MAXILLOFACIAL

PROSTHODONTICS

By
Dr. Ashraf Emil
Eskander

Department of Prosthodontics
Faculty of Oral and Dental Medicine
MTI University
2021-2022
 Contributor

Dr. Ashraf Emil

Eskander

Professor of Prosthodontics
Faculty of Dentistry.
Cairo University &MTI University
Director Of the Maxillofacial
Prosthodontic Unit
(Cairo University)
 ‫الرؤية‬
‫تتطلع الكلية إلى أن تكون من أكثر الكليات تميزا على المستتو اإقليمت والتوول‬
‫فت ماتتاب طتف الات واأست ان والبحتتا الملمت بمتا يت استتف متع أخالقيتتات المة تتة‬
.‫وممايير الاووة‬
‫الرسالة‬
‫تقو الكلية عل إعواو أطباء أس ان يتميزون بالاوارة المة ية وقاورون عل مواكبتة‬
‫التطور الملم واإسةا فيه باال شطة البحثية بمتا يلبت احتيااتات الماتمتع وستو‬
. ‫الممب المحل والوول‬
Vision
The college aspires to be one of the most distinguished
colleges at the regional and international levels in the
field of oral and dental medicine and scientific research in
line with professional ethics and quality standards.

Mission
The college based on preparing dentists of professional
merit who are able to keep pace with scientific
development and contribute to it in research activities to
meet the needs of society and the local and international
labor market.
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Introduction
& DEFINITIONS

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CHAPTER I INTRODUCTION &DEFINITIONS

INTRODUCTION &DEFINITIONS

 Maxillofacial Prosthetics: It is the branch of Prosthodontics concerned with

the restoration and /or replacement of intra-oral and associated facial structures.
The structures may be missing as a result of surgery, trauma, as well as congenital
or developmental defects.
 Maxillofacial Prosthesis: Any prosthesis used to replace part or all of the
stomatognathic and/or the craniofacial structures.
 A maxillary defect: Disruption in the continuity of the normal oro-nasal partition.
 Cleft:: A gap or a split between two things.
Types of Maxillofacial Defects :
There are three types of maxillofacial defects:
a) Congenital defects: These are defects which are present since birth e.g.
cleft palate, cleft lip, and missing ear,
b) Acquired defects: These are defects which occur after birth and may be
caused by surgery, pathology or accidents
c) Developmental defects: prognathism, or retrognathism.
Classification of Maxillofacial Appliances:
Maxillofacial prostheses can be classified into different groups according to its site:
1. Intra-oral appliances:
a) Obturators:
Used to close a congenital or an acquired defect in the palate.
b) Stents:
Stents may be used to control bleeding., to promote healing, as a
vehicle for radiation therapy or to hold grafts in position.
c) Splints:
Splints are used to hold fragments together in cases of fractures until
healing takes place.
d) Resection Appliances:
these are used in cases of mandibular defects to correct the path of
closure of the mandible.

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CHAPTER I INTRODUCTION &DEFINITIONS

2. Extra-oral appliances:
a) Radium shield: Used for protection from radiation.
b) Restoration of missing eye, missing nose or missing ear by eye
prosthesis, nose prosthesis, and ear prosthesis.
c) Ear plugs for hearing aids.

3. Combined intra-oral and extra-oral appliances:

Used in cases where there is a lost part of the maxilla or mandible
together with the facial structures.

4. Cranial and facial restorations :

a) Cranial onlays and inlays: Used to compensate for the lost cranial
bones due to skull injury.
b) Extra-oral implants.

Maxillofacial Team:
A team can be defined as a group of people working together to achieve
a certain purpose The management of patients with acquired or congenital
defects require a multidisciplinary cooperation. It involves the cooperation and
coordination of care among members of a multidisciplinary medical team..
The members required for the formation of the maxillofacial team include:

1. Plastic surgeon: Plays an important role in treatment planning , repair and

surgical reconstruction of deformities and the final success of the surgical
rehabilitation of the patient. The decision should be based on the
determination of the patient’s need, the assessment and evaluation of the case
and the functional benefits gained by surgical reconstruction.

2. Prosthodontist: In inoperable cases, prosthetic management might be the

only way employed in the rehabilitation of maxillofacial patients. Whenever
possible, all prospective patients for head and neck surgery who are potential
candidates for any maxillofacial prosthesis should be seen by the maxillofacial
prosthodontist for diagnosis and treatment planning before surgery.
Coordination between the plastic surgeon and prosthodontist can result in a

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CHAPTER I INTRODUCTION &DEFINITIONS

defect that is best suited for prosthetic appliances. Structures that provide
valuable support, retention and stability for the prosthesis should be preserved.

3. Orthodontist: The orthodontist plays an important role in treatment of

malocclusion associated with cleft lip and palate patients especially, in the
period of mixed dentition.
4. Oral surgeon: Cooperation and coordination between the prosthodontist and
the oral surgeon is very important in planning the steps of rehabilitation.
Also, the oral surgeon may be called upon for extractions in the fields to be
irradiated.
5. Speech Therapist: The role of speech therapist is to correct defective speech
caused by palatal defects. Thus, the rehabilitation of maxillofacial patients
requires speech assessment which is most valuable in congenital cleft palate
cases. The occurrence of congenital defect presents a more complicated
problem than the acquired defect. In the former condition , the normal speech
pattern is not formed and so, even with correction of the anatomical defect ,
the patient needs speech therapy to break the abnormal pattern first and to
learn normal speech. In cases of acquired palatal defects, the speech returns to
nearly normal pattern immediately after the correction of the defect, because
the speech pattern is already formed. The speech therapist will help the patient
to articulate the words correctly after surgery.
6 Otolaryngologist (ear-nose-throat specialist): The otolaryngologist
will assist in the evaluation of hearing ability and the management of the
common symptoms associated with patients with cleft palate.

7. Psychologist: Patients with oro-facial defects are usually shameful, rejected

and suffer from maladjustment. The psychologist can help the patient to
accept the problem with a proper perspective, to improve the morale and
psychological attitude of the patient, and to gain the patient’s co-operation
in the course of treatment.
8. Dental technician: The cooperation and coordination between the
prosthodontist and a well trained, skillful dental technician is very

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CHAPTER I INTRODUCTION &DEFINITIONS

important in constructing various maxillofacial and surgical prostheses

required for these cases.

9. Social Worker : The social workers have special skills and training for
providing guidance and counseling for the child and the family in dealing
with the social and environmental aspect of cleft abnormality. The social
worker discusses the problem with the parents and the patient and guide
the patient for his future life after the treatment.

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 CONGENITAL

DEFECTS

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CHAPTER II CONGENITAL DEFECTS

CONGENITAL DEFECTS

 Normally the nasal cavity is separated from the oral cavity by a complete partition
(the maxilla and the palate), which prevent communication except at the most
posterior end through a well-coordinated velo-pharyngeal sphincter (palato-
pharyngeal sphincter).

 The palate is formed due to fusion of the two palatine processes and the
premaxilla.

EMBRYOLOGY:
The development of the lip and alveolar process begins around the 5th week of
intra-uterine life.
The primary palate is formed during the 4th to 7th week of intra-uterine life
from the median nasal process which forms the premaxilla (the area containing the
four incisor teeth) and the philtrum of the upper lip.
The secondary palate is formed at the 6th week of intra-uterine life as bilateral
projections emerging initially in a vertical direction. Then, the mandible grows
allowing the tongue to drop downwards and then, the two palatal shelves rotate in a
horizontal position.
Fusion between the primary and secondary palates occurs in the form of a Y
shaped configuration starting in the centre and progresses anteriorly and posteriorly
to be completed at the 12th week of intra-uterine life.Thus, the fusion of the
premaxilla and the two palatine processes forms the hard palate, the soft palate and
the uvula
Also, the upper lip is formed by fusion of the median nasal process with the
lateral nasal processes.
Therefore, the lack of fusion between the embryonic processes results in the
formation of clefts.
In Bilateral cleft lip, both maxillary processes fail to unite with the merged
median nasal process. Thus, when the cleft is a complete bilateral cleft and involves
the alveolus, the premaxilla is free and protrude anteriorly .

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CHAPTER II CONGENITAL DEFECTS

CONGENITAL CLEFT LIP AND PALATE

Incidence of Clefts:

• It varies according to the population. The highest incidence occurs in

American Indians (1 in every 278 live births). While the lowest incidence
occurs in scandnavian countries (1 in every 3000 live births).
• The generally accepted incidence rate is 1-1000 of infants were born with
some sort of cleft.
• Left-sided clefts are more common than bilateral clefts of the lip and palate
(on both sides of the mouth) and the least is right-sided clefts.
• Incidence of clefts is twice in males than in females.

Etiology of Clefts:
The specific cause of many birth defects is unknown, but several aspects
associated with pregnancy can increase the risk of birth defects:

- The abnormal position of the embryo may play a role in inducing the cleft.

- Pressure of the amniotic fluid, failure of the tongue to drop or persistence

of epithelium at the junction of the two palatal halves could be the cause
of failure of union between the palatal shelves.

Factors that influence the induction of clefts:

I- Hereditary or genetic factors :They play a greater role in the incidence of clefts.
Cleft lip and/or palate are greater in children of parents with deformities.
II- Environmental:
1. Endocrine factors: Hormonal disturbance or cortisone therapy influence
cleft formation.
2. Radiation and X-ray: Large number of deformities including clefts
occurs when mothers receive therapeutic radiation of the pelvis during the
early months of pregnancy. Also excessive X-ray exposure has similar
effect.

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CHAPTER II CONGENITAL DEFECTS

3. Nutritional deficiencies: High percentage of cleft palate is caused by

dietary deficiency as vitamin A and riboflavin. The endocrine disturbance
occurring with dietary deficiency might be responsible for the occurrence
of clefts.
4. Infection and disease: Infectious disease of the mother and German
measles were thought to induce clefts in children.
5. Stress and disturbances of fetal circulation: Anxiety associated with
first trimester of pregnancy might cause cleft.
6. Chemical irritation: Mothers exposed to chemical irritation e.g. hypoxia
and hypervitaminosis A.

Classification of Cleft Lip and Palate

Most clefts can be generally categorized into three broad categories:
a. cleft lip without a cleft palate
b. cleft palate without a cleft lip
c. cleft lip and cleft palate together
Cleft lip with or without cleft palate is generally more common among boys;
however, cleft palate occurring alone is more common in girls than boys (Fig. 4).
Because a cleft lip is visible , it is often easier to identify than a cleft palate alone.
A cleft lip may be detected through prenatal ultrasound; however, diagnosing a
cleft palate by this way is more difficult and it might not be seen. .Even if a cleft
condition is detected during pregnancy, the diagnosis and extent of cleft lip and
palate is confirmed by physical examination after the birth of the child.

International Confederation of Plastic and Reconstructive

Surgery classification (Beumer et al.)
This system prefer a simple classification based upon embryology. It
includes three categories:
 Group I : Defects of the lip or alveolus (primary palate).
 Group II: Clefts of the secondary palate (hard palate, soft palate, or both).
 Group III: Any combination of clefts involving the primary and secondary palates.
It also includes further subdivisions to denote whether unilateral or bilateral
cases.

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CHAPTER II CONGENITAL DEFECTS

VEAU’S CLASSIFICATION
Veau's classification system divides the cleft lip and palate into 4 groups, which are as
follows :

 Type I : Clefts of the soft palate(velum) only.

 Type II : Clefts involving the hard and soft palates.
 Type III : Clefts involving both the hard and soft palates and unilateral cleft of
the alveolus and upper lip.
 Type IV : Clefts involving both the hard and soft palates and bilateral cleft of
the alveolus and upper lip.

Kernahan and Stark symbolic classification

This classification highlights the anatomic and embryonic importance of
the incisive foramen formed during week's 4-7 gestational age (GA). The
secondary palate forms the roof of the mouth from the incisive foramen to the
uvula during weeks 7-12 GA.
This system provides a graphic classification scheme using a
Y-configuration, which can be divided into 9 areas .
 Areas 1 and 4 - Lip
 Areas 2 and 5 - Alveolus
 Areas 3 and 6 - Palate between the alveolus and the incisive foramen
 Areas 7 and 8 - Hard palate
 Area 9 - Soft palate.

DISABILITIES ASSOCIATED WITH CLEFT LIP and

PALATE:

1. IMPROPER FEEDING AND MASTICATION:

 Babies with cleft lip cannot perform suckling due to lack of negative
pressure in the oral cavity.

 Masticatory function is impaired in cleft patients causing malnutrition and

debilitation. Masticatory function is also impaired due to the missing teeth
and malocclusion.

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CHAPTER II CONGENITAL DEFECTS

2. SWALLOWING:

 Especially when clefts occur in both the hard and soft palates, as a result,
fluids and food will regurgitate to the nasal cavity.

3. ESTHETICS:

 Presence of cleft lip and/or palate causes a distorted facial appearance.

4. GENERAL HEALTH:

 It will be deteriorated due to insufficient feeding, inadequate nutrition and

also due to mouth breathing.

5. PSYCHOLOGICAL TRAUMA:

 Children with clefts hardly communicate with the society.

6. SPEECH:

 Children with clefts suffer from incompetent lips and\or inadequate velo-
pharyngeal closure as a result, the air stream necessary for production of
sound will thus escape through the nose rather than through the oral cavity.

 Vowels and Nasal consonants are the only sounds that are NOT affected by
cleft palates.

 N.B. speech problem is usually more complicated in congenital defects than in

acquired defects as speech is A LEARNED PROCESS.

SEQUENCE OF TREATMENT
1. Presurgical phase
 Early intervention and counselling.
 Feeding devices.
2. Surgical treatment.
 For cleft lip.
 For cleft palate.
3. Prosthetic treatment.

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CHAPTER II CONGENITAL DEFECTS

I.Presurgical phase
Starts at birth and may continue up to 3 months till the surgery is performed.
It includes:

1. Early intervention and counseling:

When an infant is 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.

2. Feeding
• Maintaining nutrition is necessary for growth and development.
• It helps infant’s preparation for the 1st surgery
• Depending on the TYPE and SEVERITY of the cleft, a variety of feeding
devices are available:
 Infants with isolated cleft lip often feed normally or use A BROAD BASE
NIPPLE.
 In cleft palate [with or without cleft lip], the feeding problem is more
significant, as they cannot generate a negative pressure during suckling .
 The following guidelines may be useful:
1. Use of a soft, broad nipple adapted to the palatal defect.
2. Cross-cut nipples allow for easier flow of milk, thus decreasing the strain of
the child.
3. Longer nipples are more successful as they are placed posterior to the
defect.
4. Using a squeezable plastic bottle.
5. Put the infant in a semi-sitting position during bottle feeding.
5- Construction of a Feeding Appliance.

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CHAPTER II CONGENITAL DEFECTS

II) Surgical Treatment

It is the treatment of choice for congenital defects. It should be carried out in the
proper time when no contraindication exists.

a)For the Lip:

It is usually performed at around three months in order to:
1. Facilitate feeding.
2. Improve the appearance.

Lip repair without excessive tension will help to:

1.Establish favorable contour in the premaxillary area.
2.Narrow the palatal cleft [if present].

The time of surgery depends upon:

THE RULE OF TEN

1. 10 pounds in weight.
2. 10 weeks old.
3. Hemoglobin count of 10.

b) For the Palate:

The aim of palatal clousure:
1. Enhance the development of speech.
2. Proper swallowing and breathing.
3. Decrease the dento-alveolar deformities.
4. Maintain proper maxillary growth.
• The surgery on the palatal shelves should not be performed too early because as
the child grows;
o The palatal shelves continue to grow and the cleft narrows.
o In addition, growth of sufficient tissue to help proper closure.
• Timing for palatal closure varies:

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CHAPTER II CONGENITAL DEFECTS

• Early palatal closure with bone grafting :9-18 months may results in negative
effect on maxillary growth
• From 12months to 4years, depending upon the width of the cleft.
• Delayed closure (Mixed dentition) is preferred by most teams if the cleft is very
wide, no sufficient tissues will be available for closure .
c) Bone Grafting of the Alveolar Cleft:

 The timing for surgical closure of the alveolar cleft, can be divided into 3
categories:
1. Early closure: Closure of the oro-nasal fistula with or without placement
of bone graft in the alveolar cleft at the time of lip closure [less than 1
year of age].
2. Secondary closure: Applied to those patients who have a fistula that
should be closed and bone grafting of the alveolar cleft is required,
[during the mixed dentition stage].
3. Delayed closure: Applied to those patients having their alveolar cleft
grafted after their growth is essentially completed.

III) Prosthetic Treatment

a)For Infants:

A) Feeding Appliance:
A prosthetic way of management that aids in the feeding of cleft palate
infants during the pre-palatal surgery period.
 The feeding device is in the form of an acrylic plate that covers the palatal
defect. It is either attached to the neck of the feeding bottle or it may be
designed with a wire handle to allow the mother to push the plate against the
cleft in order to obliterate it during feeding.
The role of the feeding appliance in cleft palate infants:
1. It facilitates the feeding process and reduces nasal regurgitation,
2. It helps to position the tongue in the correct position to perform its
functional role in the development of the jaws. It also helps in preventing
the continuous pressure of the tongue and prevents it from entering into the
defect which increases the lateral displacement of the palatal segment.
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CHAPTER II CONGENITAL DEFECTS

3. It prevents the forcing of the nipple upwards against the edges of the
borders of the cleft leading to an increase in the width of the cleft.
4. The feeding plate obturates the cleft and restores the separation between
oral and nasal cavities.
5. It creates a rigid platform towards which the baby can press the nipple and
extract the milk.
6. It reduces the incidence of choking and shortens the length of time required
for feeding.
7. It contributes to speech development.
8. It reduces the nasal regurgitation of food thus reducing the incidence of
otitis media and naso-pharynhgeal infections.
9. It restores the basic functions of mastication, deglutition and speech
production until the cleft lip and/or palate can be surgically corrected.

Steps of Fabrication of the Feeding appliance:

-A primary impression was made with molding the low fusing impression
compound with hand adaptation to the palate of the patient or on the back of a
tea spoon. (Fig. 8).
-The infant was held upright by the mother to prevent aspiration of any excess
material .
-The primary cast was fabricated with dental stone
-A customized special tray was fabricated with auto-polymerizing acrylic
resin.
-The final impression was made using rubber base impression material to
record the precise details of the supporting structures and the defect.
=The master cast was fabricated and unnecessary undercuts were blocked
out with modeling clay.
1. The wax pattern of the feeding plate was adapted on the master cast.
2. Flasking and wax elimination was done and the feeding plate was fabricated
with heat-cured clear acrylic resin for obturating the defect. A wire handle
may be used to facilitate easy insertion and removal of the prosthesis and also
it acted as a safety measure to prevent swallowing of the appliance

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CHAPTER II CONGENITAL DEFECTS

3. After proper trimming, finishing and polishing the feeding plate was tried in
the patient’s mouth, and minor adjustments were made and final polishing of
the feeding plate was done.
4. The prosthesis was then placed in the infant’s mouth and the patient’s mother
was asked to feed the baby.
5. The infant’s mother was instructed about the method of usage, function,
cleaning and maintenance of the feeding plate.
6. A regular follow up of the patient was done after 24 hours and mweekly
follow ups were scheduled. At the ninth month, the feeding plate was changed
following the same procedure.

