,degluttition and
speech.
• Such defects-psychological.
• Major deficiency addressed by prosthetic
management-interim care time-degluttition
and speech.

15. Interim care
• An initial focus on improvement in swallowing and
speech with the interim prosthesis can help boost the
rehabilitation process significantly.
• Objective of interim obturator prosthesis-separate-oral
and nasal cavities-obturating communication.
• Such obturator prostheis commonly refers – obturation
of hard palatal defects-same for soft palate.

16. Interim care
• To artificially block free transfer of speech
sounds and food/liquids b/w oral and nasal
cavities.
• Prosthesis-surgery.
• Surgical obturator prostheis-control-surgical
access closure and split thickness skin graft-
postsurgical period.

17. Interim care
• Such prostheis-stabilized-wiring-teeth-alveolar
bone.
• Teeth-wires in prostheis-undercuts
• Immediate placement of prostheis-pts acceptance
of surgical defect.

18. Interim care
• Preferable-stabilize surgical dressing-suturing
sponge bolster-split thickness graft.
• Following primary healing-interim prostheis
placed.

19. Interim care
• Interim prostheis-wire retained resin
prosthesis-no teeth-modified-addition of
teeth.

20. Interim care
• Total maxillectomy-prosthesis support stability
and retention –not satisfactory-extension of
defect.
• Teeth present-impact of defect lessened.
• Few unilateral teeth-stability-prosthesis is less.

21. Potential complications
• Duration for interim phase-3-4 months.
• Primary objective-surgical-observation phase.
Common interim prosthetic complications :-
• Tissue trauma and associated discomfort.
• Inadequate retention of max prostheisis.
• Incomlete obturation with leakage of air,food and
liquid around obturator portion-prostheis.
• Tissue effects of chemotherapy and radiation
therapy.

22. Potential complications
Common interim prosthetic complications :-
• Tissue trauma and associated discomfort.
• Inadequate retention.
• Incomplete obturation (leakage of air,food and
liquid).
• Tissue effects of chemotherapy&radiation therapy.

23. Discomfort related to use of interim prosthesis-
• Surgical wound healing dynamics.
• Defect conditions.
• Mucosal effects of adjunctive Rx/prosthetic fit.
• Common areas of surgical wound pain include
junctions of lip/cheek mucosa-maxillectomy
pts.
• Lateral scar band-skin grafts heals-discomfort.
• Alveolar bone cuts not rounded-perforate-oral
mucosa-discomfort.
• Most common in mandibular resection-lower
and labial contour.

24. Potential complications
• Prosthesis movt-dependent on quality of
supporting structures.
• When teeth present-retention-clasps.
• For edentulous pts-denture adhesives.

25. Potential complications
• When max resection leaves cheek
unsupported by bone-prosthesis-support-
wound maturation.
• During immediate postoperative healing stage-
surgical defect-change in dimension-fit and
seal.
• Adjustments-temporary resilient denture lining
materials.
• Pts instructed not to swallow large quantities-
head horizontal-swallowing-water tight seal.

26. Potential complications
• Midline soft palate resection-difficult-retain prostheis-
water tight seal.
• When combination Rx (chemotherapy,physiotherapy)
– post surgical phase.
• Major intraoral complication-mucositis.
• Long term effects of radiation therapy-radiation
induced xerostomia and capillary bed changes-within
mandible-dentition-osteoradionecrosis.
• During interim prosthesis stage-xerostomic effects.

27. Defect and oral hygiene
• Surgical pack removal-defect site mature with
time.
• Initial loss of incompletely consolidated skin
graft,mucous secretions mixed with blood and
residual food debris –common.
• Pts instructed to clean defect of food debris
and mucous secretions routinely.

28. Defect and oral hygiene
• Defect hygiene-timelier healing-improve-fit of prosthesis.
• Common defect hygiene practices-rinsing of defect-bulb
syringe,sponge handled cleaning aid.
• Teeth-oral hygiene.
• Xerostomia-fluoride.

29. Definitive care
• Initiated-completion of active Rx phase-defect
tissue matured sufficiently-to tolerate aggressive
manipulation and obturation.
• Primary emphasis-prosthetic management.
• Design of prostheis differ-interim prosthesis.

30. Definitive care
• For some pts definitive prostheis delayed-general
health concerns,questionable tumor prognosis
and improper hygiene.
• For control of maxillofacial prostheses-large
skilled performance of pt required.(oral and defect
structures important for success.)

31. Definitive care
• Understanding of impact of post surgical
characteristics and soft tissue reconstruction on
MFPmanagement :-
• Opportunity for max prosthetic benefit-necessitates
surgical site characterestics that are separate from
classic tumor approaches.
• Ability of pt to biomechanically control large
removable prostheis following surgery-hindered-
surgical closure/reconstruction options.

32. Intraoral prostheses design
considerations
• For maxilofacial reconstruction with RPD-well
supported stable,retentive prosthesis-min movt-
preserving-max amt-supporting tissue.
• Max coverage-edentulous ridge-remaining teeth.
• Normal resistance-functional load-P.attachment-
natural dentition.
• Partial edentulous-support,stability-teeth.

33. Intraoral prostheses design
considerations
• Several post teeth-support-teeth and mucosa.
• No teeth-support-mucosa-residual ridges.
• Tumor-loss-tooth & supporting structures-
support-combination-teeth/ridge.
• For both partial & complete tissue supported-
functional load support-mucosa-unsuited.

