Removable prosthodontics
Maxillofacial
Congenital defects
Marwa Hassan Mostafa
Assoc. professor
Maxillofacial Prosthesis
Maxillofacial prosthetics The branch of Prosthodontics concerned with
the restoration and/or replacement of intra-oral and associated facial
structures by artificial substitutes. The structures may be missing or
mutilated as a result of surgery, trauma, and congenital or
developmental defects.
Maxillofacial prosthesis
Maxillofacial defect
Anatomy of oral and nasal cavity
• Normally the oral and the nasal cavity are
separated by a complete partition maxilla and
plate which prevent communication except at
the most posterior end through velo-pharyngeal
sphincter
There are three types of maxillofacial defects:
I- Congenital defects: e.g. cleft palate, cleft lip, missing
ear, and facial cleft.
II- Acquired defects: May be caused by surgery,
pathology or accidents
III- Developmental defects (progress of growth):
prognathism, or retrognathism.
• Essentials of maxillofacial appliance
• Classification of maxillo facial appliances
according to position
Maxillofacial Team
Group of people work together to achieve a certain pupose
1-Plastic surgeon: Repair and surgical reconstruction of
deformities
2- Prosthodontist: Artificial restoration
3- Speech Therapist: Rehabilitation of maxillofacial patient
requires speech assessment.
4- Otolaryngologist (ear-nose-throat specialist)
5-Orthodontist:
Treating malocclusion associated with cleft
6- Psychologist: Patients with such defects are usually shameful,
rejected and suffer from maladjustment. The psychologist can help
the patient to accept the problem
7- Social Worker (support groups):
General education about the problem. guide the patient for his
future life after the treatment.
8- Dental technician:
Cooperation and coordination between the prosthodontist and
well trained dental technician is vital in constructing successful
appliances needed for these cases.
Congenital Defects
• A birth defect, also known as a congenital is a
condition present at birth regardless of its cause.
Birth defects may result in disabilities
• Cleft lip & palate.
DISABILITIES
1) MASTICATION
2) SWALLOWING
3) ESTHETICS
4) GENERAL HEALTH
5) PSYCHOLOGICAL TRAUMA
6) SPEECH
Definitions
Congenital defect of lip and palate:
Lack of fusion of the embryological processes
Cleft lip: incomplete formation of the
lip due to fetal development , it varies
from notching to severe opening of the lip
Cleft palate: lack of continuity of the roof of
the mouth through the whole or part of his
length in a form of anteroposterior fissure
Cleft lip & palate
Palatal development [ PALATOGENESIS ]:
Begins at 5th W.I.U & completed by the end of 12th W.I.U.
Develops from 2 primordia;
1.1ry palate [median palatine ”nasal” process]
• Develops at the end of the 5th W.I.U.
• Develops from the median
nasal processes.
• Gives rise to PREMAXILLA.
2. 2ry palate
• Begins at 7th W.I.U.
• Fusion begins at 9th W.I.U & completed
by the 12th W.I.U.
• Gives rise to THE HARD
& SOFT PALATE.
• The Incisive Foramen remains the embryologic border
between the 1ry & 2ry palate
• The fusion start at future position of the incisive
papilla and continue anteriorly and posteriorly
• Cleft is the lack of fusion between the embryological
processes
Lack of fusion between the embryologic
processes leads to what is called
CLEFTS
CLASSIFICATION OF CLEFTS
1ST CLASSIFICATION
1. Cleft lip &alveolus
(1ry palate).
1. Cleft of the hard & soft
palate (2ry palate).
2. A combination of both .
Clefts can be UNILATERAL
or BILATERAL
2ND CLASSIFICATION
{EMBRYOLOGICALLY}
Anterior clefts:
• Caused by defective development
of the 1ry palate [mesenchymal
deficiency].
• Includes Cleft lip with or without
Alveolar cleft.
Posterior clefts:
• Caused by defective development
of the 2ry palate [growth
disturbances].