Special precautions:
1. Feeding is done in a semi-upright position, to reduce nasal regurgitation.
2. Feeding requires more time and should be un-hurried.
3. On completion of feeding, a wet oral swab is used to clean mucous and milk
from the cleft.
4. If there is a unilateral cleft of the alveolus, the nipple should be pointed toward
the unaffected side.

B)Naso-alveolar molding device:

-This device may be made to realign the alveolar segments to prepare them for surgical
closure with or without bone grafting.
-Also, it helps to mold and position the surrounding soft tissues in order to bring the
columella of the nose into a more midline position .
-It also helps the reshaping of the nostrils.
-It takes about 5-6 months for the tissues to become optimized and the patient is ready for
surgery.
-The realigning forces are applied through the use of elastics fixed to the side of the face
using steristrips and connected to the extended rods of the appliance .
1.

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CHAPTER II CONGENITAL DEFECTS

C)EXPANSION PROSTHESIS:
The jaw growth and dento-alveolar development do not follow the normal
growth patterns in children with clefts; this may be due to:
 Intrinsic tissue deficiency.
 Early or improper surgical treatment.
Also, anterior alveolar process narrowing and narrowing of the maxillary arch
may result from:
 Pressure from LIP REPAIR.
 Scar tissue following PALATAL REPAIR.
This may results in mal-alignment of teeth and thus require the expansion of the
maxilla to correct the palatal segments position and cross-bite .
This is carried out by using a palatal expansion type prosthesis done at the age
of 7 years [when the permanent incisors and first molars are erupted] This appliance
will expand the collapsed clefts and properly align the lateral segments to prepare
them for surgical closure with or without bone grafting.
It consists of two separate lateral sections united by an expansion device covering
the hard palate .
Monitoring the eruption of teeth should be carried out as they do not follow a
normal pattern. A decision is made whether to leave the missing lateral space opened
or not.
D) Interim Speech aid Prosthesis
This may be done to restore the palato pharyngeal function during childhood.
Or for patients with HYPERNASALITY following surgical procedures.
It consists of two parts:
a) The palatal section is in the form of a clear acrylic plate retained by
Adam’s clasps or conventional wrought wire clasps.
b) Then, the extension of the prosthesis into the defect is carried out using
dental compound and thermoplastic wax (The pharyngeal part or
speech aid) to achieve improvement in speech and deglutition.
Following processing ,the contours are checked with pressure indicating
paste (PIP).

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CHAPTER II CONGENITAL DEFECTS

The prosthesis restore the velo-pharyngeal functions very effectively and is well
tolerated by the patient. It needs to be removed periodically to account for growth
and eruption of the permenant dentition.

a)For Adults:

A) Mobile prosthesis
It was introduced in the past, where a prosthesis with a soft rubber
velar is constructed. However, the movement could not simulate the
physiologic function.

B)Meatus Obturator
It was designed to reduce the resonance of the nasopharynx,
particularly in the lateral region around the auditory meati. It is in the form of an
upward projection extending from the posterior border of the prosthesis.

Thus, the Meatus Obturator establishes closure with the nasal structures
at a level posterior and superior to the posterior terminus of the hard palate.

The obturator extends superiorly and slightly posteriorly from the hard
palate border separating the nasopharynx and nasal cavities at the level of the
inferior Choncae.

Indications:
1. Patients with extensive defects of the soft palate and who exhibit a very
active gag reflex.
2. Edentulous patients when retention is a problem (because the vertical
extension is closer to the palatal portion of the prosthesis, there is less torque
placed on the palatal portion, thus decreasing the tendency to dislodge).
Disadvantages
-The obturator does not enable the patient to control the nasal air emission
because it is positioned in the area devoid of muscle function.
Thus, nasal airflow is created by:
 Drilling one or two holes 5 mm in diameter in the obturator ,however,
-Holes can be obstructed leading to hyponasal speech and impaired
nasal respiration

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CHAPTER II CONGENITAL DEFECTS

-They can be opened widely predisposing to excessive nasal emission.

 By reducing its lateral extensions.

C)Fixed pharyngeal obturator(Speech aid prosthesis):

It is made to compensate for tissue deficiency being held in the lower region
of the nasopharynx.
It acts as a core against which the palato-pharyngeal musculature can
form a seal.
Velopharyngeal closure:
In the past, the anterior tubercle of the atlas bone was used as a
reference point to place the pharyngeal section, however, it varies between
individuals.
Then, the Passavant ridge was taken as a reference area for the
pharyngeal portion  present only in 33% of individuals. Passavant described a
horizontal ridge or cushion (cross roll) around the lateral and posterior walls of the
pharynx at the horizontal level of the hard palate and believed that it is a
component of the usual mechanism of closure during speech.
Recently, studies showed that velopharyngeal closure takes place at or
above the level of the palatal bone.
Sections of the speech aid:

1)Palato-maxillary section:
It covers the cleft of the maxilla, contains clasps for retention and
carries dental replacements when indicated.

2)Palato-velar section:
This part should remain in constant lateral contact with the soft palate
during rest and function to increase the deglutition and speech efficiency.
3)The pharyngeal section:

It extends posteriorly in the pharyngeal cavity to be surrounded by the sphincteric

action of the phxxaryngeal muscles during deglutition and speech. It is the functional
component providing contact with the pharyngeal musculature. It is also called the
Speech bulb.

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CHAPTER II CONGENITAL DEFECTS

 The design of the speech obturator is similar to partial denture design for
non-surgical patients, but the extension of the obturator away from the hard
palate and teeth will increase the lever arm.
 The long lever arm together with the additional weight of the prosthesis will
increase the effect of the gravitational forces and potential of rotation
around the fulcrum line.
 This is more significant in patients requiring Kennedy class I or class II
skeleton partial dentures and minimal for patients with class III and IV
 This additional force require clasping into disto-buccal undercuts
(especially in the 1st molar area) to resist downward forces of the soft
palate against the prosthesis and effective indirect retention.
Fabrication:
1. Extension of a stock tray with base palate wax.
2. An alginate impression is taken to record the defect accurately.
3. An acrylic special tray is constructed with a wire loop extending
posteriorly into the defect.
4. Modeling plastic is added to the wire loop.
5. The patient is instructed to:
a. \ Extend and flex the head to mold the posterior wall (30º).
b. Move his head to the left and right to mold lateral walls.
c. Speak and swallow.

These movements activate the remaining velopharyngeal musculature and mold

the modeling plastic.

6. The secondary impression:

In case of constructing a metallic framework P.D, the mouth preparation. Is
carried out and then, the secondary impression using medium body rubber
base was made and poured to obtain the master cast.
.
7. Constructing metal framework P.D (in the same way done in conventional
P.D) with a meshwork extension into the defect The meshwork extension
should extend into the soft palatal defect slightly above the palatal bone and
does not contact the activated Velopharyngeal musculature.

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CHAPTER II CONGENITAL DEFECTS

8. The metal framework was tried in the patient's mouth.

9. The modeling plastic is added to the metal meshwork and the molding was repeated
10. Scrap the modeling plastic to allow for addition of fluid wax for final
impression (fluid wax is soft at 37º and harden at room temperature 25º).
11. Wax is added and the prosthesis is left in the patient’s mouth for 5 minutes
during which functional movement are performed.
8. The completed impression is removed from the mouth and chilled with cold
water.
10. The excess wax is trimmed with scalpel.
11. Additional wax may be added, flamed and tempered if the molding is not
prefect (i.e. the wax is still lustrous).
12. The prosthesis is reinserted and functional movements are repeated.(N.B. The
impression can be made using tissue-conditioning material)
13. The completed impression should have:
 Convex superior surface to allow nasal secretion to flow on it.
 Concave lateral and inferior surface for enough tongue space.
14. Boxing of the completed impression to pour a new cast “altered cast impression”.
15. Then the vola and pharyngeal sections are processed in clear AR (either heat or
self- cured) and well polished.
16. The completed prosthesis is adjusted in the patient’s mouth using PIP (so that
blanched mucosa can be seen through the transparent AR). Only `minimal
adjustment is usually made at that time.
17. Speech should be checked by phonetic tests:
- If sound is hypo-nasal this indicates a tight prosthesis.
- If sound is Hyper-nasal this indicates an ill fitting prosthesis.
- Plosives should also be checked.
18. Delivery of the prosthesis:
If the patient complains of
- Soreness.
- Pressure.
- Hypo-nasal speech.
- Difficulty in breathing.
The Obturator should be reduced accordingly.

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CHAPTER II CONGENITAL DEFECTS

PROSTHETIC REHABILITATION FOR ADOLESCENTS AND ADULTS

1. Fixed partial dentures.

2. Removable partial dentures.
3. Complete denture.
4. Maxillary overdenture.
5. Osseointegrated implants.
.
1-Fixed partial denture:
Most prosthodontists prefer to fabricate all the anterior fixed units at the
same time (around 25 years).

2-Removable partial denture:

The same designs as for non-cleft patients, EXCEPT for patients with
velopharyngeal deficiencies, where the R.P.D must support either
 A palatal lift prosthesis.
 An obturator prosthesis.
The prosthodontist must consider the long lever arm created by the
extension, thus requiring adequate indirect retention as in KENNEDY
CLASS I CASES.

3-Complete dentures
The problems encountered:
a. The reduced size of the cleft maxilla.
b. Excessive inter-arch space, due to reduced downward and forward growth
of maxilla.
c. Lack of bony palate leads to lack of support and stability of Complete
Denture.
d. Poor alveolar ridge development and shallow depth of the palate
compromise the stability and support.
e. Scarring from lip closure may reduces the effective depth of the labial
vestibule and denture stability.

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CHAPTER II CONGENITAL DEFECTS

4-Maxillary overdenture:
May be supported by:
• The remaining teeth.
• Combination of remaining teeth and implants.
• Implants alone
5-Osseointegrated implants:
A patient with an alveolar cleft is usually missing the permanent lateral
incisor on the side of the cleft. An implant- supported restoration to replace the
missing lateral incisor offers the following advantages:
 Abutment tooth preparation is not required with the decreased
possibility of damage to the dental pulp.
 Increased loading of the abutment teeth is avoided.
 The implant in the alveolar cleft may transfer functional forces to the
graft, which could decrease the resorption of the graft.

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 CHAPTER III SPEECH

[Type a quote from the document or the summary of an interesting point. You can position
the text box anywhere in the document. Use the Text Box Tools tab to change the
formatting of the pull quote text box.]

SPEECH
&
SOFT PALATE
DEFECTS

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CHAPTER III SPEECH

THE PALATOPHARYNGEAL SPHINCTER

The palatal and pharyngeal muscles are the muscles required for normal deglutition
and production of some speech sounds, such as plosives. For vowels and nasal
consonants the palatopharyngeal part will be opened in varying degree..

1- Anatomy of the Soft Palate

The soft palate is a curtain of soft tissue attached anteriorly to the posterior
border of the hard palate and laterally to the walls of the pharynx. Its posterior border
is free with the uvula hanging from its center.
There is a large ridge occupying the central portion of the nasal surface of
the soft palate called the VELAR EMINENCE which is an essential component
of velopharyngeal closure.
The soft palate is composed of paired extrinsic muscles entering from each side to
be inserted into the soft palate these muscles are:
a. Palatoglossus Muscle:
Origin: Sides and base of the tongue.
Insertion: Undersurface of the soft palate in a fan shape.
In contraction they have three functions:
1. It acts with the tensor to depress the palate against the levator
palatini during swallowing.
2. Raise the back of the tongue.
3. Help to seal the oral cavity from the oro- pharynx.

b. Palato-pharyngeus muscle:
Origin: Pharynx.
Thyroid cartilage.
Insertion: In the velum
They have three actions:
1. Depresses the soft palate.
2. With the levator veli palatini contracted, they retract the soft palate
slightly and makes it more dome-shaped.
3. With the posterior fibers contracted they form part of the velo-
pharyngeal sphincter.

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c. Tensor Veli Palatini muscle:

Origin: sphenoid spine and scafoid fossa.
Insertion: ends in a tendon that passes around the pterygoid hamulus.
The tendon spreads anteriorly to insert into the velum.
In contraction:
It depresses the soft palate and makes it tense and tight during
swallowing, thus assists its contact with the tongue.

d. Levator Veli Palatini muscle:

Origin: Petrous part of temporal bone.
Thyroid cartilage.
Insertion: in the velum
They have three actions:
Their contraction elevates the soft palate upwards and backwards
causes the free margin of the soft palate to touch the posterior
pharyngeal wall as in swallowing or oral breathing.

e. Musculus Uvulae:
Origin: The aponeurosis of the velum anteriorly.
Insertion: It spreads posteriorly and inserts into the uvula.
In contraction:
It pulls the uvula towards it and above.

2-The Pharynx:
The pharynx is a simple, funnel shaped tube which consists of the following:
1. Pharyngeal constrictors Muscles: which includes the superior, middle and
inferior constrictor muscles of the pharynx.
2. Salpingo-pharyngeus muscle of the pharynx.
The constrictor muscles are so arranged by inter-locking fibers that a wave
of constricting impulses helps the food to pass towards the stomach.
The upper part of the pharynx is formed by the superior muscles; this part is
concerned with both speech and swallowing. While it's lower part is concerned with
swallowing only.

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Speech Mechanism:
During swallowing and oral breathing., the levator veli palatini muscle
draws the soft palate upwards and backwards causing its free margin to
contact the posterior pharyngeal wall.
During speech, also the pharynx contracts and causes an inward
movement of its lateral and posterior walls to form the palato-pharyngeal
sphincter (Velo-pharyngeal sphincter).

Velopharyngeal closure:
In the past, the anterior tubercle of the atlas bone was used as a reference
point to place the pharyngeal section of the obturator, however, it varies
between the individuals.
Then, Passavant described a horizontal ridge or cushion (cross roll) around
the lateral and posterior walls of the pharynx at the horizontal level of the hard palate
(Ridge of Passavant) and believed that it is a component of the usual mechanism of
closure during speech and became visible by the presence of a cleft.
The Passavant ridge was taken as a reference area for the pharyngeal portion of
the obturator However, it was found that the Passavant ridge is present only in 33%
of the individuals.
Recently, studies showed that velopharyngeal closure takes place at or
above the level of the palatal bone (Hard palate).

3- The Tongue:
The tongue is the principal articulator for speech. Learning its anatomy and
physiology is essential to understand the role of its position for a given sound.

Tongue is formed by two groups of musculature:

1- The intrinsic muscles: mainly affect the tongue size and shape.
2- The extrinsic muscles: are responsible for tongue position, which is
considered as the key for speech learning.
Tongue has intimate relationship to the mandible directly through its
attachment of genio-glossus and indirectly by its attachment to the mylohyoid
muscle; so, the tongue will follow the mandible during various functional
movements.
To describe the role of the tongue in speech, the dorsum of the tongue is
divided into a back portion which approximates the soft palate, and a front
portion which approximate the hard palate, and the sides are referred to as the
tongue blade, and the apex is called the tongue tip, or apex. The tongue is the
principle articulator for the vowels (a. e. i. u. o) and for consonantal speech.

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Valving Function:
Speech production can be considered in simplest terms as imposition on the
breath stream by the influence of a series of musculo-skeletal valves.
The vocal folds constitute the first-glottal-valve; adduction of the folds
permits the production of a voiced tone and their abduction permits
uninterrupted or voiceless passage of air. The muscles of the soft palate and the
pharynx constitute the palato-pharyngeal valve, which couples or uncouples
the nasal cavities.

The tongue contacts different parts of the oral cavity to produce different valving
effects:
1. The back of the tongue touches the soft palate to produce a linguo-velar valve;
2. The blade of the tongue rises to contact the hard palate, creating a linguo-
palatal valve.
3. The tip of the tongue rises to touch the alveolar ridge, constituting a linguo-
alveolar valve; it protrudes between and touches the teeth, creating a linguo-
dental valve.
4. The lips function in two valving activities: the maxillary incisors and the lower
lip form a labiodental valve; the lips work together to form a labial valve.

The various valves interrupt, impede, and constrict the air stream in many
ways to produce the complete repertoire of speech sounds. Impairment of function
of any of the valves may lead to a communication disorder, its severity depending
on the degree of uncompensated alterations in speech that attract attention and are
evaluated negatively by listeners.
The work of the prosthodontist relates primarily to the processes of
articulation and resonance. These processes are closely related, their separateness
being mostly an artifact of the words used to describe them; for example vowel
articulation is accomplished by alterations of the character of the oral cavity as a
resonator; articulation of the nasal consonants requires nasal resonance; and
improper coupling of the nasal resonating cavities to the oral cavity leads to
distortion of the so-called pressure consonants.

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Velopharyngeal function and Speech mechanism:

The velopharyngeal sphincter is a precisely coordinated valve formed by

several muscle groups.
At rest, the soft palate drops downwards, so that the oro-pharynx and
naso-pharynx are opened allowing for normal breathing.
During swallowing and oral breathing., the levator veli palatini muscle
draws the soft palate upwards and backwards causing its free margin to contact
the posterior pharyngeal wall.
During speech, also the pharynx contracts and causes an inward movement
of its lateral and posterior walls to form the palato-pharyngeal sphincter (Velo-
pharyngeal sphincter)

The velopharyngeal sphincter is also opened in certain speech sounds as

vowels and nasal consonants
1- Closure of the nasal cavity from the oral cavity and the
pharynx:

When the velopharyngeal sphincter closure is required as in deglutition and

some speech sounds e.g. plosives; the following occurs:
The Soft palate (middle 1/3): it arcs upwards and backwards (action of levator
veli palatini) to contact the posterior pharyngeal wall at the
plane of the palate.
The lateral pharyngeal wall: moves medially to contact the margins of the soft
palate.
The posterior pharyngeal wall: moves anteriorly to facilitate contact with the
soft palate.
When oral sounds are produced during speech, the velopharyngeal valve closes,
thus directing both sound energy and airflow from the pharynx into the oral
cavity to prevent speech distortion.

2- Closure of the oral cavity from the nasal cavity and the
pharynx:

This position of is achieved by downward movement of the soft palate and

upward and backward movement of the tongue.

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This closure is required during

1-Suckling: During suckling closure of the oral cavity by the lips anteriorly
and the soft palate and the tongue posteriorly creates negative intra-oral
pressure that is necessary for the flow of milk.

2- Speech: In the pronunciation of the nasal sounds. M, N and “ing” are

nasal consonants that are produced with the soft palate lowered
allowing the air stream to escape through the nose. In the M sound the
escape of air is totally through the nose , while in the N and “ing”
sounds the escape of air is partially through the nose and partially
through the mouth

Speech Mechanism
a. Speech as formulated, perceived and decoded is unique to human.
b. There are NO organs for speech per se.
c. Speech is a learned process, which makes use of the anatomical structures
for respiration and deglutition by selective modification of an outgoing air
stream.
d. Speech is a learned process that is developed over years, it starts at the age
of 2 (1 year to walk, 2 years to talk) and takes up to 6.5 years in girls and
7.5 years in boys to master it.
Components of Speech:
The production of speech sounds is a phenomenon of several highly
integrated components including:
1. Respiration.
2. Phonation.
3. Resonation.
4. Articulation.
5. Neurologic integration.
6. Audition.

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1. Respiration:
It is the action of expelling a column of air with sufficient volume and
pressure past the vocal cord by the expiratory muscles, which produces the
raw material for speech.
During speech, the inhalation is shortened and exhalation is
prolonged.
During exhalation the diaphragm moves upwards, and the intra-
pulmonary pressure will be higher than the atmospheric pressure
allowing air to be expelled.
2. Phonation:

As the exhaled air is expelled and leaves the lungs, the breath stream is
set into vibration by the approximated vocal folds of the larynx and a
complex tone is generated.
If the vocal cords are partially or completely adducted (closed) they
impede the expired air. With the proper tension and sub-glottal pressure the
vocal cords vibrate imparting phonation to the air stream e.g. O, A and E
letters
For other letters that do not require phonation, the vocal cords are
abducted (opened) .

3. Resonation:
Resonance is the amplification of voice tone. The sounds produced at the
level of the vocal cords are augmented and modified by passing through the
pharynx, the oral cavity and the nasal cavity.
These cavities act as resonating chambers which amplify some
frequencies and mute others, thus refining the tone qualities.

4. Articulation:
Ultimately, the breath stream is shaped into sounds through impedence
produced by the various articulators.
The resonated sounds are transformed into a meaningful speech within the
oral cavity through the articulation of the tongue, teeth, lips and palate.
The tongue is the most important articulating structure.

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5. Neurologic integration:
The factors for the production of speech are highly coordinated by the
central nervous system.

6. Audition:
It is the ability to receive acoustic signals.
It is important for normal speech because:
a. It permits reception and interpretation of acoustic signals.
b. It allows the speaker to monitor and control the speech output.

CLASSIFICATIONS OF SPEECH SOUNDS

American English contains 44 different speech phonemes (Speech sounds) that

are classified according to the place of production into Vowels and Consonants.

1- Vowels (a, e, i, o and u):

Vowels are open voiced sounds (laryngeal phonation) i.e. sounds
involving vibration of the vocal folds and relatively unimpeded by the oral
valves in their egress.
The tongue is the principal articulator for vowels. Tongue height and
position, lip protrusion or rounding, as well as, the degree of mouth opening
are all factors that alter the shape of the oral cavity to produce the acoustic
requirements for each vowel.
Thus, vowels are produced by a continuous air stream
passing through the oral cavity which is in the form of a single
chamber for A,O,U sounds and a double chamber for the I,E
sounds, the division occurring through the dorsum of the tongue
touching the soft palate. In all vowel sounds, the tip of the tongue
lies in the floor of the mouth contacting the lingual surface of the
lower anterior teeth.

To pronounce “ A ” sound, the dorsum of the tongue is arched with the

blade contacting the alveolar ridge and the tip resting behind the lower
incisors, the position for “ E ” sound is essentially the same, except the

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dorsum is arched a little higher, with the blade in heavier contact with the
alveolar ridge and the tip is raised slightly.
To pronounce “ I ” sound, the tongue is pulled back with the dorsum
flattened at the beginning of the sound, but raises to the “ E ” position for the
completion.
To pronounce “U” sound, the tongue first assumes the E position then
falls back with the dorsum flattened for the second part of the sound.
For the “O” sound, the tongue is in its flattest and lowest position with
no palatal contact.

2- Consonants:.
These are produced by the air stream being stopped in its
passage through the mouth by the formation of complete or partial
seals or stops, either by the tongue pressing against the teeth or
palate or by closing the lips. The sudden breaking of the seal
produces the sound.

Classification of Consonant Sounds:

Consonants could be classified according to the voicing feature into:
1. Voiceless consonants: Formed by a column of air without laryngeal
phonation e.g. p, t, f.
2. Voiced consonantscombine laryngeal phonation and air flow e.g. b, d, g.

Consonants may be classified into according to manner of production

into:
1. Plosives (stops): Stops are characterized by complete stoppage of the air
stream, building up pressure in the oral cavity, and sudden release
and explosion of the breath. They require complete contact of the
articulators [e.g. p, b, t, d, k].
2. Fricative: They are characterized by friction of the air stream, being forced
through loosely closed articulators or narrow passage way. They
include: f/, /v/, /s/, /z/, /sh/, /th/, and /zh/.

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3. Affricative: They are complex consonants that begin as a stop and are
released as a fricative (friction), accomplished by articulation of the
tongue and the anterior hard palate. The affricates include J and Ch.
4. Nasal: the air stream passes through the nose. The passage way into the nasal
cavity is made by lowering the soft palate. The nasals (/m/, /n/, and
/ng/).
5. The Glides: The term glide describes the gradual articulating motions that
characterize these sounds. They have a well defined formant
structure associated with a degree of vocal tract constriction that is
less severe than for stops, fricatives and affricates. They include:
/w/, /j/, /m/, /r/ /e/ and l/.

Consonants may be classified into according to Place of articulation into:

The place of articulation refers to the points of contact or near contact
of the active and passive articulators in producing a speech sound.
1- Labial or Bilabial Consonants: These consonants are formed mainly by lips.
They include: /p/, /b/, /m/ and /w/.
2- Labiodental Consonants: These are formed by the lips and teeth. They include
e.g. f, v,Ph.
3- Linguodental Consonants: These are formed by the tongue and teeth. They
include e.g. the fricatives/θ/, and /th/
4-The Linguopalatal Consonants: These are formed by the tongue and the
palate. They include the following:
a)Tongue and anterior portion of the hard palate:
These include (D,T,C “SOFT”,S,Z,R).
b)Tongue and posterior portion of the hard palate:
These include (J,Ch,Sh,L,R).
c)Tongue and soft palate:
These include (C”hard”,K,G,NG).
5- Uvulars:
They are those consonants produced by the movement of the uvula. They
include ( /q/, /x/, and /ɣ/).
6- Pharyngeals:
They are those consonants produced by constriction of the lateral
pharyngeal walls, lowering of the epiglottis, constriction of the laryngeal

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inlet, retraction and lowering of the tongue, and constriction of the

vestibule of the larynx. They include,( /ħ/, and /ʕ)/.

N.B:The fricative sounds can be used to evaluate the VDO:

 Premature tooth contact during articulation indicates high
VDO.
 Excessive space between anterior and posterior teeth during
continuous speech indicates low VDO.
 Closest speaking space (CSS): It is the space between upper
and lower incisors during pronunciation of S sound (1mm). It
is used to verify anterior tooth position in the try – in stage of

the denture.

SPEECH AND MAXILLOFACIAL PROSTHESIS

The maxillary obturator is considered a useful speech rehabilitation aid.

It has to be noted that immediate, interim, and definitive obturators are
all important in the speech rehabilitation of patients with surgically acquired
maxillary defects.
Speech is usually interrupted after maxillary resection. Speech is a
function carried through the combination of respiratory, laryngeal,
velopharyngeal and articulatory systems. A breakdown in one of these systems
results in malfunction.
A patient with a maxillary defect suffers from reduced intraoral air
pressure during speech production (due to oro-nasal communication) causing
inaccurate articulation, hypernasal speech, nasal air emission, and reduced
vocal loudness. Thus, the impairment of speech intelligibility interferes with
the quality of life.
Effective obturation of maxillary defects produces sufficient separation
of the oral and nasal cavities to improve the quality and intelligibility of speech.
It also enhances the masticatory function, deglutition and esthetics.
Speech therapy in obturator cases demands a team approach comprising
the patient, speech therapist, prosthodontist and parents/relatives for an
effective outcome.
In palatal defects, the plosive sounds are the most affected as the seal will be
broken. Therefore, they cannot build up pressure.
They suffer from:
a)Resonance disturbance
b)Articulation disturbance

a)Resonance disturbance is manifested as:

1)Hypernasality:
Excessive nasal resonance due to escape of air through the nose due
to the presence of a maxillary defect. In these cases,the patient is unable to

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control and divert sufficient airflow into the oral cavity, thus most of the air
stream is expelled through the nose.
2)Hyponasality:
Insufficient nasal resonance which may occur in
 ENT Problem,
 or over-sized obturator
b)Articulation disturbance are manifested as:
1)Distotion(not clear).
2)Subistitution(glottial contact).
3)Omission(closure of nasal opening).

Therefore, maxillofacial defects are highly individual and require the

clinician to call upon all his knowledge and experience to fabricate a functional
prosthesis.

SOFT PALATE DEFECTS

Velopharyngeal Function:

a. The palatopharyngeal valve or sphincter functions through the action of

several muscle groups.
b. Complete palatopharygeal closure is required for normal deglutition and
production of some speech sounds, such as plosives. For vowels and nasal
consonants the palatopharyngeal part will be opened in varying degrees.

The velopharyngeal deficits are categorized as:

a. Velopharyngeal insufficiency.

b. Velopharyngeal incompetence.

Velopharyngeal insufficiency:

The patient has inadequate, short length of the soft palate for closure.

Causes: a- Congenital or developmental defects.

b- Acquired defect due to surgical resection of neoplastic disease.

Movement ability:

Movements of the remaining tissues are within normal limit.

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Result: Deficient (Insufficient) palatopharyngeal closure.

Treatment: Speech aid prosthesis or pharyngeal obturator.

Velopharyngeal insufficiency can be further categorized into:

 Median border defects

 Lateral border defects

a)Median border defects

It is due to either:
Congenital: the remaining soft palatal tissues after surgical
correction are insufficient to perform velopharyngeal closure.
Acquired: resection of part of the soft palate at the midline.

b)Lateral border defects

It is due to unilateral resection of a part or all of the soft palatal tissues

Velopharyngeal incompetence:

Patients with normal velopharyngeal structures but the intact mechanism

are unable to perform velopharyngeal closure.
Causes: Acquired causes such as neuromuscular disorders of the soft
palate and/or the pharynx, in which the soft palate is clinically
normal, but the muscles do not function adequately due to
partial paralysis.
Movement ability: No movement to allow for velopharyngeal closure.

Result: Deficient (Unable) palatopharyngeal closure.

Treatment: Palatal lift prosthesis.

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APPLIANCES USED FOR SOFT PALATAL DEFECTS

1.Obturators for Congenital Soft Palatal Defects

(Fixed pharyngeal obturator ,Speech aid prosthesis

or Speech obturator)
The speech aid prosthesis is used for the management of congenital soft palate
defects(discussed before).

2.Obturators for acquired Soft Palatal Defects

( Pharyngeal obturators)
These are constructed for cases with resection of part of the soft
palate
Construction:
The steps of consruction are similar to the speech aid prosthesis.

3.Palatal lift prosthesis

Uses:
This type of prosthesis is useful for patients with velo-pharyngeal
incompetence who exhibits compromised motor control of the soft palate and related
musculature. Examples include:
1. Myasthenia gravis.
2. Cerebral palsy.
3. Cerebro- vascular accidents.
4. Traumatic brain injuries.
5. As a sequela following adenoidectomy, tonsillectomy or maxillary
resection.
Objective:
The objective of the palatal lift prosthesis is to displace the soft palate to
the level of normal palatal elevation enabling closure by pharyngeal wall action.
Advantages of palatal lift prosthesis:
1. The gag response is minimized due to the superior position and sustained
pressure of the lift portion of the prosthesis against the soft palate.

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2. The physiology of the tongue is not compromised due to the more

superior position of the palatal extension.
3. The lift principle can be applied to many patients who cannot be treated
with palatal surgery.

Contraindication
1. Adequate retention is not available for the basic prosthesis.
2. The palate is not displaceable.
3. The patient is uncooperative.
Fabrication
1. The custom resin tray is extended with base plate wax and the impression is
taken.
2. A partial denture framework is fabricated with retentive meshwork or wire
loops extending to cover the anterior 2/3 of the length of the soft palate.
3. Modeling plastic is added to the retentive meshwork until the appropriate
displacement of the soft palate is achieved (it should look like “beaver tail”
after molding).
4. Speech should be monitored for appropriate nasal resonance during the waxing
sequence.
4. A thermoplastic wax is used to record tissue details.
5. The lift may be extended posteriorly gradually by sequential addition over
several appointments if adaptation of the prosthesis is difficult for the patient.
6. The rest of the procedures as in speech obturator.
Palatal lift with obturator prosthesis:
The palatal lift prosthesis can be constructed with or without a
speech bulb in order to obtain an effective velo-pharyngeal clousure as in
case of patients with partial maxillectomy defect, if the speech remained
hypernasal after obturation with a silicone bulb due to the loss of
innervation to remaining soft palate. In this situation, a palatal lift
prosthesis with obturator bulb added is constructed and the speech
returns to normal level.

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 Acquired
MAXILLARY
Defects

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CHAPTER IV ACQUIRED MAXILLARY DEFECTS

Definition
A defect in the maxilla which results from trauma, disease or
surgical resection of a diseased process involving the palatal
structures.
Obturator is derived from the Latin verb obturare,
which means to close or to shut off in order to reestablish oro-
nasal separation.
ETIOLOGY AND DISABILITIES

Etiology of acquired defects:

Acquired maxillary defects may be due to

1. Traumatic accidents: due to

a. Sharp instrument or pencil.
b. Gun-shot.
c. Comminuted fracture of the maxilla.
d. Motor vehicle accident.
e. Suicidal attempt.

2. Disease:
a. T.B.
b. Syphilis.
c. Osteomyelitis of the palate.
d. Secondary fungal infections in immuno- suppressed, or severely
debilitated patients.
e. Cancer.
f. Suction disc (used as a retentive mean placed on the palatal surface of
the maxillary denture).

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CHAPTER IV ACQUIRED MAXILLARY DEFECTS

3. Surgical treatment:

A. Surgical removal of malignant or benign tumors

involving the palatal structures.
 The extent of the resection is dependent upon the size, location and
behavior of the tumour (malignant tumours require excision with safety
margin to minimize the possibility of recurrence).

Disabilities associated with acquired maxillary

defects:
1. Speech:
 Constant air escape through the nose leads to hyper-nasality of speech
(all of the speech is tinged with the tone of M,N).
2. Swallowing:
 Nasal regurgitation (fluid leaking into the nasal cavity).
 Difficulty in swallowing of solids or liquids.
3. Appearance:
 Appearance is greatly affected due to loss of support of the facial
structures which varies in severity depending on the size of the
resected part.
 Sometimes, surgery may extend to the inferior border of the orbit
leading to disfigurement of the face, lowered level of the eye which
may lead to diplopia.
4. Psychological trauma:
 Loss of a part of the face may lead to severe psychological trauma
which may deprive the patient from all their social involvements.

CLASSIFICATION
A. According to the location:
They can be named as anterior, posterior, median, or lateral defects.

B. According to the size and area of involvement:

 Unilateral total maxillectomy (hemi-maxillectomy).
 Unilateral partial (sub-total) maxillectomy.

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 Bilateral total maxillectomy.

 Bilateral partial (sub-total) maxillectomy.

C. Aramany’s Classification of defects in partially edentulous

maxillectomy patients:
 Class I: lateral defect reaches the midline.
 Class II: lateral defect that doesn’t reach the midline.
 Class III: median defect.
 Class IV: lateral defect that crosses the midline.
 Class V : posterior defect with anterior teeth remaining.
 Class VI: anterior defect with posterior teeth remaining.

SURGICAL MODIFICATIONS THAT ENHANCE

PROSTHETIC PROGNOSIS

Indications of Surgical Reconstruction:

1. Defects resulting from trauma.
2. If the defect size is small.
3. No susceptibility for recurrence.

Outlines of the resection:

- The surgeon is always asked to preserve as much of the oral structures as
possible without jeopardizing the concept of proper tumour control and
prevention of recurrence.
- The need for aggressive blind resection to assure safe removal has greatly
declined with the new imaging techniques (C.T, MRI) which allow exact
evaluation of the tumour extension.

Hard palate:
- It forms the medial margin of lateral defects, anterior margin of posterior
defect, or posterior margin of anterior defects.
- The hard palatal margin of the defect is often the fulcrum around which
the prosthesis rotates during function, particularly in edentulous patients.

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Posterior margin (soft palate):

It is important that the remaining portion of the soft palate retain the
ability to affect velo-pharyngeal closure

Retention of key teeth:

 The cuspid tooth is of particular importance to the prosthodontist because
of its greater bony support when compared to its immediate neighbors.
 The trans-alveolar resection should be made as distant as feasible from the
tooth adjacent to the resection. The next distal tooth should be extracted
and the trans-alveolar cut made through the distal portion of this socket.

 This will result in the retention of more bony support and extend the
clinical usefulness of the tooth adjacent to the resection
 The tooth adjacent to the resection will soon be lost if the resection is
made through the transeptal bone approximating the tooth bordering the
proposed defect. The tooth adjacent to the resection may become mobile
or symptomatic, often necessitating endodontic therapy, amputation at the
gingival margin, or extraction.

Lateral margin:
- The surgeon improves the tolerance and retention of the obturator if the
reflected cheek flap is lined with a split thickness skin graft.

Advantages of skin graft:

a. This keratinized surface is more resistant to abrasion than respiratory mucosa
and, therefore, is a more suitable denture bearing and supporting surface.
b. The graft also limits scar contracture and increases the flexibility of the cheek
flap. This enables the prosthodontist to displace the cheek on the resected
side more readily, thus achieving relatively normal mid-facial symmetry.
c. Additional benefits are derived from the scar band formed at the skin graft-
mucosal junction.

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Skin graft mucosal junction:

 It is the junction between the skin graft applied at the lateral aspect of the
defect to cover the inner raw surface of the cheek (split thickness skin
graft) and the lining mucosa of the cheek and lip
 Healing at this area results in a tough fibrous tissue termed the scar band
 As this area contracts longitudinally during healing, it does so like a purse
string, often creating a sizable lateral undercut superior to the scar band.
 This scar band is most prominent laterally and postero-laterally, tending to
blend with the normal oral mucosa anteriorly and posteriorly.
 Engaging the scar band superiorly and inferiorly with the prosthesis serves
to enhance stability, support, and retention.

Placement of osseo-integrated implants.

The placement of osse-integrated implants in selected sites could be of value

in the retention of the definitive prosthesis later on.

IV. PROSTHETIC REHABILITATION OF ACQUIRED

MAXILLARY DEFECTS
Indications
4. Large defects that cannot be corrected by surgery.
5. When there is a possibility of recurrence or during active stages of infections.
6. Large soft palatal defects as they are difficult to restore surgically with
normal function.

OBTURATORS
Definition:
 It is a prosthesis used to close a congenital or acquired defect in the maxilla.
Obturator is derived from the Latin verb obturare which means to close
or to shut off in order to re-establish oro-nasal separation.

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Phases of prosthetic rehabilitation for a patient with

acquired surgical defect of the maxilla:

1- Surgical obturator (Immediate or delayed obturator).

2- Interim obturator: (Starts 2-4 weeks post-surgically).
3- Definitive obturator (Starts 3-4 month after surgery).

1. Surgical Obturation

- It entails the placement of prosthesis at or immediately after the surgery.

- The prosthesis must be modified at frequent intervals to accommodate for the
rapid soft tissue changes which occur within the defect during organization
and healing of the wound.
- The objective of surgical obturation is to restore and maintain oral function
at a reasonable level during the postoperative period until healing is
completed.
Surgical obturation is achieved by placement of either:
a. Immediate obturator.
b. Delayed surgical obturator.

a- Immediate surgical obturator:

- They are fabricated on a maxillary cast obtained prior to surgery.

Advantages:
a. Functional:
1. Provide a matrix on which the surgical pack can be placed.
2. Enable the patient to speak more effectively postoperatively.
3. Permits deglutition.
b. Hygienic:
- The obturator separates the surgical site from contamination with oral
contents during immediate post-surgical period, thus reducing the
incidence of local infection.
c. Psychological:
1. The prosthesis lessens the psychological impact of the surgery.
2. The prosthesis restores the patient’s self image.
3. The prosthesis reduces the period of hospitalization

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Principles of design:
1- The prosthesis should be kept simple, light in weight, and
inexpensive.
2- The obturator should terminate shorter than the skin graft –
mucosal junction.
As soon as the surgical pack is removed extension into the defect is
made either with tissue conditioning material or soft liner.
3- Normal palatal contour to facilitate speech and deglutition.
4- No posterior occlusion at the defect side.
5- An old denture if available can be used after some modification
(reduction of flanges and removal of posterior teeth at the defect
side).
6- Add a couple of wire loops at the fitting surface to hold the lining
material.
7- Retention:
a. For Dentulous patients:
 The prosthesis should be perforated at the inter-
proximal extensions (using small bur) to allow wiring
of the prosthesis to the teeth at the time of surgery.
 Another retentive means as light wire clasps, or buccal
retaining flange can be added on the intact side to aid
in retention and allow the use of the obturator as an
interim prosthesis
b. For edentulous patients:
Retention is obtained through wiring of the prosthesis to the
remaining bony structures (peri-alveolar, circum-zygomatic wiring, or
wiring to the anterior nasal spine).

N: B.: Surgical enhancement of the lateral margin of the defect:

- The surgeon improves the tolerance and retention of the obturator if the
reflected cheek flap is lined with a split thickness skin graft .

Technique of construction:
Before surgery the prosthodontist should:
a- Examine the patient thoroughly

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b- Make impressions for diagnostic casts, and mount them on a suitable

articulator.
1. Impression procedures:
 Tray modification: A suitable stock tray is modified to accommodate the
extent of the future surgical defect. If the soft palate is to be removed in the
surgery the tray could be extended posteriorly to record this area.
 Material used: rapid-setting irreversible hydrocolloid.
 The vestibular depth on the resected side should be accurately registered so
that the approximate position of the skin graft-mucosal junction can be
determined.
 Mandibular impression and jaw relation is obtained.
 The impressions are poured and the obtained casts and mounted on a
suitable articulator.
 The maxillary cast is duplicated for future reference.

2. Alteration of the cast:

 The proposed surgical margins are outlined on the maxillary casts by the
surgeon and the prosthodontist so that the cast is altered to conform to the
proposed surgical resection.
 The tumor and any exostosis (torus) are scrapped to reproduce normal palatal
contour.
 The teeth to be included in the resection are removed from the cast and the
alveolar height is reduced.
 The residual ridge is trimmed on the labial and buccal surface to reduce the
stress on the soft tissue closure.
3. Wire retainers (wire clasps) are prepared on the standing teeth
In case of edentulous upper jaw, the obturator can be retained by wires to the
zygomatic bone (circum-zygomatic wiring).

4. Waxing of the prosthesis and Processing of acrylic obturator:

 The prosthesis is processed in transparent acrylic resin so that the extensions
and possible pressures areas can be detected and corrected at the surgery.
Anterior teeth may be added to the obturator for esthetics.

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5. Surgical room procedures:

 The surgical obturator is immersed in a disinfectant solution and all the
prosthetic instruments are autoclaved.
 In most cases the immediate surgical obturator is easily fitted and secured.
 If the surgery is more extensive than planned it is preferable to add a lining
material (e.g. tissue conditioning material) to the prosthesis.

6. Postoperative care:
 7-10 days post-surgically and prior to dismissal of the patient from the hospital,
the prosthesis and packing are removed;
 The prosthesis is cleaned and occlusal adjustments are made.
 Adjust the lateral extension and anterior aspect of the obturator short of the
skin graft-mucosal junction to avoid pressure on this area and until correct
facial contours are obtained without creating excessive tension during closure.
 A new application of soft liner or tissue conditioning material is added to the
prosthesis in order to improve adaptation, seal and comfort.
 Give instruction to the patient to irrigate and clean the surgical defect.
 The patient is seen every two weeks and the lining material is changed to
account for tissue contraction.

Delayed surgical obturator:

 Delayed surgical obturator is placed 6 to 10 days post-surgically.

 If the patient is edentulous, the surgical defect is to be extensive, and the
margins are in question, this approach may be an acceptable alternative.

Technique of construction:
1. When the packing is removed from the defect, and before the patient is
dismissed from the hospital, a maxillary impression is obtained with irreversible
hydrocolloid impression material.
2. The surgical area will be tender and the patient is apprehensive. Therefore, this
procedure must be accomplished carefully and considerately.
3. The buccal and/or labial flanges of the complete or partial denture tray must be
shortened on the side of the defect or bend it medially.

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4. All flanges of the tray are covered with peripheral beading wax, with additional
wax added in the area of the defect to provide support for the impression
material.
5. The tray is coated with a suitable adhesive to aid in the retention of the
impression material.
6. The impression should record as much of the lateral portion of the defect as
possible.
7. Major medial undercuts are generally not useful and should be blocked out with
gauze lubricated with Vaseline. Sensitive areas should be similarly blocked out.
8. The lubricated gauze can also be used to limit the extension of the impression
material into the defect.
9. The impression material should be placed on the lateral side of the tray
corresponding to the defect in order to record the contour of the lateral cheek
surface.
10. After the tray is positioned and seated, the cheek and lips should be carefully
manipulated, especially on the defect side.
11. The impression is gently released from the mouth and examined for proper
extension and adaptation.
12. The prosthesis is then constructed, delivered to the patient and then adjusted
using pressure indicator paste, disclosing wax, and articulating paper. Often, it
is necessary to extend the prosthesis with auto polymerizing acrylic resin to
cover the margin of resection on the soft palate.
13. After the prosthesis is adjusted, it is relined with an intermediate relining
material
14. In edentulous patients, it is preferable to utilize the patient's existing maxillary
prosthesis as a delayed surgical or interim obturator.

2- Interim Obturator

 It is usually made 2-4 weeks after the initial surgery.

 It serves to bridge the gap between the surgical and definitive obturator.
 It is considered when the defect has stabilized to the point that the continuous
changes will be minimal.

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 Both of the immediate surgical obturator and interim obturator prosthesis have
the same objective of maintaining patient’s comfort and function until the
definitive prosthesis can be fabricated
 There are many reasons for constructing a new prosthesis:
1. The periodic addition of interim lining materials increases the bulk
and weight of the prosthesis, and these temporary materials tend to
become rough and unhygienic with time.
2. If teeth were included in the resection; the addition of anterior and,
possibly, posterior denture teeth to the obturator can be of great
psychological benefit to the patient.
3. A well-made interim obturator can serve as a backup prosthesis,
which may be useful when the definitive prosthesis needs to be

repaired, relined, or rebased.

Prosthetic consideration in the design:

1. The obturator depends on light wire clasping but cast wire may be used.
2. An acrylic resin base is the most practical for this prosthesis.
3. Anterior teeth can be included.
4. Posterior occlusion should be avoided to reduce :
 Abutment stresses and
 Movement of the acrylic resin extension against the tissues.
6. The need for soft relines is minimized or eliminated because the defect
area will be recorded with reasonable accuracy in the impression.
7. If the patient already has a denture it can be used as a delayed surgical
obturator after relining.

3- Definitive obturator
 It is constructed three to four months after surgery when the surgical site
becomes stable dimensionally to permit construction of the definitive
prosthesis.

The timing will vary depending on:

1. Size of the defect.
2. Progress of healing.

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3. Prognosis for tumour control.

4. Effectiveness of the present obturator.
5. The use and timing of post-surgical radiation therapy.
6. The presence or absence of remaining teeth.
7. Healing of placed osseo-integrated implants.

The condition of the remaining teeth is assessed and any required treatment is
done:
1. Any carious tooth should be restored
2. Non-restorable teeth are extracted.
3. Periodontal evaluation is made for the teeth that may need splinting to
increase their longevity.

Prosthetic consideration in definitive obturator design:

1- Movement of the prosthesis:

-The degree of movement will vary with:
 The number and position of the teeth available for retention.
 The Extension, size and configuration of the defect.
- Tissue ward movements caused by the force of mastication should be
managed by Proper extension into the defect especially in the lateral aspect to
decrease the displacement. Tissue away movements caused by Gravity acting
on the weight of the prosthesis when the teeth are not in contact should be
managed by increasing the retentive elements.

2- Tissue changes:
-Dimensional changes of the tissues occur due to:
 Scar contracture and further organization of the wound which continue to
occur for at least one year.
 Movement of the prosthesis during function.
-Therefore, the obturator portion of the prosthesis should be constructed from
acrylic resin to allow for relining or rebasing to compensate for these
changes.
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3- Covering prosthesis:
Obturators for acquired defects of the maxilla are basically covering
prosthesis serving to establish the oro-nasal separation.

4- Extension into the defect:

 The degree of extension into the defect depends on the need of retention,
stability, and support. If these properties can be obtained from the
remaining maxillary structures (as in class III) then, there is no need for
extensive extension into the defect.
 The extension of the prosthesis into the defect will vary according to the
configuration and the character of the lining tissues of the defect:
a. The lateral aspect of the defect is related to the inside of the
cheek surface, which is lined with the skin graft. The extension in
this area will improve support and minimize prosthesis movement
b. The medial aspect of the defect is usually related to the nasal
cavity. This area is highly sensitive and usually posses extensive
undercuts, thus extension in this aspect is of less importance.
3- Teeth:
 The presence of teeth enhances the prognosis to assist in retention,
support, and stability of the prosthesis.

4- Weight:
 The weight of the obturator should be minimal to decrease the stresses on
the remaining teeth and supporting tissues.
 Hollowing of the obturator bulb (whether the obturator has open top, or
closed top) will decrease the weight by 7-33% depending on the size of the
defect.

I- Obturators for completely edentulous patients:

Maxillary obturator prosthesis for edentulous patients with a total

maxillectomy defect will exhibit varying degrees of movement depending on:
a. The amount and contour of the remaining hard palate.
a. The size, contour and the lining mucosa of the defect and

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b. The availability of undercuts and the areas that can be engaged

within the defect.
In edentulous patients with a total maxillectomy defect, the axis of
rotation is located along the medial palatal margin of the defect. The portion of
the obturator most distant from this axis will exhibit the greatest degree of
rotation (Fig 12).
In such situation retention of complete dentures is impossible due to:
a. Air leakage.
b. Poor stability and support
c. Reduced bearing surface
These factors lead to ill compromised adhesion, cohesion, and peripheral seal.

Therefore, to improve the prognosis the following should be considered:

1- The surgical defect should be well-healed prior to the fabrication of the
definitive obturator prosthesis.
2- The resection margin on the hard palate should be covered with keratinized
mucosa because it is the main fulcrum around which the prosthesis rotates.
3- Any part of the soft palate even if paralyzed should be left to avoid
increasing the size of the defect (even if this compromise the velo-
pharyngeal seal).

Retention, stability and support:

In most cases acceptable retention, stability and support can be gained
from the residual palatal structures by engaging the defect appropriately. The
surgical defect should be well healed before fabrication of the definitive
obturator.

1.Remaining palatal structures:

The arch form, the amount of palatal shelf remaining and the character
of the residual alveolar ridge and depth of the sulci can influence the stability
and support of the prosthesis.

2. Acceptable retention can be gained by:

1. Engaging key areas within the defect: Engagement of the skin graft
and the scar band formed at the skin graft-mucosal junction will

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improve retention. The scar band is flexible and permits the prosthesis
to be inserted; yet it tends to resist dislodging forces.
2. Appropriate obturator-tissue contact superio-laterally.
3. Extending the prosthesis along the nasal surface of the soft palate.
4. Flexible materials are sometimes used.

3. Engagement of key portions of the defect can improve support and stability.
 Lateral, anterior, and posterior undercuts can be engaged.
 Medial undercuts generally not practical because:
a. These undercuts are very deep.
b. They are lined with respiratory mucosa which is sensitive and
intolerant to stresses.

 Stability is enhanced by:

Engaging the superio-lateral portion of the defect and sometimes the
medial margin (When lined with keratinized epithelium).
 Support can be obtained from:
The oral side of the skin graft-mucosal junction and from the oral
surface of the soft palate.
Construction of definitive obturator

1. Primary impression:
 Block the undesirable undercuts using a gauze lubricated with petroleum
jelly and adhesive is applied to the tray.
 Impression is taken using irreversible hydrocolloid material in a
modified metal tray.
 Impression is poured to obtain the diagnostic cast.

2. Master impression
 The undesirable undercuts recorded in the 1ry cast is blocked out with
wax.
 Special acrylic tray is fabricated.
 Mouth preparation is performed (in case of dentulous patient).
 Border molding is made using modeling plastic.
 Impression is taken using elastic impression material.

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 If the patient exhibit extreme trismus the surgical obturator cot uld be used
to obtain the impression with tissue conditioning material.
 The metal framework is fabricated.

3. Jaw relation:
 Centric jaw relation is recorded by conventional check bite method but
care must be exercised to insure that the maxillary record base is not
displaced during registration.

4. Occlusal schemes:

 In edentulous patients non-anatomic and/or functional posterior teeth

are used.
5. Processing, delivery and follow up:
 Denture is processed heat cured acrylic.
 Pressure indicating paste is used to determine pressure areas.
 Disclosing wax is used to check peripheral extension.
 Home care instructions and recall appointments are arranged.
 Re-basing may be needed within 1 year of delivery.

II- Definitive obturators for partially edentulous patients

with total maxillectomy defects:

It has better prognosis with the presence of teeth which assist the retention,
support and stability.

Problems complicating RPD design:

1. Multiple axis of rotation.
2. Compromised support on the defect side.
3. Lack of cross-arch stabilization because of the loss of the palatal
structures on one side.
4. Long lever arms.
5. Forces of gravity become more significant.
6.There is greater risk of overloading the abutment teeth with inappropriate
partial denture designs. Therefore, RPD designs must anticipate and

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accommodate the movements of the prosthesis during function without

exerting pathologic stresses on the abutment teeth .
7.It has to be noted that the fulcrum lines are dynamic and once the sites of
occlusal rests are selected, the axes of rotation are dependent upon the sites of
load application.

Treatment concepts

1- Location of the defect:

Surgical resection usually includes the distal portion of the maxilla and
rarely does a distal abutment remain. The extent of the resection anteriorly
varies. Thus Kennedy class İİ partial denture with extensive lever arm is that
required.

2- Movement of the prosthesis

With the resection of the maxilla, the mucosal and bony support are
compromised. Hence the defect must be used to minimize the movement
trying to reduce the stresses on the abutment teeth.

3- Teeth
Preservation of the remaining teeth is important for retention. Partial
denture design must anticipate and accommodate the movements of the
prosthesis during function without exerting pathologic stresses on the teeth.
Maximum retention, stability and support must be obtained from engaging
the defect.

The design should fulfill the following principles:

All the bio-mechanical principles and structural details of RPD components
should be followed:
1. Diagnostic casts are surveyed to locate undercuts, guiding planes and
select the path of insertion.
2. Major connectors must be rigid and placed so that the impingement on
the soft tissues will be avoided.
3. Occlusal rests must direct the occlusal forces along the long axis of the
teeth.
4. Guiding planes are employed to enhance stability and bracing.

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5. A tooth closely adjacent to the anterior margin of the defect must have a
rest and a retainer.
6. Retention must be within the limits of physiologic tolerance of the
periodontal ligament.
7. The clasp arm should be passive when not functionally stressed and
provide only the minimal retention needed to resist displacement
8. Maximum support is gained from the adjacent soft tissues denture bearing
surfaces.
9. Complete crown restoration permits the prosthodontist to establish
improved contours for retention guiding planes and occlusal rests
10. Designs must consider the needs of cleanliness and sanitation.
11. The fulcrum line is determined by the position of the occlusal, incisal, or
cingulum rests . Since there is no cross arch reciprocation of either buccal
or lingual retention, this partial denture may be viewed as a unilateral
partial denture. For this reason both buccal and lingual retentive arms are
considered to obtain cross-tooth retention and reciprocation.

Prior to impression making, medial palatal undercut in the defect is blocked

out with vasilanized gauze . however, the lateral portion of the defect should be
recorded with the impression as these contours will be necessary to fabricate the
tray for the altered cast impression. Also , the tray is molded before making the
impression using green stick compound to facilitate the orientation of the tray.

 The master cast is made and the metal framework is fabricated.

 The obturator portion should be made from acrylic resin to allow for
adjustment and rebasing.

 Retention for the obturator portion should extend laterally into the defect and
should be located 2mm superior to the normal palatal contour.

 When the framework seats properly, the undesirable undercuts within the
defect are blocked out on the cast with wax.

 Self curing acrylic resin is molded to the framework.

 Adhesive is applied to the obturator part and altered cast impression is

performed using an elastic impression material.

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 The impression is boxed and poured in dental stone.

 Record the jaw relation, try in, processing in the usual manner then finishing
and polishing of the obturator is carried out .

 In the finished obturator, slight pressure against the cheek is desirable to

ensure maximum retention, stability and support.

Methods to Enhance Retention of Definitive Obturators

1. Clasping: For partially edentulous patients, the presence of teeth will enhance the
retention of the prosthesis. Clasp placement should be broadly
distributed throughout the remaining teeth. Clasps should be placed on
abutment teeth adjacent and distal to the defect (Fig. 20).
Cross tooth retention and reciprocation should be considered in cases with
lateral defects. Lingual retention and buccal reciprocation should be
designed for the tooth away from the defect. This clasp disengages from
the tooth during occlusal movement of the prosthesis, reducing the
rotational stresses transmitted to the posterior abutment.(Alternating
buccal and lingual retention)
2. Undercuts in the defects (in dentulous patient).
The engagement of undercuts in the defect improves the retention greatly.
Lateral, anterior, and posterior undercuts can be engaged. While medial
undercuts generally not practical because:
1- These undercuts are very deep.
2- They are lined with respiratory mucosa which is sensitive and
intolerant to stresses.
3. Engagement of the skin graft, and the scar band formed at the skin graft
mucosal junction, will improve retention significantly.
 As this scar band organizes, it contracts longitudinally in the
manner of a purse-string, thus creating an undercut superiorly
and a concavity inferiorly.
 The scar band is flexible and permits the prosthesis to be
inserted; yet it tends to resist dislodging forces.
4. Maximum extension against the lateral wall of the defect (in both dentulous
and edentulous patients). In edentulous patients with total maxillectomy

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defect the axis of rotation is located along the medial palatal margin of
the defect. The part of the obturator away from this axis (lateral portion)
will exhibit the greatest degree of motion. Accordingly, the obturator
should cover as much of the lateral wall superiorly as possible. This will
decrease the lever arm of displacing force on the teeth and provide an
extremely valuable area of resistance to vertical displacement.

5. Swing-lock attachment (In Dentulous patients) :

 It is used in definitive obturators.
 Retention is obtained through a continuous labial bar from which
multiple I-bar clasps project to engage teeth undercuts.
 It requires sufficient depth of the labial and buccal vestibule to
accommodate for the labial bar
 The assembly does not disengage through flexibility but rather through a
hinged-gate mechanism.
 Used mainly when few remaining anterior teeth are present
6. Buccal retaining flange (in dentulous patients) :
 It is mainly used in immediate or interim prosthesis.
 It is an acrylic plate that engages both teeth and tissue undercuts on the
intact side.
 Flexibility of the flange is obtained through two stainless steel wires that
pass distal to the last abutment and anterior to the most anterior
abutment.
7. Flexible acrylic resin in the defect will permit the engagement of bony
undercut more forcefully, thus, improving retention of the appliance.
8. Refitting the base: Bases adaptation must be frequently re-evaluated and
corrected by relining or rebasing to compensate for rapid tissue changes.
9. Compound path of insertion: Two piece sectional obturator with two
paths of insertion. One section is in the defect side and the other in the oral
cavity. It is indicated for edentulous patients with acquired palatal defect
involving large area of the palate. This usually presents problem in prosthesis
retention.

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CHAPTER IV ACQUIRED MAXILLARY DEFECTS

This is also valuable for patients with bulky prosthesis and small mouth
opening.
The path of insertion of the two pieces should be different to help in retention.
10. Denture adhesives and creams.
11. Osseointegrated dental Implants in the intact side :
Recently, excellent retention and stability can be provided by the
placement of osseointegrated dental implants in the residual ridge and
within the bony regions of the defect. The placement of osseointegrated
dental implants into multiple regions of bone within the defect provide
rigid, immobile base which can be used to retain the prosthesis using
suitable attachment system (magnets or clip bar attachment). The
prognosis of osseointegration for irradiated patients is less favourable
because of changes in the supporting structures. Successful
osseointegration can be achieved by the use of hyperbaric oxygen
therapy. This improves hypoxia, hypocellularity and hypovascularity in
irradiated patients.
Sites of implant placement:
1. Premaxillary segment:
 The best site for implant placement because:
i. The bone quality is better than the rest of the maxillary structures
ii. This area is relatively away from vital structures which allow for
placement of longer implants
2. Posterior maxilla and tuberosity:
 The area is not favourable for implant placement due to:
i. Poor bone quality.
ii. The area is frequently very near to the maxillary sinus which,
limit the vertical length available for implant placement.
3. Zygomatic bone:
Very difficult position for implant placement.

12. Attachments in the non-defective side:

 Resilient attachments are preferred than rigid ones to minimize the stresses
on the abutment teeth.

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CHAPTER IV ACQUIRED MAXILLARY DEFECTS

o The attachments used may be Extra-coronal resilient attachments

attached to splinted crowns (ex: Ceka, OT strategy,….etc)
o Bar and clip attachments: The design should allow for clip rotation.
o Stud attachments: used when greater degree of movement is required
o Magnetic attachments
13. Magnets in the intact side:
Magnetic retention is an effective method for retaining maxillofacial
prosthesis .Most of the prosthesis incorporating magnets are sectional
prosthesis, in which each section of the prothesis contain magnet. When
the sections are properly oriented, the magnets attract each other.
14.Reducing the weight of the obturator :
a)Hollowing the obturator bulb
This is carried out to reduce the weight of the obturator in order to
decrease the stresses on the remaining teeth and supporting tissues.
Methods of hollowing the obturator bulb:
1st technique: The lost salt technique:
1. During packing a small cellophane bag filled with sand is packed
into the bulb.
2. After processing, a hole is drilled through the bulb and the sand is
drained away.
3. The opening is then closed with self-curing acrylic resin.
2nd technique: The closed top obturators
1. During waxing up, a 4 mm of wax is adapted in the defect area to
allow for future correction without perforation of the processed
acrylic resin.
2. Then, the defect is filled with clay and a layer of tin foil, which
prevent adhesion between the wax and the clay.
3. A wax led is burnished over the tin foil.
4. The wax led is processed separately into acrylic resin.
5. The clay and tin foil are removed
6. The obturator and the led are processed separately.
7. The acrylic led is fixed to the base with self-curing acrylic resin.

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CHAPTER IV ACQUIRED MAXILLARY DEFECTS

b)The use of an open-top obturator:

1- The obturator will be less in weight.
2- Easier to adjust.
3- It allows for better airflow and resonance which leads to improved
speech. However, Nasal secretions will accumulate causing bad
odour and added weight.

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ACQUIRED
MANDIBULAR
DEFECTS

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CHAPTER V ACQUIRED MANDIBULAR DEFECTS

MANAGEMENT OF ACQUIRED MANDIBULAR DEFECTS

The most common cause of partial mandibular loss is surgical removal of a
neoplasm. The tumor may have begun within the mandible, or it may be in close or
direct apposition to the mandible. The most common intraoral sites for squamous
cell carcinoma are the lateral margin of the tongue and the floor of the mouth. Both
locations predispose the mandible to tumor invasion, often necessitating its
resection in conjunction with large portions of the tongue, the floor of the mouth,
and the regional lymphatics.
Partial mandibular loss may also be seen secondary to trauma, congenital
defect, and /or osteoradionecrosis.

Disabilities resulting from such resections may include:

 Impaired speech articulation
 Difficulty in swallowing
 Problems with mastication
 Deviation of the mandible during functional movements
 Compromised control of salivary secretions
 Severe cosmetic disfigurement.

Predisposing factors:

The exact cause of oral cancer is unknown. Variation in incidence rates among
different groups or populations can be explained by differences in exposure to
carcinogenic initiator or promoters.

1- Viruses: Many factors can cause cells to become malignant, but the role of
viruses is being increasingly examined. The phenomenon of viral
carcinogenesis is well established in experimental animal systems,
and there is little doubt that several viruses would cause cancer in
human beings if given the opportunity.

2- Dentures: Chronic irritation may be a cofactor in the formation of some oral

cancers. Some squamous
-90 - cell carcinoma appears to be an irritation
from prosthesis in addition, some intraoral malignancies are found
adjacent to ill-fitting removable prostheses, but no evidence is

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CHAPTER V ACQUIRED MANDIBULAR DEFECTS

available indicating a direct relationship between oral cancer and

oral prosthesis.

3- Alcohol: The risk of developing oral cancer is increased significantly in

alcoholics.

4- Tobacco: Heavy smoking also potentiates the risk of oral carcinoma. The
association between tobacco products and oral malignancies include
use of cigar, pipes, and chewing tobacco as well as cigarettes.

5- Leukoplakia: is defined as any white patch on the oral mucous membrane that
cannot be scraped off. It is asymptomatic and discovered during a
routine dental examination. Various forms of tobacco usage may be
a predisposing factor. Leukoplakia may undergo malignant changes.

6- Oral lichen planus: Is a disease of unknown etiology that affects skin and oral
mucous membrane, it appear reticular, plaque and erosive or
combination. Lichen planus is considered a benign keratotic lesion
without malignant potential, a, small number of cases are associated
with carcinomas. Periodic follow up is indicated.

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CHAPTER V ACQUIRED MANDIBULAR DEFECTS

Classification of Mandibular Defects

First Classification
(Cantor and Curtis classification)

Cantor and Curtis classified mandibular defects into six different categories based
on extent of the defect and the method of restoration in edentulous patients.
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.

Second Classification

Second classification categorized partial mandibular defects into two main groups:
I- Marginal resection and
II- Segmental resection.

I- Marginal resection (Continuity defects)

 Is a simple marginal resection, in which mandibular continuity is retain as it

involves a superior resection of the alveolar or basal bone with the overlying
soft tissues, leaving the inferior border intact.
 The muscles of mastication are usually intact, so the mandibular movement is
not disrupted and the resulting disabilities are less severe.

Problems associated with alveolar resection:

 Loss of vertical ridge height and vestibular depth will cause a reduction in
stability for tissue supported prosthesis.
 Loss of load bearing tissues available for support.
 Tethered border tissues may be present, which limit the prosthesis border
extension for maximum retention, support and stability.

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II- Segmental resection ( Discontinuity defects)

 It involves complete resection of a segment of the mandible from the alveolar

crest to the inferior border of the mandible , thus discontinuity results and the
function of the remaining mandibular segment is severely compromised.
 The deviation of the mandible occurs secondary to compromised
proprioception and muscle imbalances and is easily resolved with mandibular
guidance therapy.
 The mandible is deviated towards the resected side and the mandibular
occlusal plane is rotated inferiorly.

Functional results of deviation and rotation of the mandible:

 Facial disfigurement.
 Loss of occlusal contact between maxillary and mandibular teeth.
 Loss of ability for lip approximation for proper salivary control.

Management of mandibular deviation:

1. Intermaxillary fixation:
 An approach used in the past to reduce the deviation associated with
resection of the mandible, but is currently not in favor.
 It was to place the patient into inter-maxillary fixation immediately,
using arch bars and elastics.
 Intermaxillary fixation is maintained for 5 to 7 weeks following surgery.

2. Physio-therapy:
 Initially, the patient should be placed on an exercise program.
 Following maximum opening, the mandible is manipulated by grasping
the chin and moving the mandible away from the surgical side. These
movements tend to loosen scar contracture, reduce trismus, and improve
maxillomandibular relationships.

3. Mandibular guidance prosthesis:

 The earlier mandibular guidance therapy is initiated, the more successful
the result:

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CHAPTER V ACQUIRED MANDIBULAR DEFECTS

 If the patient has undergone an extensive resection, or a considerable

period of time has elapsed since the surgical procedure, guidance
procedures are much more difficult, and a compromised occlusal
relationship may result and the patient may never be able to achieve
normal maxillomandibular relationships.
 Presence of teeth is an important requirement for construction of
guidance prosthesis i.e. if teeth are not present, guidance is not effective.
The excessive lateral forces generated during guidance of the mandible
will serve to dislodge complete dentures.
 All guidance prostheses are utilized on an interim basis until acceptable
occlusal relationships and proper proprioception are re-established..
 The patient should be informed that, as mandibular deviation is reduced,
the facial disfigurement on the defect side will be accentuated, for the
deviation of the mandible towards the surgical side will tend to
camouflage the defect.

Types:
A. Lower mandibular guidance prosthesis (Buccal training flange).
B. Upper mandibular guidance prosthesis (Palatal ramp).

A- Buccal training flange:

Indication:
When the mandible can be manipulated into an acceptable
maxillomandibular relationship but the patient lacks the motor control to
bring the mandible into occlusion.
Structure
 This mandibular guidance prosthesis consists of a removable partial denture
framework, with a metal flange extending 7 to 10 mm laterally and
superiorly on the buccal aspect of the bicuspids, and molars on the non-
defect side.
 This flange engages the maxillary teeth during mandibular closure, thereby
directing the mandible into an appropriate intercuspal position.

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 The guidance flange may be constructed of cast chrome cobalt metal or

acrylic resin (reinforced with a metallic mesh). The material of choice will
depend upon the existing occlusal relationship of the patient and the need for
adjustability:
1. If the mandible can be manipulated comfortably into an acceptable
occlusal position, then a cast metal guidance ramp will be
appropriate.
2. If some resistance is encountered in positioning the mandible, then a
guidance ramp of acrylic resin is suggested, as this material can be
periodically adjusted as an improved relationship is obtained.
 In most instances, it is necessary to construct a maxillary framework with a
buccal plate incorporated within the design.
Advantages:
i. Protect maxillary teeth and gingiva from trauma that can be caused by
the buccal flange.
ii. To resist the forces of arch contracture and maintain the maxillary teeth
on the defect side in proper alignment until an appropriate intercuspal
position is achieved.
B. Palatal ramp:

Indication:

 This form of guidance is indicated in most patients with mandibular deviation.

 Maxillary guidance ramps are more adjustable than mandibular guidance
ramps, and are preferred for the patient with severe mandibular deviation.

Design:
1. It is a maxillary prosthesis usually constructed of acrylic resin with either
cast- or wrought-wire retainers, since they serve only on an interim basis
until an acceptable occlusion can be established.
2. The full palatal coverage prosthesis is constructed, following conventional
prosthodontic guidelines, and then fitted and adjusted in the mouth.
3. The mandible is manipulated laterally toward the desired position, and the
occlusal contact with the palatal prosthesis is established in a prepared
acrylic resin index in the palate.

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CHAPTER V ACQUIRED MANDIBULAR DEFECTS

4. This index is usually lingual to the maxillary teeth and the patient should be
able to close into the index, using appropriate manual manipulation of the
mandible.
5. The index should not extend below the level of the maxillary teeth because, if
it does, it may interfere with speech, deglutition.

Prosthetic rehabilitation of mandiblectomy patient

A- Marginal resection:

1-Surgical considerations
Soft tissues are used to reconstruct marginal mandibulectomies.
Skin graft, local flap, pedicle flap, or microvascular free flap can be used for
reconstruction of continuity defects.

2-Prosthetic considerations

1. Anterior continuity defects:

 These are patients with anterior inner table resections and patients with
anterior resections in whom mandibular continuity has been re-established
with reconstructive surgery.
 Problems:
i. These patients have posterior teeth and an extensive edentulous area
anteriorly, creating the need for a Kennedy Class IV partial denture.
ii. The anterior edentulous segment will usually display unusual soft
tissue configurations and compromised bony support for both types of
patients.
iii. In large defects, the lack of attached mucosa and the obliteration of
vestibules may require a vestibuloplasty and skin graft.

Prosthetic option:

a- Conventional removable partial dentures

 It will enhance aesthetics, provide support for the lower lip and
cheek, frequently lead to improved articulation of speech, and
enhance the control of saliva.

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CHAPTER V ACQUIRED MANDIBULAR DEFECTS

b- Implant retained prosthesis

 Implants are either placed in the remaining bony segment (in case of
marginal resection), or in the bone graft placed to restore
discontinuity.

Implant retained prosthesis have two forms:

i. Removable overlay prosthesis

 Preferred for restoring these defects because:

a. Support for mastication is provided by the implants anteriorly and
by the residual dentition posteriorly.
b. Denture flanges can be contoured to reposition and support the
lower lip.
c. Access for oral hygiene is easier for the patient.
 2-4 implants are required to restore most defects.

ii. Implant supported prosthesis:

 If it is going to be used the following should be considered:

a. A minimum of 4 to 5 implants should be used to provide adequate support
b. The mesio-distal and bucco-lingual positions of the implants become
critical to obtain adequate esthetic.

2-Lateral continuity defects

a- Conventional removable partial denture

 Lateral defects, in which posterior dentition remains on only one side of the
arch, are particularly difficult partial dentures to design. The extremely long
lever arms and compromised edentulous bearing surfaces contribute to
excessive movement of the prosthesis during function.
 Maximum coverage of the edentulous bearing area is suggested.
 The occlusion should be refined so as to achieve contact in centric occlusion
only, and the patient should be instructed to masticate on the non-defect side
with the residual mandibular dentition.

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CHAPTER V ACQUIRED MANDIBULAR DEFECTS

b- Implant-retained prosthesis

 In these large defects, osseointegrated implants significantly improve the

retention, stability, and support for removable partial dentures.
 If the bone volume permits, and the anterior mandible is edentulous, 2 or more
implants should be placed in this region.

Advantages:
1) The primary benefit is support. The patient can incise much more
effectively with the prosthesis.
2) Improve retention and stability of the prosthesis
3) The purpose of the portion of the prosthesis that extends into the defect
is to support the lip and cheek
4) Prevent hyper-eruption of opposing dentition

B-Segmental resection
1-Surgical consideration.
2-Prosthetic consideration.

1-Surgical consideration
All mandibular defects are reconstructed with bone. When the posterior
lateral defects are present, soft tissue microvascular free flap can be used.

2-Prosthetic consideration:

1-Definitive prosthesis for Lateral discontinuity defect:

a- Prosthodontic Rehabilitation of dentulous Patients

Partial denture design:

The usual principles of partial denture design and fabrication apply to
lateral discontinuity defects:
1. Major connectors should be rigid.
2. Occlusal rests must direct occlusal forces along the long axis of teeth.
3. Guiding planes should be employed to enhance stability and bracing.
4. Retention must be within the limits of physiological tolerance of the
periodontal ligament.

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CHAPTER V ACQUIRED MANDIBULAR DEFECTS

5. Maximum support should be gained from the adjacent soft tissues.

6. Retainers, minor connectors, and proximal plates should be designed so
that they do not express excessive lateral forces on the remaining teeth
during function.
7. Due to mandibular deviation and frontal plane rotation, the location of
the fulcrum line is not as easily determined, making it more difficult to
predict movement patterns of the prosthesis during function.

b. Prosthodontic Rehabilitation of Edentulous Patients

1- Conventional complete denture.
2- Implant retained and supported overlay dentures.

1- Conventional complete denture

 Complete dentures for these patients are primarily for esthetics. They improve lip
and cheek contour and replace missing teeth. In selected patients, these
prostheses improve the articulation of particular speech sounds.
 Only with implant retained and supported overlay dentures does the patient have
the hope of efficient mastication.

Factors determining the prosthetic prognosis for conventional

complete dentures:
1- The extent of the bony and soft tissue resection.
2- The status of the remaining tongue.( If the motor and/or sensory control of
the tongue has been significantly compromised by the resection, the
prosthetic prognosis becomes extremely guarded).
3- Mandibular deviation and the character of mandibular movements.
4- Radiation therapy.

2- Implant Retained and Supported Overlay Dentures

 Osseointegrated implants enable the fabrication of well-retained and

stable overlay prostheses.

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CHAPTER V ACQUIRED MANDIBULAR DEFECTS

 The support derived from the residual denture bearing surfaces, and the
retention and stability provided by the implants, is more than sufficient
to allow effective mastication.
 In mandibular resection patients, if implants are to be placed into the
mandible to retain and support an overlay prosthesis, consideration
should be given to placing implants in the opposing maxilla as
theunilateral occlusal loads, and the increased lateral forces generated
during the chewing cycle, tend to dislodge the upper denture.

 Xerostomia secondary to radiotherapy may further compromise

peripheral seal.
 If Two implants are placed in the cuspid positions, They will provide the
necessary retention and stability and it is better to be splinted with Hader
Bar.

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TRISMUS

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CHAPTER VIII Trismus

TRISMUS
(Limited mandibular movement)
Trismus is defined as: A reduced mobility resulting from tonic contraction of the
muscles of mastication.

The effects of limited mouth opening include:

Trismus which limits mandibular movement and restricts opening of the mouth
might lead to
a- Compromised oral hygiene.
b- More difficulty in chewing and/or swallowing.
c- Limits access for dental treatment.
d- Increased risk of aspiration.
e- Impaired speech.
f- Increased risk of osteoradionecrosis (death of bone).
Unless the jaw is exercised, mouth opening can become more limited. Pain,
inflammation, and degenerative joint changes are secondary effects of trismus.
Early intervention is essential to minimize the effects of trismus and a thorough
evaluation is crucial to any treatment plan.

Etiology of Trismus:
I- Acute factors.
II- Chronic factors.
III- Treatment related factors.

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CHAPTER VIII Trismus

I- Acute factors:
1- Local trauma:
- Can occur during an inferior alveolar block injection which can
result in muscle inflammation that limits movement and causes
pain.
- Trauma due to accident.
- Post surgical effect (nerve damage, muscle damage or scaring).
2- Drug toxicity:
- Neuroleptic agents.
- Halothane.
3- Infection of the pterygomandibular space or the lateral pharyngeal space can
limit mandibular movement (e.g. pericoronitis).
- Post surgical infection.

II-Chronic factors:
1- Temporomandibular joint dysfunction is the most common chronic cause
of trismus (Poor joint architecture. Malposition of the disk and muscle
splinting can restrict motion.)
2- Rheumatoid arthritis can also be a cause of TMJ pain and restrict
mandibular movement.
3- Pathological processes as osteoma of the mandibular condyle or the
zygoma, cysts, and overgrowth of the condyle or coronoid process of the
mandible.
4- Intracapsular (True) or extracapsular (False) ankylosis of the TMJ can
restrict mandibular motion.
5- Scleroderma.
6- Systemic diseases: Meningitis, Epilepsy or brain tumour (CNS disorders).
7- Congenital and developmental disorders:
- Coronoid condyle hyperplasia
- Abnormal elongation of the coronoid process.

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III-Treatment related factors:

1- Radiation therapy may limit mandibular movement if the muscle of

mastication or TMJ is included in the treatment fields. It is most
noticeable following nasopharyngeal, palatal and nasal sinus tumours.
2- Chemotherapy increases the severity of the condition.
3- Surgical resection of the maxilla and mandible cause Trismus: After
orthographic surgery, limited movement may be due to muscular
atrophy as a result of fixation.

Evaluation of Trismus:
Evaluation includes
- A thorough case history.
- A comprehensive oral mechanism examination.
- A clinical evaluation of swallowing, and a careful assessment of pain.
Results of the evaluation are reviewed with the patient and treatment objectives
are discussed.

Treatment of Trismus:
Trismus occurs with unknown frequency and severity. A maximum
mandibular opening may be reduced to 10 to 15 mm, impairing mastication
and preventing convenient oral access of a bolus of food.
So the treatment modalities fortrismus or limited mandibular movement
include:
1- Medical treatment.
2- Surgical treatment.
3- Physical treatment:
a- Exercise.
b- Mechanical device.
Each mode may be used alone or in combination with other modes of
treatment.

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CHAPTER VIII Trismus

1- Medical treatment:
- Antibiotics: When infection is the cause of trismus, antibiotics are the
treatment of choice.
- Anti-inflammatory: Arthritis inflammation of the joint can be treated
with anti-inflammatory agents which relief pain and result
in some improvement in motion.
- Muscle relaxants: may help in acute cases of limited mandibular
movement.

2- Surgical treatment:
- Surgery is the treatment of choice for removal of tumours, cysts or
foreign bodies.
- Surgery may also be indicated in TMJ ankylosis and scleroderma
after more conservative therapy has failed.

3- Physical treatment:
Objectives of physical treatment include:
1. Stretching connective tissue.
2. Strengthening muscles that have weakened.
3. Mobilizing the joint.
4. Reducing pain and inflammation.

Several methods have been utilized to counteract trismus and increase

inter-arch space including:
1- Exercises.
2- The use of mechanical devices.
3- Hot application aids to improve circulation.

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CHAPTER VIII Trismus

I-Exercise:
Indications: Exercise is helpful:
1- During Radiation therapy.
2- Following orthographic surgery and
3- For scleroderma patients.
Techniques: These include
a. Opening the mouth as wide as possible 20 times at least
three to four times per day.
b. 8 to 10 actively assisted Protrusive and lateral excursions
should be done to exercise the pterygoid muscles.
c. Improve circulation by heat application.
d. For scleroderma patients, manually assisted exercise can
also be used.
e. Chewing gum has little or No therapeutic effect on
trismus because it exercises primarily the closing muscle
instead of stretching the fibrotic tissues that hold the
mandible closed.

II- Trismus device (appliance):

An auxiliary prosthesis that assists the patient in increasing the
oral aperture width to eat and maintain oral hygiene.

Indications for using Trismus devices:

1. Adhesions and Ankylosis.
2. Arthroplasty and Arthroscopy.
3. Arthritis.
4. Disuse Atrophy.
5. Facial Muscle Disorders.
6. Radiation Therapy.
7. Reconstructive Surgery or Joint replacement.
8. Temporomandibular joint dysfunction Syndrome (TMD).
9. Trauma and Condylar Fracture.
10. Trismus.
11. Stroke.

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Types of Mechanical devices:

Mechanical devices can be used to increase mouth opening on a slow,
incremental basis these include:

A- Simple devices:

Traditional Treatments
The simple device allows patient to control timing and degree of pressure
required to gradually increased jaw separation, but produce a unilateral force.
1. Manual pressure (mobilization) can have some positive effect on
mouth opening; however, passive motion has been demonstrated to be
more effective .
2. A wooden clothespin can also be inserted between the arches while the
patient applies gradual pressure.
3. A tapered threaded acrylic screw (corkscrew) placed and turned
between the teeth, the patient does this several times a day to apply a
force to exercise a patient’s mouth opening .
4. Tongue depressors (Blades)
- Can be lubricated with petroleum jelly or glycerine and placed
between the arches for 1 minute to increase opening.
- Additional depressors can be added one at a time to increase
opening.
Applying the bilateral technique to overcome the force that exerting
unilaterally by using corkscrew or wooden tongue depressors without and with
stents .
B- Dynamic bite opener (Trismus stent, temporomandibular joint
exercise):
These produce bilateral force the prognosis for this type of prosthesis is
enhanced when teeth are present.

Old devices
a- The dynamic opening device: Consists of a steel frame-work attached to
maxillary and mandibular stents .
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CHAPTER VIII Trismus

b-The inflatable bite opener: Consists of maxillary and mandibular stents.

An inflatable pediatric blood pressure is consisting of bag,
rubber bulb and tubing (Fig. 7).
b- An intraoral prosthesis with interarch spring :
It can be used for edentulous and edentulous patients.
Recent devices
New exerciser devices were introduced to help mandibular mobility and
improve restriction in the temporomandibular joint. These devices are available
in different forms either:
a. Springs .
b. Devices work by a pump action .
c. Mechanical stretching devices .
d. The most recent one is the Computer-controlled continuous passive
motion device .

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RADIOTHERAPY
&
CHEMOTHERAPY

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CHAPTER VII RADIOTHERAPY PROSTHESIS

DENTAL CONSIDERATIONS IN CHEMOTHERAPY AND

IRRADIATION TREATED PATIENT

Different treatment modalities used in treatment of head
and neck cancer:
\\

a. Surgery
b. Radiation
c. Chemotherapy
d. Combination of any of the above mentioned

Surgery and radiation remain the primary modes of treatment for most tumors.
Surgical resection of a tumor has the advantage of physically removing the
bulk of malignant tissue. Surgical excision alone or in conjunction with other
forms of therapy can be done.

Radiation has the advantage of localizing morbidity to the specific area of the body.
Both modalities have adverse effects on normal tissue, such as cellular changes
and reduced vascularity, but morbidity is usually limited to the tumor area.

Chemotherapy treatments are unable to match the success of surgery and/or radiation.
These agents are being used for reducing the severity of the disease in some
cases, with a curative purpose in other cases.

Radiation and chemotherapy may be administered independently or in combination

depending of the pathology, location and severity of the lesions. Bone marrow
transplantation is a procedure that effectively utilizes multiple chemotherapeutic
agents in combination with total body irradiation.

Chemotherapy causes direct cytotoxic effect that is felt to be etiologic in mucositis,

leukopenia and lowering patientimmunity to infection and many complications.
Oral complication occur in nearly half of the patients receiving chemotherapy
for non head and neck lesions and most patients with oral complication for
head and neck malignancies.

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CHAPTER VII RADIOTHERAPY PROSTHESIS

I- Side effects and Oral manifestations of Chemotherapy

to the head and neck and how to manage them:
Chemotherapeutic manifestations include: mucositis, Xerostomia, bleeding and
infection.
Oral Mucositis
Mucosal surface become sore and sticky with generalized ulceration, sloughing,
thinning and atrophy of oral epithelium without compensatory renewal results
in thinning and erythyma of oral mucosa, also discoloration can be detected.
The signs increase with greatly diminished capacity for oral hygiene. The
surface collects debris, invites microbial invasion and prolongs healing.

Xerostomia
Dry mouth is thought to be caused by the effects of chemotherapy on major and minor
salivary glands. Xerostomia increases the pain and discomfort associated with
oral mucositis. Decreased salivary flow results in diminished protective
constituents, limited natural cleansing and alterations of the oral environment
which render the patient at increased risk of secondary infections, periodontal
disease and root caries ,difficulty swallowing and loss of ability to taste food
and difficulty wearing denture with lack of retention and tissue injury .

Oral Hemorrhage
The frequency and severity of hemorrhage is directly related to the degree of
thrombocytopenia. Spontaneous intraoral bleeding is most common from the
gingival crevice. The sulcular epithelium may also be more susceptible to
chemotherapy induced ulceration than the oral epithelium because the former is
thinner and has a slightly higher mitotic rate.
Infection
Infection is the most serious complication in chemotherapy patients with bone marrow
suppression. Lower immunity is a result of leukopenia inhibiting antibody
responses and compromising delayed hypersensitivity. There are many sources
of microorganisms for infections. These microorganisms often have resistance
to many antibiotics and can be extremely difficult to manage, including
bacterial infection, viral infection and fungal infection .

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Prevention and treatment prior to chemotherapy

a- Dental treatment such as prophylaxis, dental restorations, root canal therapy,
surgical or extraction may be indicated.
b- Prosthetic appliances should be thoroughly examined for proper fit, function
and smoothness. Inadequacies and defects in prostheses that the patient has
previously adapted to may become the source of problems during
chemotherapy.
c- Complete and/or partial dentures should be adjusted, relined if indicated, or
new dentures should be fabricated. Improperly constructed dentures should

II-Radiation therapy
A tumor can be destroyed by radiation if the dose is sufficient and is
within the tolerance level of the adjacent normal tissues. Post radiation
complications are significant and may result in total morbidity.
An understanding of the possible forms of damage in and about the
field of radiation is a necessity for achieving satisfactory prosthetic results in
the management of the irradiated patient.

Types of Radiation: Radiation therapy may be applied through:

I. Clinical radiation generators (external beam radiation)

A- Orthovoltage therapy or deep therapy The term Orthovoltage therapy or
deep therapy is used to describe treatment with x-rays
B- Supervoltage therapy X-ray therapy has been designated as high-voltage
therapy or Supervoltage therapy.
Subsequent development of higher energy machines as cobalt-60 and
megavoltage units.
C- Megavoltage therapy MeV.and clinical megavoltage machines are accelerators
such as linear accelerator, and microtone and teletherapy units such as cobalt-60.

II. Brachytherapy
Interstitial therapy (implants): The radioactive sources are fabricated in the
form of needles, wires or small seeds, which can be inserted directly into the
tissues. There are basically two types of interstitial implants temporary and
permanent.

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Factors affecting the rate of damage

1. The larger the dose the greater is the incidence of post-radiation complications.
2. The mode of delivery of radiation: radiation delivered by an external source
may cross normal adjacent structures before reaching the tumor, thus affecting
these structures. On the other hand, if the radiation source is implanted, the
radiation is more confined to the area. In general high-energy beams (Co60,
MeV) are less detrimental to bone than low energy beams (Orthovoltage).
3. The rate of delivery: radiation infraction (fractionation scheme) is most
effective as it ensures that radiation affects most tumor cells at the most
radiosensitive phases of their cycle. Recovery from effects does occur, when
the rate of delivery of dose is slow enough, recovery may occur at a rate equal
to the damage.
4. The field of treatment: the greater the mass of irradiated tissue, the greater
the possibility of tissue damage.
5. Tissue varies in their radiosensitivity. As a rule the effects of radiation are
most readily seen in tissues which are constantly replicating their cells as
embryonic tissue, intestinal mucosa, and skin. The changes that occur are
atrophy, fibrosis and neoplastic transformation.
6. Radical neck dissection prior radiation reduces blood supply and increases the
risk of breakdown.

EFFECTS OF RADIATION ON THE CELL

The primary effects of radiation occur within the nucleus since it is 100 to
1000 times more sensitive to radiation than the cytoplasm.
General tissue effects can be divided into two categories
a- Somatic changes (Damage) -: (affect the individual who has been irradiated).
Damage to non-reproductive cells
 Can lead to cancer at high radiation levels
 Can seriously alter the characteristics of specific organisms
b- Genetic changes (Damage): (affect the offspring, perhaps after several
generations): Damage to genes in reproductive cells can lead to defective
offspring.

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Effects of radiation on oral and paraoral tissues:

Effects of radiation include immediate effects, which occur early in the
course of treatment or delayed effects, which occur later in the course of treatment
or weeks, months or even years after the end of therapy.

A. Immediate effects

1. Oral mucous membrane:

Damage of the oral mucous membrane appears early in the course of treatment.
Buccal mucosa shows initial erythema due to:
a. Thinning of the oral epithelium,
b. Reduced keratinization,
c. Vascular dilatation and
d. Inflammation of the submucosa.
Erythema leads to:
a. Ulceration and desquamation, resulting in radiation mucositis. It
appears 2 to 3 weeks after the start of therapy and reaches its peak
towards the end of therapy.
b. Acute oral candidiasis is a common complication of radiation
mucositis.
White patches appear on the lips, cheeks and tongue and overgrowth
of candida albicans is a common complication, which may be due to
the imbalance in oral flora
c. Reduced salivary outflow and sloughing of the mucosa. Healing is
usually rapid and is within 2 to 3 weeks after completion of therapy.
Immediate effects on skin are mainly erythema; redness and swelling that resemble
thermal burns.

2. Tongue and lips:

The sides of the tongue show evidence of severe irritation and become sensitive
to spicy, very cold or hot food. Ulceration of the lips and corners of the mouth
occur (Angular chelities).

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3. Eyes:

Eyes if left unshielded become irritated and persistent conjunctivitis occurs

with copious and continuous tears. Permanent depilation of the eyebrows and
eyelashes will be the result.

4. Salivary gland:
Changes in volume (decrease) and increase the viscosity are firstly manifest
following radiation of major salivary glands.

B. Delayed effects

1- Salivary glands

Changes include:

1. Reduced salivary output (80%) (Xerostomia (dry mouth).

2. Reduced pH (3.5) (PH more acidic),
3. Increased viscosity that is accompanied by difficulty in swallowing, taste
impairment and loss of appetite.
4. Changes in the organic and inorganic constituents predispose the patient to
caries, periodontal disease and serious bony infection.
5. Since, saliva acts as an effective lubricant, the reduced salivary outflow and
increased viscosity may affect the prosthetic management. The patient cannot
tolerate their prosthesis due to more friction during function. Retention is
compromised, as the peripheral seal may be difficult to obtain

Management:
1. Mouth rinses based on carboxymethyl cellulose; glycerin and mucin have
been advised. Also simple mouth rinses can be prepared by adding 50%
Hydrogen peroxide (10 volumes) plus 50% glycerin with natural flavoring
agent to improve the taste have a beneficial effect.
2. Pilocarpine has been shown to stimulate salivary secretions.
3. Chewing sugarless gum.
2. Eyes: Effects include damage to eye lens and development of cataract.

3. Teeth and periodontium:

 Decalcification of teeth due to radiation may occur.

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 Reduced vascularity of pulp tissue leads to fibrosis and atrophy.

 Fibers of the periodontal ligaments are disoriented, thickened, with
decreased vascularity and are more prone to infection, which may be
associated with bone resorption and eventual loss of teeth.
 Radiation caries
- Common occurrence, which usually starts 3-6 months after therapy
- They occur whether the teeth are in the field of radiation or not as long as
the salivary glands are in the field of radiation (Frank et al 1965)
Two patterns detected:
a. Cervical decay
b. Heavy brown – black discoloration
Management of radiation caries:
a. Good oral hygiene
b. Topical fluoride application
c. Re-mineralizing solutions
d. Periodic check up
e. Filling of cavities and root canal treatment for carious lesions
with pulp exposure

4. Tongue and mucosa:

Taste buds show signs of degeneration, atrophy and the patient
experiences partial or complete loss of taste that is accentuated by reduced
salivary outflow. Recovery is common and salivary flow plays a significant
role in regaining taste.
Severe mucositis is most common and severity varies in different parts
of oral mucosa. It is more severe in the soft palate followed by the floor of the
mouth, buccal mucosa, and base and dorsum of the tongue.
5. Diet:
As a result of reduced salivary output, mucositis, and pain during
swallowing and loss of taste, the patient experiences loss of appetite,
nausea and malaise.

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6. Skin:
Changes may go on from erythema to ulceration and necrosis. The
epithelium becomes thin atrophic and superficial blood vessels become
telangiectatic or occluded. Progress may include atrophy, pigmentation
and even epithelioma.

7. Bone:
Bone absorbs radiation 1.8 times than does a comparable volume of
soft tissue. The more the density the more is the absorption of radiation.
This explains why the mandible absorbs more radiation than the
maxilla. More absorption of radiation coupled with reduced blood
supply in the mandible than the maxilla makes it more susceptible to
osteoradionecrosis. It becomes virtually non-vital with poor response to
trauma and infection. Changes within the bone include:
 Disorganization and decease in the number of bony cells.
 Sclerosis of the blood vessels.
 Marked acellularity, avascularity and fatty degeneration of the
bone marrow.
Hyperbaric Oxygen
-It stimulates neovasular proliferation in marginally necrotic tissues.
- Enhances the bactericidal activity of white blood cells.
-Increase the production of bone matrix.
8. Trismus:
Radiation in the temporomandibular joint area and muscles of
mastication may lead to fibrosis 3 to 6 months after the completion of
therapy leading to trismus (limited mandibular movement). It may be
reduced to 10 to 15mm impairing mastication and preventing food
intake. Treatment includes exercising and the use of dynamic bite
opener.

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RADIOTHERAPY PROSTHESIS

IMPORTANCE

 It reduces the side effects of the treatment.

 It protects tissues that are not meant to receive radiation.
 It is safer for the radiotherapist to treat this patient.
 It increases the accuracy of radiation source and assures that the area of
treatment is the same every time the patient is irradiated.
 It results in a more cooperative patient since discomfort and injuries are
reduced.

REQUIREMENTS

1. Comfort
The patient should be able to wear his prosthesis comfortably while
receiving radiation. All surfaces must be smooth; a tissue conditioning material,
which is soft, may be used to line the prosthesis in contact with sensitive areas.

2. Minimal weight
The lighter the prosthesis, the better it will be tolerated by the patient.

3. Retention and Stability

For the edentulous patient it resembles occlusion blocks, retention may be
obtained as for complete dentures or by pressure of arches against the prosthesis.
For dentulous patients teeth may be used for retention or by occluding against
the prosthesis.
Stability is important as any movement during treatment may result in
displacement of the radiation source

4. Accuracy
It must be accurate and most adjustments must be done in the dental
laboratory or in clinic. Only minor adjustments should be made in radiotherapy
treatment room. If too many changes are needed it is better to construct a new
prosthesis.

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5. Suitable strength
The material used should be of suitable strength that resists breakage;
acrylic resin is suitable material.

6. Easy to repair and clean

Self-curing resin may be used for repair. All surfaces should be smooth
that no debris could be attached to the prosthesis. A soft brush, soap, and water
are sufficient to clean the prosthesis.

7. Allows the patient to breathe easily

Perforations may be performed through the prosthesis to allow the passage
of air.

8. Allows visualization of tissues

Clear acrylic resin is the material of choice because it enables the
radiotherapist to see tissues in contact with the prosthesis. It also makes it easier
for the prosthodontist to observe any blanching of the tissues due to excess
pressure.
9. Easy to place and remove by the patient

Types of Radiotherapy Prosthesis

1. Fluoride tray (Fluoride stent)
2. Positioning stents or prosthesis to displace the tissues
3. Peroral cone positioning devices or beam locator or beam director:
4. Positioning radioactive sources or carrier or applicator
5. Shielding or tongue protectors.
1. Fluoride tray (Fluoride stent)
Radiation induced xerostomia increases the incidence of radiation
caries. Topical application of fluorides is begun immediately, which
dramatically reduces the incidence of caries.
Backscattered radiation from metallic dental restorations in the mouth
is a great problem during radiation.

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This creates a more severe, localized mucositis in adjacent tissues.

Wearing patients' fluoride tray during therapy can easily prevent this. These
simple stents create enough space between the mucosa and metallic restorations
to minimize localized mucositis.

2. Positioning stents or prosthesis to displace the tissues

This type of stent may be used to place the diseased tissue within the
radiation field and normal tissues away from the radiation field.
These stents are useful for tongue and floor of mouth lesions treated
with external radiation. They serve to direct the tongue or floor of the mouth
towards the radiation field and concentrate the tissues in a single location.
If the tongue is not depressed by the stent, the radiation field extends
from the inferior border of the mandible to the hard palate. Lowering the
radiation field spares significant amount of the parotid gland from radiation,
therefore, leading to higher salivary output after therapy.
It consists of an interocclusal stent that extends lingually with a flat
acrylic resin to depress the tongue within the lower border of the mandible. A
hole is made anteriorly in which the tongue is placed to establish a reproducible
position.

3. Peroral cone positioning devices or beam locator or beam

director:

It is a prosthesis used to direct and reduplicate the path of radiation to an

oral tumor during a split course of radiation. It is used in the treatment of smaller
superficial lesions in accessible regions of the oral cavity such as the anterior
floor of mouth, hard palate, soft palate or tongue.
This stent is used to orient the peroral cone in a repeatable position
during therapy. Maxillary and mandibular casts are obtained and mounted at an
open vertical dimension of occlusion. The lesion should be visible in the cast, so
as to facilitate positioning of the cone in the laboratory. An acrylic-resin tube is
fashioned that will accept the peroral cone. This tube should be at least six cm in
length to ensure the stability of the cone.
The tube is then positioned over the tumor site and attached to acrylic
resin record bases (for edentulous patients) or to occlusal indices (for dentate

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patients) with self-curing resin. The prosthodontist and radiation therapist verify
the position of the peroral cone at the patients next visit. If the tongue is
protruding into the end of the cone, then a beveled cone may be needed to
displace the tongue away from the tumor site.

4. Positioning radioactive sources or carrier or applicator

A device used to administer pre-calculated dose of radiation to confined

areas. Its function is to hold the radiation source securely in the same location
during the entire period of treatment. Generally, the stent or radiation carrier is
used to position the radioactive source (cesium 132 or iridium 192) near the
tumor site. Radiopaque shields and/or tissue positioners (stabilizers) can also be
incorporated into the radiation carrier to spare surrounding tissues from
unnecessary radiation exposure.
The techniques for fabricating radiation carriers vary depending on the
anatomical site being treated. Generally, an impression of the tumor site is made.
A master cast is obtained from this impression. The base portion is constructed
on the cast either in self-curing acrylic resin or heat curing resin. The base
portion is tried into patient’s mouth.
The radiotherapist then determines the location of the radioactive
sources. Radioactive material may be embedded in the fitting surface at the
required areas, at the exact distance from the lesion or through polyethelene
tubing and covered with self-curing resin. A metal wire carrying radium capsule
at one end and attached to the base at the other end can also be used and adjusted
to direct the radium material in the exact position.
Similarly a positioning dosimeter device to measure radiation may be
constructed.

5. Shielding or tongue protectors

An intraoral prosthesis designed to shield adjacent tissues from radiation
during Orthovoltage treatment of malignant lesions of head and neck regions.
Shielding is helpful for protection when a patient is to receive a
unilateral dose of radiation. The stent was designed to displace the tongue
away from the treatment area and to open the vertical dimension of occlusion.

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Cerrobend alloy has been shown to be as lead in preventing the passage

of an electron beam. Cerrobend has a low melting point. The main advantage of
cerrobend over lead is it melts at about 70C compared with 327C for lead.
Therefore, it can be easily cast into any shape. At room temperature, it is harder
than lead. The metal must be covered with wax or acrylic to prevent backscatter
radiation, which is harmful to the adjacent tissues.
Cerrobend alloy is quite effective in shielding an electron beam. It has
been reported that a 1 cm thickness of cerrobend alloy will prevent transmission
of 95% of an 18 MeV electron beam. Though limited in the number of
applications where shielding can be employed, it can significantly reduce the
complications associated with radiation therapy.

Prosthetic Evaluation and Treatment for the Irradiated

Patient

Pre-irradiation treatment:
- Some clinicians have recommended full mouth extraction prior to therapy,
whereas others prefer to extract only those teeth in the primary beam.
The risk of osteoradionecrosis is always greater in patients requiring
removal of teeth either prior to or after completion of radiation therapy.
- Any periodontally involved, decayed or questionable teeth within the field
of radiation should be removed prior to radiotherapy to avoid the risk of
osteoradionecrosis afterwards. Teeth lying within the tumor region should
not be removed since their removal may result in the dissemination of the
tumor cells. All sharp spicules and bony undercuts should be removed as
they may predispose the patient to osteoradionecrosis.

Post-irradiation treatment:
- The treatment should be conservative, strict oral hygiene rinses with H2O2
or warm saline and frequent regular examination.
- Antibiotics and analgesics are indicated only when there is gross infection
or pain. Any surgical intervention is contraindicated since surgical removal
of damaged bone is followed by massive tissue loss. Any surgical
intervention should be postponed to at least 14 months after therapy.

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- Any remaining teeth in the mouth after radiation should be treated with
topical applications of 10% stannous fluoride for 10min/daily during the
treatment and weekly for many months after.

Timing of placement of dentures:

The construction of dentures for irradiated patients should be made if 12 to
14 months had elapsed for mucosal healing. Some patients must wait 2 to 3
years before the mucosa has recovered sufficiently for dentures to be tolerated.

Prosthodontic considerations during complete denture

constructions for irradiated patients:

Follow basic prosthodontic principles with slight modifications, Success of

prosthodontic treatment depends on:
1. Pre-operative data.
2. Thorough oral examination.
3. Prosthodontic treatment (A non-traumatic and non irritating denture).
4. An effective follow up system.

1. Pre-operative data
Information collected from therapist should include the type and site of
tumor, mode of therapy employed, total dose, data of treatment, radiation fields,
tumor response, and the prognosis for disease.

2. Oral examination
Oral examination includes:
- Appearance of oral mucous membrane, scarring and fibrosis at the tumor
size, degree of trismus and status of salivary function.
- The amount and viscosity of saliva is an important determinant of
prosthodontic success. The less saliva, leads to more friction at denture
mucosa interface and more mucosal irritation and hence poorer tolerance
to dentures.
- The denture foundation should be examined for undercuts, tori, high
tissue attachments, enlarged maxillary tuberosities, flabby tissue and
abnormal jaw relations.

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- Undercuts in the mouth are particularly undesirable if they lie within the
field of irradiation, since necrosis could take place in these areas, during
insertion and removal of dentures causing irritation.
- The entire oral cavity should be examined visually and palpated for any
soreness. Pale fibrotic oral mucosa indicates poor tolerance to prosthetic
restoration and increase the risk of mucosal breakdown.
After completing the oral examination, the patient should be informed of the
findings and also about possible complications resulting from wearing dentures.
3. Prosthodontic procedures
It is essential that all oral procedures necessary in constructing the denture
be carried out with as little trauma and irritation to the oral mucosa as possible.

Impression:

1. Use alginate for primary impression rather than a thermoplastic material,

which may result in tissue abuse.
2. Conventional border molding: using polyether or heavy body rubber base
should be performed with care to avoid overextension particularly
lingually because overextension could result in a mucosal
perforation. The mylohyoid area is a critical spot on which to avoid
excessive pressure.
3. Use spacer in the special tray and take final impression with rubber base
4. Avoid using zinc oxide impression paste for final impression
5. If xerostomia is detected a thin coating of Vaseline may be applied over
the soft modeling plastic to prevent its sticking to the dry mucosa.
6. Removal of residual viscous secretions with gauze or a mouth rinse
immediately prior to obtaining the final impression will improve
surface details.
7. Final impression is made in rubber base material. Zinc oxide eugenol
material and impression plaster are contraindicated because of their
irritating and also drying effect. The completed impressions are
boxed and poured in dental stone. Record bases (occlusion blocks)
are prepared in the usual way .

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Jaw Relations

Vertical dimension
Reducing the vertical dimension (increasing the interocclusal space)
may limit the extent of the forces applied to the supporting mucosa and bone
during a forceful closure. Also, in patients with clinically significant, trismus
increasing the interocclusal space will make it easier for the entrance of bolus
of food.

Centric relation
- It is established without traumatizing the mouth during manipulation of the
trial denture base.
- Wax, plaster and zinc oxide paste are suitable interocclusal media for the
final closure.
- Selection non- anatomic monoplane is more favorable, as less horizontal
force is generated. Occlusal trauma may lead to a soft tissue necrosis.

Try in and Denture insertion

1. Waxed denture base should be cut away in the fields of irradiation if
possible without greatly sacrificing the stability of the prosthesis.
2. In denture insertion: Any rough projections on the fitting surface
should be smoothed. Pressure indicator paste (PIP) is used to identify
areas of excessive pressure and overextension of the denture flanges.
3. Remounting is essential.
4. Lightly polishing of the fitting surface of denture is advisable
5. Avoid using soft liners as permanent base: The silicones exhibit
reduced wetability and this contributes to an increased drag over the
dry mucosal surface during function and does not allow the denture to
slide easily.
6. Denture and oral hygiene instructions. Strict oral hygiene is more
necessary than usual.

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Follow up
1. Patients should be seen daily for two weeks after completion of the
dentures and every three months thereafter.
2. Using PIP to check pressure areas and any slight discomfort should be
considered with concern without delay. The patient must understand the
tissue changes resulting from radiation treatments and must be available
for close follow up.
3. Cooperation of the patient is a necessity to reduce all unnecessary
complications such as bone or soft tissue necrosis.

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 SPLINTS

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CHAPTER IX SPLINTS

JAW FRACTURES
Jaw Fracture:
A jaw fracture is a facial injury that results in the jaw bone breaking or
moving out of position.
Types of Fractures
1- Simple fracture: Bone fracture not associated with open wound. It does not
require open reduction.
a. Greenstick fracture (rare, exclusively in children).
b.Fracture with no displacement (Linear).
c. Fracture with minimal displacement.
2. Compound fracture: there is an open wound.
It is severe with tooth bearing area fractures. The compound fracture
requires opened reduction and internal fixation (Plate or screw fixation).
Sites of fractures:
 Condylar fractures
The most common mandibular fracture:
 Unilateral or bilateral fractures.
 Intracapsular or extracapsular fractures.
 Angle/ ramus fracture (body fracture).
 Canine region (parasymphesial fracture).
 Midline fracture (symphesis fracture).
 Coronoid fracture (rare).
Factors influenced site of fracture and displacement:
 Anatomy of the mandible and attached muscle (canine & wisdoms).
 Weakening areas of mandible (resorption and pathology).
 Direction of force of the blow.
 Age of the patient..
Favourable or unfavourable fracture :
o Fractures can be vertically or horizontally in direction.
o They are influenced by the medial pterygoid-masseter “sling”.

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 Transverse midline fracture (symphesial) stabilizes by the action of mylohyoid

and geniohyoid muscles.
 Oblique fracture (parasymphesial) tends to overlap under the influence of
muscles action.
 Bilateral parasymphesial fracture results in backward displacement associated
with loss of tongue control when the level of consciousness is depressed.
 If the vertical direction of the fracture favors the unopposed action of medial
pterygoid muscle, the posterior fragment will be pulled lingually.
 If the horizontal direction of the fracture favours the unopposed action of
masseter and pterygoid muscles in upward direction, the posterior fragment
will be pulled lingually.
 Favourable fracture line makes the reduced fragment easier to stabilize.

Examples of the effects of muscles on displacement:

The displacement of the fragments will depend on the line of fracture; and
the line of fracture may be determined by the direction and character of the
fracturing force. The elevators of the jaw are attached to the mandible posteriorly
and its depressors attached to anteriorly:
 When the fracture runs obliquely down and forward there is little or no
displacement, because the depressors and elevators tend to press the fragments
together.
 When the fracture runs downward and backward (Fig. 3), the depressors
and elevators tend to separate the fragments. The muscles which tend to
depress the anterior fragment are the geniohyoglossus, geniohyoid, mylohyoid
(anterior portion), digastric, and platysma. The muscles which elevate the
posterior fragment are the temporal, masseter, buccinator, and internal
pterygoid.
 In case of lateral displacement, when the fracture passes without inward
and backward, then there will be little or no displacement, because the
internal pterygoid and mylohyoid draw the fragments together. (Fig. 4)
 When the line of fracture passes inward and forward, the internal pterygoid
of the injured side and the mylohyoid draw the posterior fragment inward, while
the internal pterygoid of the opposite side draws the anterior fragment outward .
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 Fractures through the region of the molar teeth the fractures run obliquely
downward and outward through the angle of the jaw. In these injuries the firm
attachment of the masseter on the external surface of the jaw and the internal
pterygoid on its inner prevent displacement.
 Fractures of the coronoid process are exceedingly rare. In them
displacement is prevented by the attachment of the temporal muscle, which
passes much farther down on the inside than on the outside.
 Fractures of the neck of the jaw are particularly serious. Inserted into the
condyle and neck of the jaw is the external pterygoid muscle.
When a fracture of the neck occurs, this muscle pulls the upper fragment
anteriorly and tends to tilt its inferior surface forward. This displacement is so
marked that an excessive amount of callus is thrown out and ankylosis may
result. The injury is liable to be overlooked in children, and as they grow up
the deformity shown in Fig. 6 develops.

MANAGEMENT OF JAW FRACTURES

FIRST AID FOR FRACTURES

 If an injured person suspect his jaw is fractured one of the most important phases
of emergency care is to clear the upper respiratory passage of any obstruction.
 He should hold the jaw still with the teeth together.
 Emergency personnel may wrap a bandage under the jaw and over the top of the
head several times (e.g., a four-tailed bandage or Barton's bandage… etc). When
wrapping the bandage, he must be careful not to cut off breathing.
1. Apply a four-tailed bandage, as shown in Fig.7. Be sure that the bandage
pulls the lower jaw forward. Never apply a bandage that forces the jaw
backward, since this might seriously interfere with breathing. The bandage
must be firm so that it will support and immobilize the injured jaw, but it must
not press against the casualty’s throat. Be sure that casualty has scissors or a
knife to cut the bandage in case of vomiting. Treat the victim for shock and
evacuate as soon as possible.
2. A Barton's bandage is used to temporarily stabilize the jaw after a fracture

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3. A crepe or gauze bandage, adhesive strapping, or a plaster bandage could

be used round the casualty chin, face, and his forehead.
4. Apply a cravat to immobilize a fractured jaw as illustrated in Fig. 9. Direct all
bandaging support to the top of the casualty's head, not to the back of his neck.
If incorrectly placed, the bandage will pull the casualty's jaw back and
interfere with his breathing.

CAUTION!
o If the fractured jaw interferes with breathing, pull the lower jaw and the
tongue well forward and keep them in that position.
o A bandage can be detrimental if you apply it in a displaced fracture.
o Casualties with lower jaw (mandible) fractures cannot be laid flat on their
backs because facial muscles will relax and may cause an airway obstruction.

PRINCIPLES OF TREATMENT OF JAW FRACTURE CONSISTS

OF three STEPS:

1- Reduction: placement of the fragments in their anatomical position.

2- Immobilization: fixing in position until bony union occurs.

3- Rehabilitation: Restoring function to normal.

These are achieved:

 For Simple fracture by: Close reduction and immobilization.
 For compound fracture by :
- Open reduction and semi- rigid fixation (using inter- osseous wiring).
- Open reduction and rigid fixation (using bone plates osteosynthesis).

Other objective of mandible fracture treatment:

 Local anesthesia or sedation.
 Control of bleeding.
 Control infection.
Management of teeth retained in fracture line
For teeth present in the fracture line, that may be damaged, lose its blood supply
or may be affected by some preexisting pathology:

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o Good quality intra-oral periapical radiograph.

o Implication of appropriate systemic antibiotic therapy.
o Splinting of tooth if mobile.
o Endodontic therapy if pulp is exposed.
o Immediate extraction if fracture becomes infected.
o Follow up for 1 year and endodontic therapy if there is a loss of
vitality.

PROSTHETIC MANAGEMENT OF JAW FRACTURES

(SPLINTS)
Splint: It is an appliance used for immobilization of soft and hard tissues until
healing occurs.
Uses:
1- Main use is in treatment of fractures.
2- Aid in plastic surgery of facial structures e.g. treatment of prognathism.
3- In conjunction with bone or metal graft of jaw bones.
4- In periodontal treatment to support mobile teeth.
Requirements of a splint:
1. Enough rigidity and immobility: Allow good fixation of the fragments for a
long period of time.
2. Biologically compatible.
3. Comfortable and reliable.
4. Do not harm the teeth and supporting structures.
5. Speed and ease of construction.
6. Easy to handle, does not require any special instrumentation or laboratory
procedures, or extra sessions of anesthesia.
7. Adaptable into required shapes and available in different sizes.
8. Stable and does not interfere with feeding and swallowing, and minimum
disturbance to normal function.
9. Fixation should cause the least minimum possible interference to occlusion.
10. Early movement of the mandible can be attained to prevent trismus.
11. Need little post-operative attention.

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Methods of immobilization:

A- For dentulous patient:

1- Wire loops (Ivy loops direct wiring or Eyelet wiring). Used in patients with
complete or almost complete set of teeth with normal shape and size (Fig. 13).
2- Arch bars are used when the patient has an insufficient number of suitably
shaped teeth to enable effective interdental eyelet wiring to be carried out (14).
3- Labiolingual splint (Stout).
4- Metal cap splint (old modality).
5- Lingual splint.

B- For edentulous patient:

1. Gunning splint.
2. Kingsley splint (old modality).
N.B.: The maxilla is utilized as a stable base for immobilization of the fractured
mandible.

A- For dentulous patients:

I- Wire loops (Eyelet wire system or Ivy loops).

*Used in patients with complete or almost complete set of teeth with
normal shape and size.
II- Arch bars: used when the patient has an insufficient number of suitably
shaped teeth to enable effective interdental eyelet wiring to be carried out.

III- Stout sectional splint (Acrylic splint – labiolingual splint or

plastic split splint):

Definition: it is an acrylic splint covering bucco -labial as well as lingual

surfaces of the teeth leaving the occlusal Surface uncovered with stainless
steal wire connecting the two acrylic portions posteriorly around the last
remaining tooth.
Uses:
1) Dentulous or partially edentulous patient without or with minimal
displacement of the fractured segments.

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2) In children.

Construction:
1) Impression:
* Accurate alginate impression is needed.
* It should record the vestibule and all teeth and soft tissue undercuts.
2) The splint is waxed up:
* The occlusal Surface must be left free.
* A sheet of wax is adapted starting from the height of contour of the tooth
to the depth of the vestibule.
3) stainless steal wire of 9 gauge – 15 cm – 1/2 rounded cross section is bent
and placed distal to the last molar so that the buccal part of the wax is
attached to the lingual through this wire.
* Make contrangle at the end of the wire for mechanical retention.
4) A button is made in the front region of the splint.
5) Before processing, the part of the teeth above the survey lire is sewed from
the cast to facilitate removal of the splint from the cast after processing.
6) The splint is flatted and processed in clear acrylic resin.
7) After polishing, holes are drilled at the inter-proximal areas to allow wiring
of the splint over the contact areas.
8) The splint is sectioned at the middle of the button vertically by separating
disc so that the splint can be easily inserted in the patient’s mouth by
the help of the flexibility of the wire.
9) The fracture is reduced under local anesthesia and then the splint is fitted in
place using legation wire around the button.
10) The splint may be lined by soft liner before fixation.

Advantages:
1) Ease of fabrication.
2) Not interfering with function or occlusion.
3) Made of acrylic so x-ray is possible.
4) Could be removed every few days to avoid Trismus.

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IV - Metal cast splint: (silver copper alloy cap splint):

Definition:

 It is a metal splint covering the buccal, lingual and occlusal aspect of teeth on
either sides of the fracture (it doesn't cover proximal surfaces).
It can be in the form of:
1) One piece cap splint (simple cap splint): used only when:
1- There is no displacement (or little displacement), or
2- The fragments can be easily positioned by the occlusion with
opposing teeth.
2) Two pieces metal cap splint (cap splint with screw connecting bar, sectional
cap splint with localizing plate)
.

Used when:
1- There is displacement between the fractured segments.
2- More rigid fixation is required.
- The 2 parts of the splint is connected by a bar and screws.
 Although it provides a rigid and efficient form of reduction and immobilization
but it is considered as one of the old modality and not used nowadays because:
1- It may interfere with occlusion.
2- The black copper cement used for cementation is very strong, which
may lead to jaw fracture during splint removal.
V- Lingual splint:

Definition:
It is a splint conforming to the inner aspect of the dental arch.
- It is the most common splint used today.
Use: Mainly in parasymphyseal fracture of the mandible.
N.B: The symphysis region is more difficult to reconstruct than mandibular body
due to abrupt curvature of the bone in this area.

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B- For edentulous patients:

1- Gunning splint:
- It is constructed for both arches as one piece so it's disadvantages:
1) It is overworked.
2) Difficult to manipulate.
3) It can't be wired to jaw bones.

Modified or two piece Gunning splint:

- It is separate splints with v-shaped grooves on the occlusal surface of one arch
and a projection to fit these grooves on the opposite arch.

Steps of construction: -

1) Impression technique and cast preparation (mentioned before).

2) 2 layers of modeling wax are adapted on the cast 2mm shorter than the
anatomical outline.
3) Occlusal bite rims are constructed for each arch with space in the anterior
teeth area to facilitate function of:
* Breathing. * Feeding * Possible vomiting
4) Vertical and centric relations are recorded and the models are mounted on an
articulator.
* If vertical dimension can't be obtained so roughly adjust it to be equal to 5mm
for the upper and lower wax rims.
5) Male and female buttons (3-5 mm deep) are created on the occlusal surface of the
wax rim so that the splints can be interlocked to maintain proper centric relation.
6) Two or four stainless steel wire loops or hooks are placed on both buccal
flanges of the waxed up bases.
7) Flasking and processing is made after removing the inner layer of wax base
plate to allow space for soft liner after processing.
8) Circumferential wiring is used to fix the mandibular splint in position.
* Maxillary splint is suspended to zygomatic arch and nasal spine.
9) The two splints are wired together (After healing the wires can be removed for
a period of line so allow early mobility of the mind).

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N.B.: Attachment between upper and lower splints could be made as follows:
1- Make a v-shape channel on the upper and lower wax rim, but put into
consideration not to touch buccal and lingual walls.
2- Processing is made as usual.
3- The two splints are attached to each other in the patient mouth by filling the
channel with black gutta percha or self cured resin.

N.B:
A) If the pt. has an old denture we can use it as follows:
1- Casts are poured and then mounted with no need for impression.
2- Dentures are removed and the splint is waxed on the model.
B) The denture itself can be used as a splint with extra-oral bandage.

2) Kingsley splint:

It is considered as one of the old modality and not used nowadays.

Uses:

1) For treatment of fractured dentulous cases or edentulous mandible instead

of Gunning splint.

2) For treatment of depressed fracture of maxilla where traction is needed.

It consists of:

1) An intra oral portion embracing the teeth or edentulous alveolar process

to which stout wire arms are attached.

2) An extra oral portion projecting between the lips and carried round the
sides of the face to provide attachment for bandages passing either under
the chin or over the head for fractured mandible and maxilla respectively.

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STENTS

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STENTS

Definition:
As described by Charles R. Stent they are appliances constructed to
cover the tissues and/or the teeth for their protection, to carry medication
or radium material or to control bleeding.
With the expansion of the dental practice, newer applications and
consequently appliances were introduced. These appliances serve other
purposes than those described by Charles R. Stent but yet they are still
described with the word “Stent”.
The term “Stent” is nowadays used to describe a wide variety of non-
prosthetic passive removable appliances that aid in the pre-operative
planning, intra-operative guidance, post-operative healing, or serve as a
temporary and therapeutic function.

Uses:
1. Carry medicament and surgical packs to keep it in position for the required
duration to the required area in the oral cavity.
2. Help to control bleeding specially in haemophilic patients.
3. Protect the tissues after skin and mucosal grafts and keep them in place
until revascularization takes place.
4. Protect teeth and associated structures in contact sports.
5. Carry radium material and keep them in place for treatment of malignancy
(especially in the inaccessible areas).
6. Preserve the depth of vestibule after sulcus deepening and ridge
augmentation procedure.
7. Promote healing through stimulation of the underlying tissues and prevent
contamination of the fresh wound.

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Material used:

1. Acrylic Resin; either:

 Heat cured
 Self cured.
Heat cured is preferred because:
 It is more stable.
 Less amount of residual monomer.
(Resin material may be lined with soft material).

2. Soft material:
 As soft rubber or soft resin
 Silicon venial rubber may be used but additional reinforcement of
resin is usually required.

3. Modeling plastic, gutta percha and silicon:

 Used in emergency cases where there is no time to construct a
stent.
 These materials can be used directly in the oral cavity on the
bleeding area.

N.B:
Primarily stents are non-prosthetic devices (i.e. they don’t
replace missing structures). Sometimes a prosthesis may
perform a stent like function.
e.g.:
An immediate surgical obturator holds a medication close to
the surgical site during healing.
The immediate denture serves an anti-hemorrhagic purpose.

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Types of stents

I- Preoperative and operative stents

1. Radiographic stent
2. Surgical stent

II- Postoperative healing devices stents:

1. Stent for the plastic surgery of the oral mucosa
2. Anti- hemorrhagic stent
3. Palatal stent.
4. Cyst plug.
5. Drainage stent.
6. Nasal stent.
7. Burn stent.

III- Therapeutic devices stents:

1. Habit breaking appliances.
2. Radiotherapy aiding devices.
3. Trismus appliances.
4. Occlusal therapy appliances.
5. Appliances for sleep disordered breathing.
6. Splints.
7. Mandibular guidance prosthesis.
(Discussed before in chapters V, VI, VII, VIII and IX.)

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I.Preoperative and operative Stents:

1. Radiographic stents:
Used as an aid in planning of implant cases. They help in determining
the proper site and dimensions for the implants to be used.

Types

i. Radiographic stents for plain radiography:

The stent is made of a radiolucent material usually acrylic
resin and a radio-opaque marker (usually a metallic ball or
gutta percha) of known dimensions which is incorporated in
the prosthetically proposed implant site.
This type of imaging help only in determining the
implant length to be used for the selected site .
ii. Radiographic stents for CT scan
The stent can be made in a similar manner to the plain
radiography stent with the exception that the radio-opaque marker
should be non metallic to avoid metal streak artifacts in the CT
image. The stent can be made also completely from a non metallic
radio opaque material (a mixture of acrylic resin and barium
sulphate) with holes at the proposed implant sites.
This type of stents helps in determining the implant length,
diameter as well as the point of entry and the implant inclination .

2. Surgical Stents (guides):

A group of devices that are prepared over modified casts (obtained from a
process called model surgery), or virtually planned on a 3D computer
software before surgery to guide the intraoperative procedures
Examples:
i. Surgical guides for implant placement, crown lengthening
procedures, or radical alveoloplasty before insertion of an immediate
denture.

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ii. Surgical guides for maxillofacial and orthognathic surgeries .

II- Postoperative healing stents

The aim of this group of devices is to promote the healing and

minimize the complications following the surgical procedures. They
include:

1. Stents for plastic surgery of the oral mucosa:

 Many intra oral surgeries result in denuding a bony area as in

vestibuloplasty (sulcus deepening procedure), or removal of a soft
tissue malignancy. The resultant denuded area is usually covered by a
skin graft to allow for better healing.

 A stent is usually required to maintain the skin graft in place until

revascularization occurs from the underlying raw area (skin or mucous
graft inlay stent) .

 A stent used after ridge augmentation.

2. Palatal stent (palatal pressure plate)

Function:
1. Apply pressure to soft tissue after surgery to facilitate healing and
prevent collapse
2. Facilitate hemostasis and avoid hematoma formation.
It is used after surgeries in the palate as in tori removal, palatal mucosal
grafting, removal of impacted canine or a large cyst in the palate.

Technique of construction:
1. An alginate impression is made before surgery.
2. Construct a palatal plate on the cast covering the palate and gain its
retention by wire clasps
3. The plate is introduced in the mouth after the surgery to apply pressure
on the raw area by the help of tissue conditioning material
4. It is left in the mouth for 2-7 days.

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3. Anti-hemorrhagic stent :

It is used to control bleeding after extraction in patients with:

i. High bleeding tendency e.g. leukemic patients
ii. Clotting problem e.g. hemophilic patients.

A. In patients with high bleeding tendency:

The problem is the lack of platelets (i.e. the early platelet plug is not
formed). The aim of the stent in such case is to apply pressure over the
extraction socket to stop the bleeding until the late coagulation
mechanism starts
1. Upper and lower impression are made before surgery and
impressions poured to obtain casts which mounted in centric
relation by the help of squash bite
2. The tooth to be extracted is removed from the stone cast and a
layer of molding wax is adapted in the cast to cover the
lingual, buccal and top surface of the ridge
3. The articulator is then closed to allow the opposing teeth to
touch the top of the wax
4. The wax is processed in clear heat cure acrylic resin or cold
cured resin (clear resin makes inspection and detection of
passive areas easy)
5. The stent is inserted immediately after extraction where
bleeding controlled as the patient closes and applies gentle
pressure over the extraction site.
N.B: the stent gains its retention by using wrought wire clasp.

B. In patients with clotting defect:

 In such cases the early platelet plug is formed but the coagulation
mechanism dependent factor VIII is not acting properly. The aim of
this stent is to maintain the initially formed platelet plug without being
disturbed.

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 The stent used is similar to the used for patients with increased bleeding
tendency but:
1. There is no pressure applied on the socket (no contact between
acrylic and opposing teeth)
2. The buccal flange is extended to the full depth of the sulcus to
avoid entrance of the appliance to the socket on so interfering with
the blood clot formed
3. It is designed only to protect the socket and clot from the tongue
and to hold a haemostatic dressing in place
4. The rigid acrylic resin stent is lined with soft resin because resin
may irritate the tissues and disturb the clotting mechanism.

4. Cyst plug:

It is an appliance which prevents closing of the opening of the cyst

before complete healing of its cavity after Marsipulization i.e. it maintains
the patency of the cyst orifice.

Technique of construction
1. The cyst is plugged with a gauze or wet cotton wool leaving the neck
part of the cavity free. Impression is taken and a cast is poured with a
small depression representing the cyst neck
2. The plug is constructed on the cast covering the palate area and
containing an acrylic projection into the cyst cavity
3. The plug must have a labial and buccal flanges with the acrylic
projection not entering into the full depth of the cystic cavity
4. If the patient is wearing a denture it can be used as a stent where the
cyst cavity is plugged with gutta percha or compound then it is
attached to the denture then the plug is replaced by self cured acrylic
5. Gradual reduction from the depth of the acrylic plug every 1-2 month
until it is removed entirely when the cyst cavity decreases in size.

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5. Drainage stent
- It allows the escape of blood or other tissue fluids from the chronic
periapical lesion with a fistula for drainage of infection.

Technique of construction
1. An impression is taken and the fistula is reproduced and marked on the
stone cast.
2. A ready-made polyethylene tube is inserted in the hole and the labial
aspect of the cast is covered with two layers of base plate wax.
3. The stent is processed with clear acrylic resin and cured in conjunction
with the polyethylene tube then polished.

6. Nasal stent :
- It is a removable intranasal prosthesis to support the form of the nose.

Functions:
1. It provides support for the cartilage transplants during post surgical
healing for the correction of nasal deformity in the cleft lip patient.
2. Maintain contour and minimize scar contraction following skin grafting
procedure to the nostril.
3. Widen the nostrils after trauma or burn prior to grafting procedure.

7. Burn stent:
It is a device constructed to minimize contraction of burned tissues
during healing. Electrical burns to the oral commissure are the most
common type in children. Contraction of wound margins doesn’t usually
begin until 5 days after injury.
The use of stent before the start of wound contraction minimizes post
burn scaring and consequent development of microstomia.

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II. Therapeutic stents:

A group of devices used to treat a pathological condition. Most of these
devices serve for a temporary period of time.

1. Habit breaking appliances:

i. Oral screen:
It is stent of acrylic resin that is worn usually at night and is bounded
by lips and cheek laterally and the teeth medially (Fig. 9).
Uses:
a) The major use is to stimulate proper nasal breathing.
b) It can be used also to control finger or thumb sucking and lip biting.
c) It can be considered as an orthodontic appliance for protruded upper
incisor teeth through the applied pressure.
Technique of Construction:
a) Impression is taken including all tissues in the buccal and labial
vestibules.
b) Casts are made and mounted according to the patient centric occlusion.
c) Double layer of modeling wax is adapted to the labial and buccal
surfaces of the cast.
d) Frena and muscle attachment must be freed.
e) The screen is processed in clear acrylic.
f) All surfaces of the stent must be highly polished except that opposite
to the tooth for frictional retention
ii. Stent that prevents tongue biting:
Although incidences of occasional minor tongue biting do not
present a serious problem, repeated or prolonged tongue biting can
causes soft tissue, vascular, and lymphatic injury that results in edema
and swelling. The swelling increases the likelihood of repeating the
injury, which will exacerbate the condition. Tongue lesions or surgery to
the tongue can also cause swelling and result in the tongue being more
susceptible to trauma.

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To prevent tongue biting for these patients, the tongue must be

retained in its normal space within the oral cavity and kept from
coming into contact with the dentition using a removable stent .

iii. Occlusal therapy appliances (occlusal Splint – stent – Bite

plate or bite guard):
III.

Definition: It is any removable artificial occlusal surface used for diagnosis

or therapy affecting the relationship of the mandible to the maxilla.
Uses:
1- For occlusal stabilization.
2- For treatment of TMJ disorders.
3- Prevent wear of dentition.
Functions and advantages of occlusal devices:
1- Primary function is to adjust occlusal discrepancies to interrupt
existing pattern of muscle function which contribute to painful
myospasm.
2- Eliminate occlusal interference.
3- Guide the mandible into retruded position for treatment of TMJ
dysfunction syndrome (Fig.11).
4- Minimize the effect of parafunctional habits as clenching of teeth in
bruxism and thumb sucking (Fig.12 and Fig. 13).

Technique of Construction:
1- Impression for upper and lower jaw is taken after proper diagnosis
and evaluation of occlusion.
2- Impressions are poured and casts obtained.
3- Mounting of the casts is made using interocclusal record.
4-The articulator is slightly opened for new vertical dimension of
occlusion
5- The appliance is waxed by base plate wax extended on the occlusal
surface then processed.

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Types of Devices (discussed in detail in chapter XI):

1- Smooth flat occlusal surface for relaxation by allowing contact of
all opposing teeth.
2- Indentation and/or ramps for mandibular reposition device.
3- Soft device for patient with bruxims or clenching to distribute the
pressure equally.
vi. Removable Appliances for sleep disordered breathing:

Types of upper airway sleeping disorders (UASD):

a- Mild form causing snoring.
b- Moderate form causing upper air way resistance syndrome (UARS).
c- Severe form causing obstructive sleep apnea (OSA).

The Airway of the Snoring Patient:

The tongue and/or the hyoid bone and overlying soft tissues,
dropping back toward the posterior pharyngeal wall .
- Increased in velocity of air.
- Vibration of the soft palate &/or uvula.
- Vibration is the sound of snoring.

Treatment Options

1- Mandibular advancement devices (MAD):

- It works indirectly by holding the mandible and hence
the tongue forward
- It may be stock devices or lab. Fabricated.
- It is either single or adjustable position devices.
Types:
a- Single position stock devices :
- Two rigid plastic sheets joined into a single unit.
b- Adjustable stock devices :
- A screw mechanism for positioning the mandible is used.

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2- Tongue Retaining Device (TRD) :

- It works through the use of hollow bulb & sufficient
vacuum to hold the tongue forward.
- It is made of non rigid vinyl mat. & the pat. Is instructed to
protrude the tongue into the hollow bulb & the vacuum
should hold it there for several hours of sleep

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