34. Surgical preservation for
prosthesis benefit
Maxillary defects –
• Surgical outcomes that impact prosthetic
success-amt of max structures removed/that
impacts the surgical integrity and quality of the
defect.
• For hard/soft palate-restoration of physical
separation of oral and nasal cavities-mastication
,deglutition,speech & facial contour.

35. Surgical preservation for
prosthesis benefit
• Typical prostheis-obturator prostheisis,speech
aid prosthesis.
• Obturator prosthesis-that restore
palatopharyngeal function for defects of the
soft palate.
• Speech prostheis-palatopharyngeal function.-
soft palate.

36. Surgical preservation for
prosthesis benefit
• Tooth preservation-greatest impact-stabilizing effect.
• Classical midline max defect-preservation of premax
accomplished-inclusion of ant premaxilla-individual
decision-tumor control and resection technique.
• Resection of pt with teeth-tooth adjacent to defect-
force-prostheis movt.
• Surgical alveolar osteotomy cut-resection-xn site –
adjacent tooth-prognosis-supportive tooth.

37. Surgical preservation for
prosthesis benefit
• Midline of hard palate-common-prosthesis
pressure.
• To provide best surgical resection-hard palate
resected.
• Vertical surface of bone cut-advancement flap-
palatal mucosa-resilient mucosal covering-
prostheis-fulcrum.

38. Surgical preservation for
prosthesis benefit
• To serve as a guide-decision-surgery-if resection leaves
less than 1/3rd of soft palate-entire palate removed.
• Exception-edentulous pt-radical maxillectomy.
• Without teeth to provide retention-pt benefits-prostheis-
above posterior soft tissue band-retention.

39. Surgical preservation for
prosthesis benefit
• Preparation of max surgical site-split thickness graft.
• If pterygoid plate,ant temporal bone-support-skin graft.
• Extension into defect-greater-edentulous-than pt-teeth.
• However all pts-lateral-post region-seal defect.

40. Surgical preservation for
prosthesis benefit
• Surgical defects 3cm or less-reconstructed to
normal contours-tissue function-surgical
management-appropriate.
• Larger defects-difficult-incapable-prostheis.
• Soft palate reconstructions-difficult-functional
tissue replacement-compromising-palatal function.
• In light of this unpredicability,the predictable
prosthetic management of such defects is most
often the Rx of choice.

41. Mandibular defects
Functions of mastication,deglutition,speech and
saliva control are possible through coordinated
efforts of separate anatomic regions which
include:-
• Oral sphincter.
• Alveolingual and buccal sulci.
• Alveolar ridges,floor of mouth.
• Tongue,tonsillar pillars.
• Soft palate,hard palate.
• Buccal mucosa.
• More regions involved-surgical procedure-greater
demand –surgical reconstruction.

42. Mandibular defects
• When mand involved-complexity-reconstruction-
location and amt of mand -resection.
• Primary prosthetic objectives-restore mastication and
cosmesis-replacement-teeth.

43. • Regardless of prostheis support-prosthetic
success-surgical management-soft
tissue,bone.
• Diseases-soft tissue structures-resection-
control.
• Soft tissue-bone removal-no prosthetic
management.
• Exception-tongue resection-augmentation-
palatal contours-speech production.
• Primary tumors-ameloblastoma-resection of
segments-tumor control.

44. Mandibular defects
• Common mand resection-lateral,ant,hemimandibular.
Debilitating defects:-
• Cosmetic deformity-lower third of face,
• Dec masticatory function,
• Compromised coordination of tongue and teeth,
• Altered speech ability, impaired degluttition.

45. Mandibular defects
• Masticatory rehabilitation-resection-with mand
discontinuity-unpredictable.
• For pts with teeth-altered mand position-functional and
cosmetic handicap.
• Reconstruction plate failure.
• Cosmetic deformity improved-reconstruction plates.
• Preserves bilateral nature of mand movt.
• Prosthetic replacement of teeth-cannot-regions superior-
recontruction bar-mucosal perforation,bar exposure.

46. Mandibular reconstruction-Bone
grafts
• Ideal prosthetic characteristics of replacement
mandible-stable union-proximal&distal segments,
restoration of contour to lower 3rd of face,rounded
ridge contour-attached mucosa 2-3mm.
• Regardless–prosthesis-bone-vital-functional use.
• For optimal chance of prosthetic function-implants.

47. Mandibular reconstruction-Bone
grafts
• Major determining factor-soft tissue reconstruction.
• Major complication-bulk of soft tissue-lack of
tongue mobility.
• Another complication-bone placement and size.
• Fibula–mand replacement.

48. Mandibular reconstruction-Bone
grafts
• Bcos of straight nature of bone it is easy to err in
both the horizontal and vertical positioning-midline.
• Post inability to recreate natural ascending curve
posteriorly-teeth-restoring occlusion-resected side.
• Mismatch-height-ant junction of graft.
• Implant supported prosthesis-implant hygiene.
• For removable prostheses-irritation-fulcrum like
action-movt.

49. References
Carr A B, Mc Givney G P, Brown D T,
McCraken’s Removable partial
Prothodontics. 11th ed, st louis: Mosby;
2008.
Stewart K L, Rudd K D, Kuebker W A,
Stewart’s Clinical Removable Partial
Prosthodontics. 2nd edition 2004.
Miller E L, Grasso J E, Removable Partial
Prosthodontics. 2nd ed, Baltimore: Williams
& Wilkins.