• Involves the soft &/or hard palate
up to the incisive foramen.
3RD CLASSIFICATION
{VEAU’S CLASSIFICATION}
INCIDENCE OF CLEFTING
• The generally accepted incidence rate is 1-700
of infants were born with some sort of clefting.
• Left-sided clefts 70%
• unilateral clefts are More Common than
bilateral clefts
CLEFT LIP
CAUSE
In Unilateral cleft lip; the maxillary process on the
affected side fails to unite with the merged median
nasal process.
In Bilateral cleft lip; both maxillary
processes fail to unite with the merged median nasal
processes.
When the cleft is complete bilateral &involves
the alveolus, PREMAXILLA is:
• Free.
• Protrudes anteriorly.
The failure of the median nasal process to develop
& merge MEDIAN CLEFT LIP [RARE
CLEFT]
CLEFT PALATE
• Failure of the mesenchymal
masses of the lateral
palatine processes to meet
& fuse with each other ,
nasal septum &/or the
posterior margin of the 1ry
palate.
• This could result in:
1.A cleft of the 1ry palate.
2.A cleft of 1ry & 2ry
palate.
3.A cleft of 2ry palate only
AETIOLOGY OF CLEFTS
A number of factors that affect the mother early in THE 1ST
TRIMESTER:
1. Infections & toxicity.
2. Poor diet.
3. hormonal imbalance.
4. Genetic factors [play a greater role].
5. Chemical irritation [e.g. hypoxia or hypervitaminosis].
6. Radiation exposure [e.g. therapeutic radiation of pelvis or x-
ray exposure].
7. Stress & anxiety.
SEQUENCE OF TREATMENT
1. Early intervention & counseling.
2. Feeding.
3. Surgical treatment.
4. Pharyngeal flaps & obturators.
5. Bone grafting the alveolar cleft.
6. Orthodontic treatment
7. Definitive prosthetic treatment.
Early intervention & counseling:
When an infant born with a cleft , the cleft palate
team should:
• Assess the severity of the case.
• Reassure the parents.
• Teaching the parents how to deal with the cleft
problems.
FEEDING
• Maintaining nutrition is necessary for growth
&development.
• It helps infant’s preparation for the 1st surgery.
• Depending on the TYPE & SEVERITY of the cleft,
a variety of feeding devices are available:
1. Infants with isolated cleft lip often feed normally or
use A BROAD BASE NIPPLE.
2. In cleft palate [with or without cleft lip], the feeding
problem is more significant, as they:
• Generate a negative pressure when sucking.
• Get tired easily unfinished feeding.
How to overcome??
By using A FEEDING
DEVICE in the form of:
1. A soft, premature nipple
adapted to the palatal
defect.
2. Cross-cut nipples allow for
easier flow of formula, thus
decreasing strain of the
child.
3. Longer nipples are more
successful as they are
placed posterior to the
defect.
4. The squeeze bottle.
5. Other forms.
Other Forms Of Feeding Devices
Special precautions
1. Feeding is done in a semi-upright position, to reduce
nasal regurgitation.
2. Feeding requires more time & should be un-hurried.
3. On completion of feeding , a wet oral swab is used to
clean mucous & formula from the cleft.
4. If there is a unilateral cleft of the alveolus, the nipple
should be pointed toward the unaffected side.
Feeding Appliance
• A prosthetic way of management that aids in
feeding of cleft palate infants during the pre-
palatal surgery period.
• Custom made acrylic plate attached to the
feeding bottle
• The role of feeding appliance
Steps of construction:
1. A 1ry impression
[7-14 days]
2. 2ry impression.
Rubbe base impression
A master cast
3. Feeding appliance construction.
Nasoalveolar molding device
To realign alveolar segments to prepare them for
surgical closure
Collumella nostrils
5-6 months
Ways to hold the feeding appliance:
• By parent’s finger during
feeding.
• Attached to the feeding
bottle.
• Hold by stuck sheets
[Plastic sheet /
Steristrips.
SURGICAL TREATMENT
The 1st surgery for the lip is usually performed at AROUND 3
MONTHS. Lip repair
THE RULE OF TEN
10 pounds 10 weeks old hemoglobin count of 10
In weight
• A preliminary operation to
close the lip &alveolus
prior to the 1ry bone
grafting procedure
• A 2nd operation is then
performed to insert
Autogenous bone graft
plus a more definitive lip
repair
Lip repair diagram
PALATAL REPAIR
• The surgery on the palatal shelves should not be
performed too early as the child grows, palatal shelves
continue to grow & the cleft narrows.
• Timing for palatal closure varies from 12months to
4years , depending on the width of the cleft;
if the cleft is very wide no sufficient tissues
available for closure
Delay closure
The soft palate is closed at AROUND 12MONTHS of
age.
The only exceptions, are:
• Very wide clefts .
• PIERRE ROBIN SYNDROME mandible is
small & retruded tongue is in a narrow
position closing the nasopharynx, so closing
the soft palate may lead to
Inability to breath through the nose
Palatal closure & push back procedures
1. Flaps are raised in hard
palate area.
2. Rotated posteriorly [to
increase length of the
reconstructed palate].
3. Denuded areas are
allowed to granulate in.
Pharyngeal Flaps & Obturators
Most Velopharyngeal discrepancies for cleft
patients are managed SURGICALLY, with a
combination of:
• Push back & palatal closure procedures{9-12
months}.
• Superiorly based pharyngeal flap procedures
{3-7 years}.
followed by Intensive Speech Theraby
Note That???
There are 2 types of patients require obturator
prosthesis:
1. Patients with clefts confined to the 2ry palate.
2. Patients with Hypernasality following surgical
procedures
3. ORTHODONTIC TREATMENT
Indications:
Preoperatively for cases having complete
unilateral or bilateral collapsed clefts.
To align lateral segments of the palate &
prepare them for surgical closure with or
without bone graft.
4. Definitive prosthetic treatment
• Rehabilitation Of Rehabilitation Of Un
Patient Who Undergo operated Patient
Surgical Treatment 1. Wide soft palatal defect.
1. Failure of surgery to close 2. Wide hard palatal defect.
the defect. 3. Partial or complete paralysis
2. Scar tissues decrease tissue of soft palatal remnants.
mobility. 4. Debilitated patient.
5. When surgery is to be
delayed to allow for proper
growth.
Definitive prosthetic treatment
1. Fixed partial denture
2. Removable partial denture
3. Complete Denture
4. Overdentures
5. Implants
6. Speech Aid Appliance
Definitive prosthetic treatment
• The initial prosthodontic care is to fabricate a well-
fitting interim R.P.D. followed by the definitive
treatment later on.
1-Fixed partial denture:
Most prosthodontists prefer to fabricate all
anterior fixed units at the same time
ideally around 25 years
2-Removable partial denture:
The same designs as for non cleft patients, EXCEPT for
patients with Vlopharyngeal deficiencies, where the R.P.D
must support
• A palatal lift prosthesis.
• Or An obturator prosthesis.
• The prosthodontist must consider the long lever arm
created by the extension
particularly in KENNEDY CLASS1 OR 2 CASES
Adequate indirect retention.
3-Complete dentures
The problems encountered:
1. The reduced size of the cleft maxilla.
2. Excessive inter-arch space, due to reduced downward
& forward growth of maxilla.
3. Lack of bony palate lack of support &
stability of C.D.
4. Poor alveolar ridge development &shallow
depth of the palate compromised
stability & support.
5. Scarring from lip closure reduces the
effective depth of labial vestibule & the
stability.
4-Maxillary overdenture:
May be supported by:
• The remaining teeth.
• Combination of remaining teeth &
implants.
• Implants alone.
5-Osseointegrated implants:
