CONTENTS

1. 2. 3. 4.

Introduction Review of Literature Anatomy & development of the maxilla & palate. Anatomy, Physiology of the Velopharynx and Speech

2 3 34 46

5. i) ii) iii) iv) v) vi) vii)

Management of palato-maxillary defects. Multidisciplinary approach. Psychological considerations. Materials used in the management. Prosthetic management of soft & hard palate defects in general. Prosthetic management of hard palate defects. Prosthetic management of soft palate defects. Prosthetic management of Cleft lip and palate. 107 178 200 65 75 86 100

6. 7. 8.

Discussion Conclusion Bibliography

226 230 231

Maxillofacial Prosthetics is the art and science of anatomic, functional or cosmetic reconstruction by means of non living substitutes of those regions in the maxilla, mandible, face and even other body parts that are missing or defective because of surgical intervention, trauma, pathology or developmental or congenital malformation.

It is considered a sub speciality of Prosthodontics, as many phases of Maxillofacial Prosthetics are merely logical extensions of

Prosthodontics. The intimate relationship between the two becomes even more obvious when it is noted that the basic techniques and materials used are similar if not identical.

Success in Maxillofacial Prosthetics as in Prosthodontics depends on full cognizance of the principles that underlie facial harmony, colour matching, anchorage and retention, weight bearing and leverage, durability and strength of materials used, tissue compatibility and tolerance.

This dissertation attempts to emphasize these principles while reviewing the rehabilitation of maxillary and palatal defects.

The MaxiIlofacial Prosthodontist normally provides appliances and devices to restore esthetics and function to the patient who cannot be restored to normal appearance or function by means of plastic reconstruction. Despite, remarkable advances in surgical management of oral and facial defects, many such defects especially those involving the eyes and ears, cannot be satisfactorily repaired by surgery alone. Further, the increased lifespan of individuals and the growing demand for health care services puts additional obligations on the maxillofacial

prosthodontist.

Patients with palatal defects labor under handicaps, which cannot be fully appreciated by those with normal palates. The prosthetic or non-surgical method of cleft-palate or acquired defects of palate correction comprises of essentially two forms of appliances i.e. the obturator and the artificial velum.

The term obturator is taken from the Latin 'obturare' meaning to stop up. It is an appliance, which corrects any opening of the hard or soft palate or of both. Early literature states that obturators and prosthesis for oral deformities were amongst the earliest appliances in the mouth, and consisted of wads of fabrics, wax, metal, leather and wood.

The following review surveys the literature and attempts to relate this information to problems encountered in the successful rehabilitation of patients with maxillofacial defects in the hard and soft palate.

Ambrose Pare28 (1510-90) was one of the first of these operators to furnish description of an obturator. Pare introduced the term 'bec-de-lievre' (harelip), merely using obturators for closing palatal defects. Obturators designed by him, had their own means of retention. The first obturator designed by him, consisted of a small sponge, which would swell by moisture distilled from the brain and puffed to fill the cavity of the palate so that the plate could not fall down. A second type of obturator described by him contained a turnbuckle which could be rotated some 90 by forceps for retention.

Fig.1: Mechanical devices that Pare used to close perforation of the palate. (a)- A dry sponge attached to prongs that swell up and provide retention. (b)- A turnbuckle type of arrangement used for retention.

Pierre Fauchard28 (1678-1761) described ingenious obturators that composed of a stalk, terminating in a screw with wings covered by sponge to aid in retention.

Fig. 2: Fauchards designs for palatal obturators. (a) Wings are in the shape of propellers, which can be folded during insertion and spread out after insertion with special key. (b) Retaining feature is butterfly shaped. (c) An obturator made in 1900 inspired by Fauchard.

Stearn 134 (1841) was the first to introduce speech aid prosthesis Rowell, Hullihen and Sversen84 introduced Velum to obturators. Velum is an obturator prosthesis designed to close a defect in soft palate. Suerson 84,104 (1867) suggested the rigid fixed obturator using a wire loop posterior extension shaped by use of warm gutta percha.

Fig. 3: Suerson type obturator for cleft palate.

Kingsley28,84 (1880) described artificial appliances for the restoration of congenital as well as acquired defects of the maxillofacial region with soft vulcanizable rubber. The Kingsley velum consists of two flaps joined throughout the midline. The lower flap, the one that completes the palatal dome, extends from the apex of the fissure posteriorly as far as the bases of the uvulae. This flap overlaps the soft parts to prevent it being pushed through the cleft. The other flap is also triangular with its posterior border curved and thinned to featheredge to prevent irritation of the posterior pharyngeal wall when it comes in contact.

Fig. 4: Kingsley Velum

Kelsey-Fry5 (1927) stressed the very great need of the close cooperation between the surgeon and the dental prosthetist and the importance of preoperative consultation to decide, as exactly as possible, the amount of tissue to be removed, which teeth (if any) to preserve and so forth. Pitchler5 (1929) discussed a vulcanite appliance used after maxillary resection, which was made in two parts. The upper hollow portion filling the space created by surgery and fitting lid like into the lower portion or denture to which it is fastened, when in position by a lateral hook. Kazanjian5 (1931) described an ingenious arrangement for hinging the anterior extension of the prosthesis so that the appliance could be more easily introduced, and after placement the anterior attachment would be swung back into position where it could be fastened or clipped in place. Schalit A.136 (1946) first described meatus obturator for cleft palate. Gaylord James50 (1951) reviewed the Fitz-Gibbon technique for rehabilitation of the cleft palate patient, which includes an all-metal obturator in gold. He also mentioned the Fitz-Gibbon classification of cleft palate patients Appleman RM5 (1951) described the prosthetic repair of defects of the maxilla due to surgery. He mentions the technique of making impressions. The preliminary impression is made in impression compound, which is withdrawn before it sets completely. This is allowed to harden outside the mouth, scraped and then an irreversible hydrocolloid final impression is made with this tray. The prosthesis in edentulous maxillectomy case is made in a way that first, the bulb is prepared over which another impression is made and then the record base fabricated to fuse with bulb, over which the records are made and then the obturator is made. He also described the use of a soft plasticizing acrylic material in the denture on the buccal side of remaining teeth for retention in partially dentulous cases where the remaining teeth are not healthy enough to withstand loads of metal retainers. Olinger NA95 (1952) reviewed cleft palate rehabilitation and described the technique for fabricating an artificial velum attached by a pin lock hinge to the palatal plate and also replacing the vomer by a vertical flange intranasally.

Torn DB

139

(1952) has described speech and partial denture prosthetics

and emphasized the need for speech therapy following both surgical and prosthetic correction. Martin BC and Trabue JC90 (1952) emphasized the treatment to be individualized for each patient and the advantage of using a team approach of a surgeon, orthodontist, prosthodontist and speech therapist. Lazzari JB
73

(1952) described prosthetic closure of a traumatic palatal

perforation and recommended that the opening in the palate be packed within 2 mm of the palatal surface of the opening as it appears on the cast. No relief is provided in and about the opening. The restoration is fabricated in gold like a regular cast partial denture. Ackerman A.J1 (1955) advocated obturator prosthesis for situations in which the hard palate has been removed completely together with some portions of the soft palate. The prosthesis was based upon extension into the nasal cavity to achieve retention. The posterior extension of the prosthesis was made to rest on the floor of the nasal cavity at the rim of the defect and the anterior extension was in the region of nasal spine. The anterior extension of the prosthesis was made movable using a wire insert to facilitate retraction and extension of the prosthesis. Nififfer T. J. & Shipron T.J.
92

(1957) described a technique for fabricating

the hollow bulb obturator. They lined the defect with two thickness of wax and adapted a paper clip so that a loop extends down into the cavity, while the ends of the wire rest on the keyed artificial stone. The paper clip lined cavity is then poured in stone. The paper clip attached stone assembly is used for making hollow bulb by forming the interface between two sections of the flasks during packing. Gibbons and Bloomer
51

(1958). They first described the palatal lift

prosthesis as a management technique for velopharyngeal incompetence. They designed a supportive type of prosthetic speech aid elevating the soft palate as a means of decreasing the lumen of the palatopharyngeal valve in speech. The basic speech aid prosthesis consisted of the retentive portion of cast metal frame with wrought wire retainers clasping teeth and a metal extension with plastic for elevating the soft palate. According to them, the degree of elevation and retraction of the palate accomplished by the supporting prosthesis presents an adjustment to several requirements. A reduction in palatopharyngeal lumen needed to decrease hypernasality and increase oral pressure for consonant articulation.

The preservation of an airway to provide for comfortable nasal breathing. The avoidance of undue stress upon the supporting teeth as the appliance resists the natural elasticity and weight of the palate in elevation. Sharry J.J
124

(1958) commented that meatus obturator first described by

Schialit (1946) resulted in remarkable improvement of speech in cleft palate patients. He stated that since, it does not depend upon palatal muscle movements to be effective, it is not affected by their anatomic limitations. It is based upon the presumption that complete occlusion of the oropharynx from the nasopharynx is not necessary for good speech by cleft palate persons. Rather, it is believed that partial occlusion of the nasal cavity results in a marked diminution or complete elimination of the nasality in the speech of cleft palate patients. He also stated that the medial wall of the prosthesis along the midline of the palate should extend only as high as remaining hard palate, because the medial wall of the defect covered by a very thin layer of mucosa would be easily irritated by a large prosthesis. Ali Aram and Subtently 6(1959) studied normal subjects, and concluded that the pharyngeal section must be properly designed at the desired level. They found that position and movement of soft palate, in relation to the pharynx changes with age. At birth and shortly thereafter, the soft palate at rest is roughly parallel to the roof of the pharynx so that the upper nasopharynx is only a narrow slot. Essentially, a superior-inferior movement of the soft palate accomplishes closure of the velopharyngeal mechanism. As growth occurs in the pharyngeal area and the adenoid tissue regress, the movement of the soft palate takes the characteristic anteroposterior elevation demonstrated by most adults. Velopharyngeal closure is slightly below the level of the palatal plane upto 8 years of age, and is consistently above the level of the palatal plane thereafter. At one time, it was believed that Passavants pad

identified the vertical locale of the nasopharyngeal portion of the prosthesis. However, the variable occurrence and location of Passavant's pad usurped its employment as a reliable landmark. Currently, the bulge of

the anterior tubercle of the atlas is used for bulk orientation, keeping in mind that the area of pharyngeal constriction may occur above this locale. Aram & Subtenly acknowledged the existence of individual asymmetries in pharyngeal junction which makes it necessary to modify the shape and placement of the pharyngeal section, and concluded that the dentist should design a bulb that is minimal in size, so as to relieve muscular strain and torque on the prosthesis while contacting both lateral and posterior pharyngeal walls. They studied the speech of 23 adult and adolescent cleft palate speakers with obturator prosthesis. They reported a wide variation in obturator position and size. The position of the obturator varied from 20mm below the palatal plane to 6mm above the plane. The vertical extension varied from 11 to 35mm. The best speech results were obtained with higher placement of the obturator. Where deficiencies were noted clinically regarding tissue approximation, the lateral dimension was most commonly found to be deficient in extension. Miglani and Drane
87

(1959) believed in the presence of teeth on the non-

surgical side as a prerequisite for an immediate obturator. They also believed in the importance of fabricating temporary obturator about 10 days postoperatively. Adisman IK.
2

(1962) described the fabrication of removable partial

dentures for patients with acquired defects of the maxilla and mandible. He stated that the fundamental objective is the restoration of function and the preservation of the remaining teeth and tissues while treating these patients. Regardless of the fact, whether, the appliance is transitional or temporary in nature, fundamental principles of partial denture designs should be followed. He advocated sectional type final impression to ensure accurate duplication of anatomic undercuts in the nasal cavity or hard palate to be assembled out of the mouth in proper position. He also advocated utilization of retentive devices for removable partial denture obturators like the internal clip attachment, circumferential, Roach and Jackson Grip Clasps and precision attachments whenever and wherever possible. He believed that to decrease the weight of prosthesis, obturator should be hollow. He stated that for defects in the hard palate it is sufficient to cover the defect and create a seal by engaging a minimal amount of the periphery of the undercut surface of the defect. Unlike, the hard palate

defects, opening in soft palate may require more extensive coverage area to create an efficient seal. Robinson J. E.
118

(1963) described a surgical prosthetic appliance for

patients undergoing surgical removal of the maxilla and floor of the orbit. It consisted of an acrylic resin template with spring wire attachment on the defect side that would project near the infra-orbital rim over the enucleated eye to be fastened, to the forehead for retention. According to him, such a surgical prosthesis will add to the success of both the operative procedures and the rehabilitation of the patient. Bulbulian AH
28

(1965) in his excellent review on the evolution of

maxillofacial prosthetics mentioned the landmark contributions of the pioneers in this field. Payne A.G.L., Welton W.G.
146 105

(1965) described an inflatable obturator

design using a mechanism similar to the air valve of a tyre. Warren D.W. (1965) discussed the physiologic approach to cleft palate

prosthesis and emphasized the use of pressure-flow technique in the prosthetic management. The technique provides a means for estimating muscle valving against the speech aid as well as relating changes in the velar structure to associated changes in speech. Roberts
29

(1965) described fabrication of closed hollow bulb prosthesis

utilizing modeling compound for filling the defect area, which is later removed and closed by acrylic lid. He advocated that the occlusion should be as balanced as possible, with freedom of lateral movements without lateral interferences, He stated that in cases where retention is less, mechanical means of retention should be utilized using springs and swivels. The action of spring is to produce forces, which will press the upper denture upward and backwards and the lower denture downwards and forwards. However lateral movements are restricted. The springs are attached to the denture in the premolar region by swivels. A.C. Roberts also advocated split model method for hollow bulb obturator in cases when casts have deep undercuts. The model is fret sawed through a depth of about 1/8 inch from the base, the saw cut extending through the cavity. The model is then fractured through the remaining 1/8 inch. This aids in reassembling and location. This method also allows the extension into the cavity to be tried in, and alterations made before finishing the obturator.

10

Roberts described obturator prosthesis for congenital defects of soft palate as movable and stationary velum prosthesis The movable velum prosthesis is one in which the velum prosthesis is under the control of the muscles of soft palate and this type of appliance responds to the delicate movements of the muscles. Such an appliance is attached to the main appliance that is the retentive appliance by a hinge mechanism. The stationary velum prosthesis is a projection from the posterior end of the denture into the pharyngeal space and is so shaped that the muscles are always in contact with the lateral and posterior surfaces of the appliances in their various movements. C. B. Thompson described velum obturator in which the velum is made hollow and consisted of two parts i.e. the main velum, which is hollowed out and a lid, which is sealed with cold cure acrylic. Roberts also described stationary velum appliances with some degree of movement. The degree of movement depending on the texture and resilience of the material used. Latex velum are used which are attached by means of tags of stainless steel wire to the flat retention plate forming an extension into the cleft. Mazaheri and Millard
29

(1965) attempted to correlate voice quality with

location and dimension of the pharyngeal bulb. This result showed that optimal bulb position varied with each individual patient. Voice quality was judged as best when the bulb was positioned in the area of greatest lateral and posterior pharyngeal wall activity. They tested three positions with interchangeable obturators - High (above the posterior pharyngeal wall activity), medium (at the pharyngeal wall activity), low (below the pharyngeal wall activity). Each obturator was adjusted for 5 weeks before speech recordings were made. Their investigations disclosed that the middle position resulted in the best speech for most patients. The inferior superior dimension of the original median obturator for these patients varied from 13 to 19mm with a mean value of 13.09 mm. Each obturator could be reduced 3mm in superior and inferior extension without any effect on speech.

Boucher Louis J.21 (1966) presented a technique in which he used silastic foam for fabrication of the obturator. The obturator prosthesis was attached to the maxillary denture by magnets. The magnets were placed as far

11

laterally and posterior in the denture as possible to obtain maximum amount of retention available. Ampil and Ellinger
4

(1967) described fabrication of hollow silicone

obturator bulb attached to acrylic resin base as temporary prosthesis for maxillectomy patients. According to them, the primary advantages, of using a hollow silicone obturator bulbs in temporary restoration are: a) It permits the placement of the pliable bulb into greater undercuts areas of the defects, thus, providing better mechanical retention and seal. b) The inherent rubber like qualities of the material tends to resist sliding and skidding of the restoration. Zarb G. A. 155(1967) stated that if the pterygoid hamulus is removed during the maxillectomy procedure, the attachment and/or function of tensor veli palatini, buccinator and superior constrictor muscles could be compromised resulting in the medial collapse of the disto-lateral position of the defect. If this situation is anticipated, the cast should be reduced 2 to 3mm medially before fabricating the prosthesis. Zarb, also believed that an immediate temporary obturator is almost always indicated as well as feasible in a maxillary resection. Such a prosthesis enhances healing, function, esthetics and, mental well-being of our patients. He advocated temporary obturation, with a resilient material, which not only protects the tissues but also retains the prosthesis. Lang B.R.
71

(1967) presented a modification in the construction of a

speech aid restoration by extending its application to cleft palate patients. He fabricated speech aid appliance with beavers tail shaped extension, which was at the level of the medial spine of the atlas. This extension was initially developed in soft modeling compound and later refined in wax. The posterior extension was finally replaced by clear acrylic resin. Lang stated that palatal lift prosthesis is a speech aid and not a means of speech correction. Complete success can be realized with these appliances when the prosthesis is used in conjunction with a programme of speech therapy. Brown Kenneth E where tissues
23

(1968) stated that in cases with maxillectomy defects been protectively conditioned by surgical

have

reconstructive graft, the peripheral contours of obturator prosthesis might be developed to create a buttress like action against them. To obtain maximum lateral retentiveness, the buttressing effect of the obturator's lateral border should be placed as high and as far away possible from the rotation axis as possible. The contouring should never impinge upon any

12

delicate unprotected structures or be of such dimensions that it would not harmonize with the dictates of the path of insertion. Beder O 11(1968) described the emergency temporary obturator. ElMahdy A.S. 45(1969) advocated a simple and accurate method based on the use of two flasks with interchangeable parts for fabrication of a closed hollow bulb obturator. Brown Kenneth E.
24

(1969) described a technique for fabricating hollow

bulb obturator by processing the defect and the maxillary portion of the prosthesis separately by using two interchangeable flasks. The two separate sections are, then joined later on, with cold cure acrylic resin. Riley Cordell
116

(1970) presented a technique for modifying patients

existing dentures into temporary obturators following maxillectomy by utilizing an intermediate soft denture reline material. After the bulb is traced from the lateral posterior corner to the anterior midline, the lateral height of the bulb should be increased to a point well above the juncture of the skin graft and the buccal oral mucosa. The weight of the bulb is lowered by scooping out a portion of set material with a scalpel in the centre and is left open superiorly. Browne Kenneth E.
25

(1970) described certain clinical considerations to

improve obturator treatment. He believed that irradiated tissues should be spared of undue stress and in instances of high radiation dosages, prosthodontic treatment may not be considered. He stated whatever tissue remained following surgery should be used judiciously for support and stability. Scar formed along the surgical margin should be utilized for retention. He advocated monoplane occlusion in conjunction with reduced tooth size to minimize masticatory stresses and laterally generated forces. He emphasized that sound prosthodontic principles should be utilized in treating these patients so, that a concept of not mere survival from disease alone, but a return to a normal functioning life is achieved. Kloeffler
69

(1970) in his report on maxillary orthopedics in cleft palate

treatment described the approach of McNeil of early maxillary orthopedics to expand the maxillary arch by using 4 to 12 graded restorations to create slow expansion. After proper expansion of the maxillary segments (which required 40 days), the floating premaxilla was retruded by the use of head cap and either elastic or adhesive tape and the lip closed at 6 months. This early treatment merits delayed surgical closure as it aligns the segment better prior to surgery.

13

Marshall R. C. et al

79

(1971) studied the effect of palatal lift prosthesis

upon the speech intelligibility of a dysarthric patient. He stated that dysarthric patients can improve their speech intelligibility with palatal lift prosthesis and that the effects of prosthesis upon a patients speech might be more adequately determined after the individual has used the device for a considerable period of time. They noticed that palatal lift prosthesis in addition to speech intelligibility reflected improvement in resonance and. articulation skills. Chalian V. A and Barnett M.U.
30

(1972) described a technique for

fabricating a one-piece hollow obturator using autopolymerizing acrylic resin shim, for decreasing its weight and making it light. Heat cure acrylic is then flowed around the shim so that the shim becomes an integral part of the bulb. Hahn George W.
54

(1972) described the fabrication of silicone bulb

prosthesis for obturating the defect following maxillectomy. He advocated the fabrication of prosthesis in two parts. Initially, silicone bulb obturator prosthesis is fabricated followed by the fabrication of a denture to fit the remaining part of the maxillary arch and the bulb. An acrylic insert is incorporated in the denture for retention. The technique had following advantages a) It allows the patient to wear and insert the bulb without wearing his dentures. b) It allows utilization of more undercuts for retention because of the flexibility of silicone bulb c) The insert holds the denture more securely in place than the usual obturator. d) Seals off the surgical defect lightly with very little discomfort. e) Lighter and more comfortable to the patients. Toremalm N. G.
138

(1972) described a simple and inexpensive technique

for fabrication of temporary obturator. He used silicone rubber (dimethyI polysilicone) for making the obturator prosthesis. The cast of the defect is used as a model for mixing silicone-rubber substances; the foam component and the catalyst. The porous surface of sponge is compressible. Elastic obturator is painted with silicone rubber to make it water proof. Adisman KI, Laney WR 3(1972) summarized the minimum acceptable laboratory procedures for maxillofacial prosthodontics and for the intraoral

14

obturator prosthesis they mention that the palatopharyngeal extension section should be designed by the dentist to have either of the following: cast metal connector, acrylic resin connector, cast metal connector or wrought wire connector embedded in acrylic resin, retention loops for nasal and pharyngeal sections, uvula ring extensions, rigid and non rigid connectors for the palatal lift prosthesis. They added that the nasal and pharyngeal extensions from the parent prosthesis (designed by the dentist) could be solid acrylic or silicone extension, hollow acrylic or silicone extensions, which may be rigid or flexible. These procedures would include the following minimum procedures in the laboratory management of impressions, management of casts, wax up (and spacers if required) of the two component system, flasking and investment, processing and assembly of components, finishing & polishing and testing the efficiency of the seal of hollow extension prosthesis. Chierici and Lawson
32

(1973) in their work on clinical speech

considerations in prosthodontics describe the seven dimensions basic to speech respiration, phonation, resonation, articulation, audition, neurologic integration and emotional behaviour. Buckner Horst
27

(1974) described a technique for fabrication of a denture

with hollow bulb obturator and lid utilizing permanent soft acrylic lining by investing, packing and heat curing in one process. The technique is of great advantage as soft acrylic resin is used to engage undercuts in the cavity, leading to increased retention. Also the prosthesis is lightweight as the thickness of the shell, and the lid can be determined and controlled in every phase of the procedure Ohyama et al
93

(1975) presented a technique to construct a hollow

extension obturator comprised of two materials. An inner hard acrylic resin hollow core is used to reduce the weight and provide dimensional accuracy while an outer layer of soft silicone enhances retention and tissue tolerance. Tautin & Shaaf
29

(1975) presented a novel approach to obturator

construction, by utilizing a superiorly based defect (facial defect) for gaining access to the oral defect in patients with trismus. Such a fabrication was termed by them as superiorly based obturator wherein the maxillary defect is approached from the top rather than from below.

15

Immekus & Aramany 57(1975) described the use of Andrews Bridge for cleft palate patients as this system permits the replacement of lost teeth as well as supportive structures necessary for proper esthetics. Parel & Drane
99

(1975) described the prosthetic support of the visual

apparatus after maxillectomy and orbital floor resection. There are three options: - one-section prosthesis (hollow or solid), two-section prosthesis with flexible antral extension and two-section prosthesis with solid antral extension. Solid one- section prosthesis is easy to insert and maintain, but it transmits jaw movements to the eye. Two-section prostheses do not transmit this but they are difficult to insert and maintain. Hence, the surgical reconstruction of the orbital floor should be treatment of choice followed by prosthetic treatment. Mazaheri M and Mazaheri EH
85

(1976) enlisted various prosthodontic

aspects of palatal elevation and palatopharyngeal stimulation Elevation, of the soft palate should he gradual to avoid placing pressure upon the teeth retaining the prosthesis and to reduce mucosal irritation. Prosthesis stimulation should be initiated as soon as palatal paralysis is noted to prevent disuse atrophy. The palatal lift prosthesis may be used as a temporary or definitive treatment for palatal in competency. When, adequate elevation of the soft palate has been achieved, the prosthesis may be discarded; otherwise the patient could wear the prosthesis as a permanent supportive device. The construction of tile combined palatal lift / pharyngeal section prosthesis includes the gradual palatal elevation and moulding of the pharyngeal section to reduce the gag reflexes and to increase palatopharyngeal muscle adaptation to the prosthesis. Speech and myofunctional therapy should be instituted in conjunction with prosthetic treatment. The palatal lift and combination prosthesis are made effective for patients with less severe neurologic impairment and speech

articulatory problems. The palatal lift prosthesis is more effective for those patients with palatal incompetency, who have no involvement of the other oropharyngeal muscles. The combination type of prosthesis is more

16

effective for patients with palatopharyngeal insufficiency without marked speech articulatory disorders. Matalon V.and La Feunte H
82

(1976) outlined a simplified technique for

processing a hollow obturator using sugar to occupy space during processing. The sugar was then removed leaving the interior of the prosthesis hollow. The hole created from removing sugar is later sealed by autopolymerizing resin. Robert H. Wood and William Carl
151

(1977) described a technique for

fabrication of hollow silicone obturator attached to a hollow dental prosthesis, by utilizing flexible impression trays for making impression of the defect. William Carl also described fabrication of immediate surgical and transitional silicone obturator prosthesis for patients undergoing maxillectomy. He stated that temporary stage should be maintained till the healing is complete and is usually 3 to 6 months before definitive obturator prosthesis can be constructed. Dalston
39

(1977) described the speech pathologists view in the

prosthodontic management of cleft palate patient. The use of an obturator as a training prosthesis to increase muscle activity during speech, occasionally to the extent that the use of prosthesis can be discontinued has been documented. However, surgery is a better option according to the author. Aaron Schneider
40 122

(1978) described a technique for fabrication of hollow

bulb obturator utilizing double investment procedure and ice. Desjardins RP (1978) stated that the defect of a partially edentulous

maxilla may need only coverage and sealing without maximal superior penetration. However, the completely edentulous maxilla requires maximal penetration and intimate contact of the obturator and extension of the prosthesis to the surrounding surfaces of the defect for retention, stability and support. He stated that for partially edentulous arch with maxillary defects, the placement of retentive clasps as near to, and as far from the defect as possible, is an excellent principle of design. He believed that the occlusal plane or the artificial teeth for the prosthesis with the jaw having the defect should be favoured. The mandibular dentition should be restored as ideally as possible to minimize or eliminate occlusal imbalances for the maxillary prosthesis, restoring a maxillary defect. He further stated that the stability of the maxillary prosthesis would be enhanced if the forces of occlusion in

17

mastication would direct the prosthesis upward inward and posteriorly in bilateral simultaneous posterior teeth contact. To prevent annoyance from mucous drainage in the well fitting maxillary obturator prosthesis, Kenneth Adisman added that providing a groove or trench on the superior surface of obturator extension inclined downward towards the nasopharynx would aid in the passage of mucous and nasal fluid posteriorly. Sometimes, an auxiliary escape channel may be indicated to prevent the accumulation of nasal mucous secretions. Aramany 7 (1978) gave the basic principles of obturator design for partially edentulous maxillectomy patients. He classified these defects into 6 categories depending on the frequency of defects occurring in a population of 123 patients. Aramany
8

(1978) described the system of forces acting on obturators for

the partially edentulous maxillectomy patient and gave guidelines for designing the prosthesis according to the type of defect present. Parr
102

(1979) described fabrication of combination obturator having rigid

and a flexible component. He said that rigid component should be used in defects where there is no undercuts to provide retention or where retention is gained from a flexible soft tissue scar band. The rigid extension is usually made hollow; to decrease the weight and the border of the extension is usually placed as high as possible to resist downward displacement. The flexible component or obturator is used in defects with hard or soft tissues undercut, also it may be allowed to extend superiorly to contact with the tissues to gain, additional support and stability for the prosthesis. The combination appliance thus presents a design of an obturator prosthesis, which takes maximum advantage of the patients remaining anatomy. Koray Oral et al
96

(1979) described the construction of buccal flange

obturator in which the obturator does not have a closed hollow section. Instead of the prosthesis projecting into the defect as a hollow section, the anterior, posterior and lateral flanges of the obturator are extended into the defect. He later studied the efficacy of buccal flange obturator in partial maxillectomy patients in comparison with hollow obturator and with no obturator to evaluate speech intelligibility. They converted the buccal flange obturator into hollow obturator by the addition of a lid made of autopolymerizing acrylic resin just prior to speech evaluation. They concluded that in both live and tape-recorded

18

speech evaluation, the buccal flange obturator produced speech, which was significantly superior to speech with no obturator. The hollow obturator also produced speech significantly superior to speech with no obturator. The buccal flange obturator showed a statistically, significant superiority as compared to the hollow obturator. Clinically the buccal flange obturator proved superior to the hollow obturator in simplicity, speed of fabrication, ease of cleaning, reduced weight retention and hygiene. Lavelle W. E. & Hardy72 (1979) stated that for optimal results with palatal lift prosthesis, the patients should have some pharyngeal wall movement. It is also desirable for the palatal, pharyngeal, and glossopharyngeal muscles to have relatively low muscle tone or be hypotonic. If these muscles are hypertonic, severe pain in the lateral pharyngeal area particularly during swallowing may occur. It is also desirable to have adequate palatal tissue to permit a drape of palatal projection around the borders of the palatal projection of the prosthesis to create a seat between the acrylic resin and the pharyngeal walls. The optimal result criteria include: Complete palatopharyngeal closure during speech Oro-nasal coupling during nasal speech production and for nasal respiration No prosthetic interference to oral articulation Acceptable oral and pharyngeal comfort Rahn et al
113

(1979) discussed prosthodontic principles in surgical

planning for maxillary and mandibular resection patients and gave the following guidelines. As much of the soft palate as possible should be preserved which helps in posterior seal and definite limits for posterior extension of obturator. The presence of soft plate also allows the extension of prosthesis posteriorly over the anterior border to increase retention especially in patients with posterior and lateral wall defects. The vomer and inferior conchae should be removed from the margins or if present, should be relieved in the prosthesis as these structures cannot tolerate and resist superior movement of prosthesis. Excision of dentulous maxilla should be done in middle of the socket of most anterior tooth to be removed and not immediately adjacent to the preserved tooth.

19

Fibrous attachments in the labial sulcus, particularly at the medial margin of the maxillary resection should be avoided, as these attachments cause limitation in extension of prosthesis. Maxillary tuberosities should be left intact as far as possible as they provide stability and support Placement of skin grafts to be encouraged as they allow patient to tolerate the prosthesis. Also the mucodermal scar band contracts to form a continuous scar band in the lateral margin of the maxillary defect. This band provides a narrowing of the defect and a relative undercut superior to the band, thus allowing the obturator to extend more superiorly and laterally to obtain retention. Zaki Hussein S.
154

(1980) described a method for adding a bypass to an

edentulous obturator to prevent nasal emission of fluids. The prosthesis consists of a hollow bulb obturator with a tube through its lateral wall, which opens onto the posterior superior aspect of the obturator at one end and into the premolar region orally. Pomerantz & Zimmerman
111

(1982) described the use of two non-parallel

canine abutments for a tissue bar overdenture obturator by joining the two abutments by TMS pin system Benington & Clifford
14

(1982) discussed a way of making impressions to

record the natural undercuts with silicone impression material to overcome the difficulty of directing the flow of material anteriorly over the palatal shelves. They described the use of a special tray with a hole prepared in the palate of the impression tray through which the impression material is injected with a syringe. Shifman A. 126(1983) described a technique to construct an open obturator against a removable silicone core to facilitate processing, recovery and polishing of the obturator that is open superiorly. Taicher et al
133

(1983) described fabrication of polydimethyl siloxane

acrylic resin obturator. Besides having usual advantages of silicone, polydimethyl siloxane resin obturator in addition, has excellent dimensional stability, is well tolerated, non-toxic and non-carcinogenic. Also, it has greater tear resistance, is more translucent without pigments. It has controlled stiffness when prosthesis with less flexibility is required and has higher density than most silicones. They advocated that such prostheses are useful in patients with severe trismus and unyielding tissue because of its flexibility and superior tolerance by intraoral and nasal tissues.

20

Ramsey WO

114

(1983) presented terminology pertaining to various

aspects of palatal lift prosthesis. He agreed with the use of term lamina or velar lamina for that portion or, a prosthesis that underlies, elevates and supports the neurologically impaired velum. He described that a lamina consists of a base that underlies the anterior one third of the velum, middle or midsection and a vertex that underlies a variable portion of the terminal one third of the velum. The outline form of the lamina could be more appropriately described as oblong - ovate or obovate than compared to spatulate, beaver tail etc. The margin of the lamina in contact with the posterior pharyngeal wall if blunt, should be best described as truncate and if notched to accommodate motor muscle must be called emarginated. Anterior posterior configuration of the velum could be either flat or arcuate in accordance with the anterior posterior curvature of a normal velum in moderate elevation. Lastly, he described the mode of attachment of velum to the maxillary denture base as fixed, adjustable, rigid or semi rigid. Taylor TD, Desjardins RP
136

(1983) reviewed the meatus type obturator

and stated that this type of obturator is best indicated for treatment of edentulous or partially edentulous with acquired soft palate defects where the retention and stability of the prosthesis are difficult to achieve. King & Martin
67

(1983) studied cast circumferential and wire clasps for

obturator retention. Light wire means non-cast type wire clasp. Wires used are platinum- gold- palladium wire, Co-Cr-Ni alloy wire; orthodontic S.S. wires are also used. Generally 18 or 19 gauge wires are used. Wire clasps are used for surgical or interim obturators, as they can be readily adapted to teeth and incorporated in all acrylic prosthesis. They found as per earlier studies that lingual retention was more effective than buccal retention. When support approached a straight line both buccal and lingual retention was required and if anterior ridge and teeth present indirect retention and bracing of the lingual plate with buccal retention was most effective. J. D. Browning et al
26

(1984) described fabrication of a hollow obturator

using fluid resin. The technique allows for precise control of the thickness of, the resin for minimum weight but with, sufficient thickness to allow for adjustment if necessary.

21

Coffey

33

(1984) discussed obturation of congenital and acquired intraoral

anatomic defects with inflatable latex balloon attached to tissue side of the rigid prosthesis. Kouyoumdjian & Chalian
70

(1984) described a technique for fabrication

of an interim obturator with duplication of the recently removed teeth and palate by using a vacuformed matrix of the preoperative cast. This duplication aids the patient as it provides an environment for the tongue similar to the preoperative one and simplifies deglutition and speech. Phankosol et al
106

(1985) presented fabrication of closed hollow

obturators with removable lid made up of mouth guard material, which is vacuum formed. Removable lid obturators, combine the benefits of both closed and open obturators. The removable lid permits cleaning of the inner hollow surface by the patient and also makes the obturator light. Also, the lid is easy to replace at a follow up visit once or twice a year. Moore et al
91

(1985) compared the rigid and flexible obturation of surgical

cleft of the soft palate using PERCI and listener judgement and found that the rigid obturator had the best fit with the pharyngeal complex (0.5 square cm area) and sounded the best to trained listeners. Thus, rigid or conventional obturation is better than an obturation technique that introduces varying degrees of flexibility. Beery et al
12

(1985) reviewed the role of oral endoscopy in prosthetic

management of the soft palate defect since its introduction by Taub in1966. They stated that it should be used to diagnose the deficit in the closure and also to assess the effectiveness of the prosthesis. Reisberg and Smith
115

(1985) described an objective aerodynamic

assessment of speech aid prosthesis to provide information about palatopharyngeal function to guide in the modification of the prosthesis to provide adequate palatopharyngeal function for speech. Palmer & Coffey
25

(1985) described the technique of fabrication of a

hollow bulb without the use of water or pressure, which when used requires opening the bulb, draining the water and resealing. Disantis
43

(1985) discussed a technique using vacuformed resin for

59

fabrication of an immediate surgical obturator, which saves a lot of time. Jacob et al (1985) described a technique for converting a surgical obturator into an interim obturator by using intermediate soft denture liner. The method allows the immediate soft denture lining material to function as

22

an impression material or to become an integral part of the interim prosthesis. Schwartzman et al

123

(1985) studied the occlusal force transfer by

removable partial denture designs in radical maxillectomy. They furthered the study carried out by Fiebiger et al (1975), which was inconclusive. They found that physiologic adjustment of the framework greatly reduced the stresses transmitted, highest stresses transferred in the premolar region for all designs. Lingual retainers produced more stresses than buccal retainers. In the anterior region and I-bar clasp with cingulum rest was the best combination for axial force transmission. From the perspective of the equitability of stress transfer, the tested designs from best to worst were the infra-bulge I-bar retainer (either buccal or lingual retention), light wire circumferential retainer with buccal retention, circumferential cast buccal retention and swing lock system. Minsley G E et al
88

(1986) gave a technique for the fabrication of closed

hollow obturator prosthesis. The technique allows for control of wall thickness of the obturator extension thereby minimizing the weight of the prosthesis. The lid placed over the open palatal portion of the obturator is ultimately sealed with an additional layer of heat-cured acrylic resin. In addition, the junction between the lid and the palatal portion is remotely located in relation to the lid thus minimizing micro leakage. Parel et al
100

(1986) discussed the intra oral applications of

osseointegration in maxillofacial prosthodontics especially in highly compromised patients for whom previous conventional treatment is marginally successful or limited from inception. Yuuji Sato et al
120

(1987) described palatal Iift prosthesis for edentulous

patients. The prosthesis consisted of a movable palatopharyngeal section that elevates the soft palate by the force of orthodontic wire. The prosthesis improved both speech and swallowing. Orthodontic wire used were Ni-Ti, which shows a unique stress-strain curve. Groetesma W.R.
52

(1987) reviewed the role of maxillofacial prosthesis as

a speech rehabilitation aid and its use in patients with velopharyngeal inadequacy, glossectomy and maxillectomy patients. Karnell et al
66

(1987) described the use of nasoendoscopy. The flexible

fibreoptic endoscope inserted nasally provides a clear view of the velopharyngeal port during speech without limiting movement of the oral

23

structures during speech production and should be used along with oral videoendoscopy especially in patients with complex etiology and patients with poor maxillary dentition as minimal bulk of prosthesis is required for retention and stability and videoendoscopy aids in developing the obturator with minimal bulk and optimal result. Spratley M. et al
132

(1988) suggested a new design for palatal lift

appliances in patients with neurogenic velopharyngeal incompetence utilizing a hinged posterior extension. Their design utilized initially a rigid hinge but this was difficult to adjust and had limited mobility. Subsequently they utilized single wire spring hinge using 0.6mm initially, which was later changed to 0.5mm twin wire, which allowed easy adjustments to achieve optimal elevation and some degree of lateral movement. The material of choice for fabrication of extension was high molecular mass copolymer vinyl mouth guard material. A wire grid constructed by bending and spot welding 0.6mm stainless steel wire was used as a base for the copolymer- extension. Such hinged appliance was found adequate to support the palate whilst remaining, comfortable to the patient. These curve and are highly flexible, thus providing both retention and causing palatal lift. Wu & Schaaf
153

(1989) conducted a study to compare the weight

reduction in different designs of solid and hollow obturators and found that hollow obturator designs had weight reduction from 6.55 % to 33.06% depending on the size of the defect. Birnbach & Barnhard
18

(1989) described a single appointment technique

to convert a solid obturator to hollow obturator prosthesis by removing the acrylic resin that fills the bulb from the palatal aspect, creating a bevel and dove tail on the margin and then construction a lid out of autopolymerizing resin. Huryn & Piro
56

(1989) described the fabrication of maxillary immediate

surgical obturator and the treatment protocol including preoperative, operative and post operative guidelines. Parr et al
103

(1989) described a series of Aramanys obturator design

templates and discussed the relative considerations for each. In all situations, they advocated the quadrilateral or tripodal design over linear design pattern. As they allow a more favourable leverage design application that will aid in the support, stabilization and retention of the prosthesis.

24

Tobey & Lincks

137

(1989) did the acoustic analysis of speech changes

after maxillectomy and prosthetic management and found that the prosthetic management resulted in the reduction of resonances by either complete elimination of resonances, reduction in amplitude or by changing the frequency of resonances to more nearby regions of the vowels. Khan
68

(1989) described the fabrication of soft palate obturator in light

60

cure resin, which is done chair side, is convenient and time saving. Jacob RF (1990) in her work on soft palate obturator design stated that the prosthesis design of indirect retainers without anterior clasps and various designs of molar clasp arrangements is esthetic, retentive, and functional and preserves existing structures. This design should also be used in congenital soft palate defects where anterior teeth are not replaced. When modification spaces must be restored, it may be necessary to include anterior clasps. Whether the indirect retainer acts as a lever or only redistributes forces around the dental arch remains to be answered. DaBreo and Ghalichebaf
36

(1990) described a method for designing and

fitting a provisional fixed restoration (instead of removable partial denture) for a patient of cleft lip and palate and emphasized that the provisional restoration provides an alternative treatment option that allows the dentist to plan the definitive restoration while providing the patient with an esthetic and functional restoration. Masumi et al
81

(1990) described the use of sectional prosthesis

consisting of a nasal retainer; hollow obturator and hollow complete denture retained together by samarium cobalt magnets to restore a partial maxillectomy defect. DaBreo
37

(1990) presented a new method of making a maxillary interim

obturator with visible light cured resin, which allows the dentist to make and deliver the prosthesis at the same visit using minimal time and equipment. Shifman
127,128

(1990) described the clinical applications of visible light

cure resin material as a tray, denture base and reline material in Maxillofacial Prosthodontics. Gardner et al
47

(1990) in a clinical report presented a technique to

fabricate a combination nasal-support breathing flange with hollow obturator in a patient with Aramany class VI defect.

25

Turner & Williams

140

(1991) described the role of fluoroscopy and

nasoendoscopy in designing palatal lift prosthesis and also suggested procedural guidelines in patient management. Jhanji & Stevens
64

(1991) described the fabrication of a one- piece

hollow obturator using silicone putty as obturating material in the fabrication procedure instead of sugar, asbestos or foam and hence, is a controlled process in which the thickness of the obturator could be easily modified by adding to or reducing the dimensionally stable putty and did not involve autopolymerizing resin. Gardner et al Williams
148 48

(1991) described a simplified technique for the fabrication

of a hollow obturator prosthesis using vinyl polysiloxane. (1991) described a technique to make the impression for a palate repaired by a bulky tongue graft providing selective pressure to the residual palate while relieving the graft, in order to fabricate the prosthesis. Jacob & Yen
61

(1991) discussed the role of processed record bases for

the edentulous maxillofacial patient. Its use increased the accuracy of registration of jaw relations and minimizes the defects in occlusion, aesthetics, lip support and buccolingual tooth placement. DaBreo
38

(1991) studied the dimensional change in maxillary prosthetic

obturators and found that light polymerized one was most stable followed by heat cured and then autopolymerized resin. Polyzois G. L. et al
110

(1992) described fabrication of an open partial

denture obturator prosthesis utilizing a visible light cure denture base resin and a resilient liner polymerized by visible light. According to them, the technique had following advantages: a) Easy and rapid fabrication. b) Better control of thickness and resiliency of the obturator prosthesis. c) Easy to repair, by using increments of resilient materials. d) Combination open obturator prosthesis provides a stable record base for securing jaw relation records. e) Can be used for partially edentulous or completely edentulous patients after maxillary resection. Black W
19

(1992) described the fabrication of a stable, versatile surgical

obturator for dentulous patient made in acrylic and wrought wire, based on the swinglock concept, which allows for simple transition from surgical to even definitive obturator.

26

Schmaman J

121

(1992) presented a technique utilizing silastic foam to

make impressions for maxillary defects to overcome withdrawal problems as flexible but harder material traumatizes tissue while hydrocolloids have low tear strength. Kaplan
65

(1992) described a way of using polyether to form a palatal

contour guide for positioning retentive framework for the obturation of a maxillectomy defect. Maurice Didier
42

(1993) utilized a new thermoplastic material polysar

(polyisopren family) to create a hollow obturator extension for immediate lightweight obturator prosthesis inserted at the time of surgery. The obturator prosthesis consists of three sections, the denture base silicone, elastomeric material intermediatory section and the obturator extension. The advantage of Polysar was weight reduction of almost 42 % compared to silicone prosthesis and as it was thermoplastic, it could be readapted to conform to the changes in tissues due to healing. Wolfaardt et al
150

(1993) carried out a pilot study to establish the

effectiveness of palatal lift appliance in treatment of patient with palatopharyngeal incompetencies. They observed that only in 2.3% cases use of an appliance followed by speech therapy was preferred treatment. In the same study, 6.9% preferred surgery followed by speech therapy. Wolfaardt et al developed a decision protocol for management of palatopharyngeal incompetency. Shimodaira et al
130

(1994) used an obturator prosthesis with small

flexible silicone extensions placed at the nasal and oral sides across the mobile anterior margin of the soft palate and found it to be most effective for patients with few remaining teeth having extensive maxillary defect extending into the soft palate but added that long term follow up is advisable as soft silicone material may harden and lose flexibility. Vojvodic et al
141

(1996) described a case of cleft palate where they used

root copings, telescopic and veneer crowns with rests and metal base partial prosthesis to provide satisfactory function, esthetics and alleviation of the deformities. Light
75

(1997) described the functional assessment in maxillofacial

prosthetics. In speech aid prosthesis; speech language pathologists can do both quantitative and qualitative analysis. The quantitative tests include tongue pressure and endurance test, tongue/palate placement and range of motion, tongue rate of movement, speed of swallow and nasal emission.

27

The qualitative tests include quality of life indices, clinical tests of performance, indirect palatography, oral speech performance, drooling and speech intelligibility tests. Roumanas et al
119

(1997) conducted a clinical evaluation of implants

retaining edentulous maxillary obturator prostheses. They concluded that edentulous maxillectomy patients could benefit from implants. Many factors such as radiation status, available bony sites and surgical procedures may influence implant prognosis and the design of the obturator components. The anterior maxillary segment is a key site for implant placement, however anterior implants showed more bone loss (almost three fold) than the posterior implants, indicating higher level of stress anteriorly. They also advised against placement of implants during surgical resection due to the high recurrence rate and mortality in these cases. Also, implants irradiated after placement demonstrate low survival rate. Hence, implants placed within the surgical defect have low probability of survival and are difficult to restore and maintain. Wang & Hirsch
144

(1997) described an easy time saving procedure that

uses visible light activated denture base materials as a reline material to close an open type interim obturators. Also it can be used in patients using definitive obturator for correcting leakage problems. Wang
143

(1997) described the use of sectional prosthesis retained by Sr

86

Co for total bilateral maxillectomy patient. McAndrew et al (1998) described an innovative investment for the

fabrication of closed hollow obturator prosthesis, which eliminates the need for the fabrication of a heat processed denture base when retention and stability of the removable record base can be readily achieved, allowing for accurate maxillomandibular relation records to be recorded. Wang R
145

(1998) described the advantages of presurgical orthopedics in

a cleft patient and the rationale and use of a thermoplastic resin reline material to remold and modify bulb prosthesis to compress a severely rotated premaxilla to a desired position before cheiloplasty. Blair & Hunter
20

(1998) described in a case report of making a hollow box

interim obturator by using a copy of the existing prosthesis to make a final closed mouth impression and using a plaster- pumice core to make a hollow box obturator.

28

Shifman et al

129

(2000) described speech aid prosthesis for neurogenic

velopharyngeal incompetence and stated that a wire extension speech aid prosthesis is an effective treatment approach and nasopharyngoscopic control is mandatory for maximizing the effect of closure around the nasopharyngeal section of the prosthesis in function and it still allows nasal breathing. Brosky et al
22

(2000) described the fabrication of radiation bolus

prosthesis for the maxillectomy patient for postoperative brachytherapy. This custom made prosthesis is simple, efficient and atraumatic to the patient while providing homogenous adequate radiation to the tissues. Esposito et al
46

(2000) used palatal lift and augmentation prostheses to

improve dysarthria in patients with amyotrophic lateral sclerosis and concluded based on the positive results that these speech aid prostheses should be considered in this adult onset neurodegenerative disorder. Ziada & Donovan
156

(2000) described a technique using visible light cure

resin to reduce the vertical height of a hollow box interim obturator to compensate for the tissue changes without remaking the entire obturator. The cap like piece 4 mm in height is cut and the obturator without the lid is tried and checked for extensions and adjusted followed by sealing of the lid by Triad light cure resin material. Dexter & Jacob
41

(2000) discussed the reconstruction of maxillectomy

defect by temporalis flap. Historically, the consensus has been not to surgically obturate the defect, but they favoured immediate reconstruction because of its psychologic benefit to patient, presence of diagnostic monitoring tools like nasoendoscopy, MRI and CT, which could offset the loss of visibility of defect to check for recurrence, it may eliminate the need of an obturator. However, a temporalis flap placement is obstructed by the zygoma, which may need to be sacrificed leading to loss of masseteric attachment and compromised chewing ability. Use of implants also becomes necessary, as there is loss of natural undercuts and the support from foundation is not adequate. This prosthesis should also be considered as an obturator as it replaces tissue and restores function to a maxillary surgical site and additional time and expertise are required to fabricate the prosthesis. Mac Carthy & Murphy
77

(2000) described a simple technique to replace

the silicone extension of an existing two piece obturator utilizing the same

29

denture base to make a pick up impression in polyether of a wax shell impression of the defect, pouring a split cast and fabricating the extension in molloplast B. Matsumura & Kawasaki
83

(2000) in a clinical report described the use of

a magnetically connected removable sectional denture for a maxillary defect with severe undercut. Okay et al
94

(2001) introduced a classification system of defects for

prosthodontic guidelines for the surgical reconstruction of maxilla. Palatomaxillary defects were divided into 3 major classes ad 2 subclasses. The aim of this classification was to organize and simplify the complex nature of the restorative decision making process for the maxillectomy patient. Cotert et al
34

(2001) described a modified flasking technique for

processing an obturator with continuous pressure injection by aligning the wax pattern perpendicularly. They also used a modified channel design and a simple method to pull back the injection funnel to increase the volume of the flask. The pulled back funnel is kept in position by means of a stone spacer; sprue channels completely surrounded with plaster are used to obtain continuous pressing of the mixed resin into the farthest regions of the flask. Parel et al
101

(2001) described the use of remote implant anchorage for

rehabilitation of maxillary defects especially using the zygoma and malar buttress. These implants provide support for cantilevered prosthetic extensions and reduce stress to teeth in the native site. Pigno & funk
108

(2001) in a clinical report described a method to extend

the obturator into the nasal aperture space to augment retention. After conventional obturator was made an impression is made with soft liner, removed, reoriented with base, a stone index made and the nasal extension made in autopolymerizing resin. The path of insertion has to be modified as the obturator has to be placed in the posterior oral cavity and then moved antero-superiorly to engage the nasal aperture. Pigno
109

(2001) in a clinical report discussed the prosthetic rehabilitation

of a maxillary defect following free flap reconstruction. However, there are problems, as although, the reconstructed defect provided vertical support, it did not allow for the attainment of a border seal or extension of the defect to augment retention. Therefore, it is not always beneficial for a patient to

30

undergo reconstruction as it may even diminish, the eventual prosthetic and overall treatment outcome. Rilo et al
117

(2002) described the use of titanium and visible light cure

resin to fabricate an obturator, which provides a biocompatible lightweight alternative, which can be relined easily. Tapia et al
134

(2002) describe a technique for the duplication of the

pharyngeal part of the interim speech aid for transfer to the definitive speech aid. This technique saves a lot of chair side time as it eliminates the reshaping the new pharyngeal part for the definitive prosthesis. Sigurgeissdoiter et al131 (2002) described a case in which they used swinglock design which allowed the patient to negotiate the path of insertion of the obturator section inspite of trismus while the innovative use of ERA attachment provided a satisfactory locking mechanism and enabled the replacement of the male cap and long term use. Parr & Gardner
104

(2003) gave a brief overview of the evolution of the

obturator framework design right from Ambrose Pare who described the first button shaped sponge and metal obturator to the present day complex surgical-prosthodontic coordination and the use of vascularized free flaps with osseointegrated implants. Chambers et al
31

(2004) described the obturation of the partial soft palate

defect, which may result from the surgical resection of the posterior border from the medial or lateral portion of the soft palate. Reconstruction is tried but, if it fails, obturation needs to be done and the residual flap complicates the successful obturation. In these patients the position and level of the obturator prosthesis in the nasopharynx is determined by the position of movement of the remaining mechanism. Generally in such patients the closure of the soft palate defect against the posterior pharyngeal wall should extend about 5-7 mm in vertical height, with closure at the level of the palatal plane and anterior tubercle of the Atlas vertebra. The author also has outlined a method to record the contours of the partial soft palate defect for proper prosthetic obturation. Habib & Driscoll
53

(2004) have described an alternative technique for

fabricating a closed hollow obturator, which is convenient and time and cost saving. During packing acrylic is packed to form the apex of the bulb followed by a sheet of acetate to act as separator and the rest of the mould

31

is packed. After curing, the lid is pried of. Obturator tried in mouth and made hollow. It is inserted without the lid. On recall, the obturator is checked and if acceptable, then the lid is sealed with autopolymerizing resin. Marunick M
80

(2004) described the design considerations for a hybrid

gate design framework that incorporates both conventional cast direct retainers and the gate design concept in the same framework.

32

The roof of the oral cavity is formed by the anterior hard palate and posteriorly by the soft palate. The hard palate is formed by the premaxilla anteriorly(which supports the incisors) and the palatal process of the maxillae and horizontal process of the palatine bones which are joined together by the intermaxillary, palatomaxillary and the mid palatine sutures.16

Fig.5: A view of the roof of the mouth.

Fig. 6: Diagram of the bony anatomy of the palate and nearby structures.

Understanding of the developmental biology of the face and palate is best attained on a platform of biological paradigms and information drawn from the multidisciplinary worlds of classical embryology, developmental biology, and, today, from the exciting worlds of molecular biology. The advent of many new and exciting clinical intervention strategies for the treatment of birth defects now allows clinicians to treat the most delicate of craniofacial abnormalities, conditions that until recently

33

were beyond the realm of treatment even for skillful practitioners due to lack of appropriate technologies. This text provides a highlighted developmental blueprint followed in human craniofacial morphogenesis, with a special focus on defects of the face, palate, and associated structures. Although recent advances in developmental and molecular craniofacial biology have contributed heavily to our understanding of face and palate morphogenesis, the almost exponential expansion of the fundamental knowledge base in these areas clearly centers on the almost universal phenomena that affect craniofacial "building block" cells at one or several points in their life cycle. These fundamental phenomena include patterns of early DNA signaling; biochemical organizers; nuclear and cellular differentiation; and proliferation, migration, and patterns of interactive behaviors at intracellular, cell surface, and extracellular matrix levels. Complete or partial interruptions of any one or combination of these phenomena have been implicated in the identification of etiologic and pathogenic causes of mammalian birth defects, including those of the human craniofacial regions. The building block cells for the head and face are identifiable both premorphologically and morphologically as early as the second intrauterine week. Once mapped out, these cells continue with their peak period of cell differentiation, proliferation and migration through the second intrauterine month. Although the classical picture of craniofacial morphogenesis can be framed on the morphogenesis of the primary germ layer cells (i.e., ectoderm, mesoderm, and endoderm), there is little doubt that the current understandings of and excitement about mammalian, including human craniofacial morphogenesis have been significantly advanced by a plethora of studies of the origins and behavior of embryonic neural crest cells. Morphogenesis of the facial regions depends heavily on the timely differentiation, directed migration, and selective proliferation of these crest cells which arise as a product of neural tube formation as the neural tube progressively pinches off from the overlying skin along the body's dorsal axis. As will be discussed later, cells and tissues within each of the embryonic facial primordia arise from neural crest cells that have migrated

34

into the facial regions, as cell clusters called rhombomeres, from their sites of origin along the portions of the neural tube which form the brain. The determinants of crest cell migrations have been variously hypothesized as including intrinsic cell "targeting" factors and chemical signaling from cells lining the extracellular cleavage planes through which the crest cells migrate. Crest cells from the developing midbrain regions migrate into upper facial regions, whereas crest cells from hind brain migrate selectively into the lower facial regions. Importantly, once the crest cells migrate into specific facial regions, they differentiate into mesenchymal cells that subsequently give rise to connective tissue and muscle cells of those specific facial regions. Although the predominantly neural crest-derived mesenchymal cells in the facial regions do co-mingle with mesodermally derived mesenchymal cells, the interactive nature of their co-mingling, or lack thereof, remains uncertain. Consistent with the tenets of the

"developmental field concept" in human morphogenesis, both human and experimental studies generally have hypothesized that significant and early interference with the normal differentiation, proliferation, and migration of embryonic cells, including especially the craniofacial neural crest cells, can lead to isolated and syndromic craniofacial defects, called neurocristopathies, whose occurrence and severity depend on a combination of environmental and genotypic factors specific to a given individual. As the embryo's cephalo-caudal axis is established, a facial developmental field is one of the first of the head regions to appear. Centrally located in this region is a discrete bilaminar tissue plate, called the oropharyngeal membrane, whose structure and location marks the junction between the oral ectoderm and the endodermal digestive tube. This membrane progressively degenerates through the normal process of programmed cell-death" which involves increased phagocytic or lysosomal activity along the inner and outer surfaces of the membrane. Once the degeneration of the oropharyngeal membrane is completed at 4 weeks, continuity then is established between the spaces of the early oral cavity and the pharyngeal portions of the digestive tube. Only rarely does the oropharyngeal membrane fail to degenerate. Interestingly, a similar ecto-endodermal plate lies at the depth of a groove which separates the first branchial from the second branchial arch.

35

At 4 weeks, a series of lateral surface elevations, called branchial arches, become quite prominent on the lateral side of the head. The branchial arches contribute significantly to the formation of the face, palate, and associated structures. Most congenital malformations of the head and neck have their beginnings during the cellular transformation of the branchial arches into their adult derivatives. As examples, branchial cysts and fistulae can occur in those rare instances in which human branchial (or gill) clefts fail to smoothe over on the lateral side of the neck. As mentioned earlier, cell masses, which contribute to the bulging prominence of the arches are the neural crest cells that have migrated into the branchial arches from specific brain regions, and which eventually differentiate into mesenchymal cells and give rise to skeletal and muscular structures specific to a given branchial arch. The first pair of branchial arches is most important in shaping the human face and associated structures and will receive the most attention in this text. The first branchial arch, often called the mandibular arch, develops as two elevations around the oral opening, which was filled in earlier by the oropharyngeal membrane. The larger, and lower regions of this arch form much of the mandibular anatomy and the malleus and incus middle ear bones, whereas the smaller and upper regions of the first arch on either side of the oral opening give rise to the anatomy of upper lip, teeth, maxilla, zygomatic bone, and squamous portions of the temporal bone. The second branchial arch is located beneath the first arch and is often called the hyoid arch because it contributes significantly to the formation of the hyoid bone and the third of the three middle ear ossicles, the stapes. These two branchial arches, like each of the other four branchial arches, are separated from each other by a surface branchial groove, which grows inwardly to meet an endodermal out pocketing from the developing pharyngeal region (i.e., the first pharyngeal pouch). As is the case with most branchial grooves and pharyngeal pouches, the contact zone between a branchial groove and a pharyngeal pouch is a bilaminar plate of ectoderm and endoderm which eventually degenerates, again through the process of "programmed cell death" and increased phagocytic activity. In the case of the first arch, however, this bilaminar plate is separated by invading crest-derived mesenchymal cells, which have been

36

linked with the failure of that specific plate to degenerate and persist normally throughout life as the adult eardrum, or tympanum. The elevated margins around the first branchial groove develop through the selective proliferation of mesenchymal cells beneath the skin into six separate mesenchymal swellings, called auricular hillocks. These auricular hillocks progressively (from both the first and second branchial arches) enlarge, migrate, and consolidate through programmed cell activity and eventually give rise to the external ear, or auricle. Failure of the auricular hillocks to develop normally can result in auricles of abnormal size, shape, and position as seen in a variety of isolated and syndromic craniofacial birth defects (e.g., first and second branchial arch syndrome, hemifacial microsomia, and microtia). The complete absence of the auricle (anotia) is a rare event. To complete this picture of the branchial arches, it is important to note that cell activity within the arches, is supported by pairs of blood vessels, called aortic arches, that distribute blood from the embryonic heart upward through the tissue of each arch toward the brain and then down to the body. As with the branchial arches themselves, not all of the aortic arches persist in humans. The aortic arches of the third, fourth, and sixth branchial arches do persist and become greatly modified throughout the embryonic period as they are reconstituted as the common carotid arteries which supply the neck, face, and brain. Especially important in this dynamic development of the craniofacial vasculature is the shifting of the primary arterial supply to the embryonic face prior to, during, and following the formation of the secondary palate. Unlike in the adult, prior to the seventh week, the primary source of blood to both the superficial and deep head tissues is the internal carotid artery and its branches. At about 7 to 8 weeks when the embryonic palatal shelves are experiencing their most critical stages of closure, an important shift occurs in the primary blood supply to the face and palatal tissues from the internal carotid to the external carotid arterial system. This transition involves a temporary vascular shunt between internal and external carotid systems provided by the stapedial artery. Failure of either the stapedial artery to form or a failure to make complete and timely transition has been hypothesized as possible sources of the pathogenesis of conditions such as cleft palate and mandibulofacial dysostosis.

37

Considerably dependent on the timely set of morphogenic events that have occurred from the time of implantation through the fourth week, the embryonic face continues through its own "developmental critical period," which spans the fifth through seventh intrauterine weeks. During this time period, human craniofacial morphogenesis is most susceptible to either known or suspected birth-defect-producing agents, or teratogens. Arising from the first branchial arch are four primordial, or building block, tissue masses that surround the large central depression of the primitive oral cavity. Continued morphogenesis of the facial prominences depends heavily on the continuing migration, proliferation, and differentiation of the neural crest cells, under the direction of developmental morphogens, to a point in time when the facial prominences, or primordia, are clearly identifiable as the single median frontonasal prominence, paired maxillary prominences on either side of the frontonasal process, and two mandibular prominences beneath the oral opening. The shape and size of these prominences, as well as development of the specific skeletal and muscular structures of each branchial arch, are critically dependent on the continued viability and differentiation of the neural crest cells, which are especially sensitive to teratogens (e.g. retinoic acid, cortisone). It is important to note that the outcomes of several distinct, brain-skin interactions in placode formation are also essential in early facial morphogenesis. By the beginning of the fifth week, oval patches of skin ectoderm lateral to the median frontonasal prominence interact with brain tissue to set off an ecto-ectodermal interaction resulting in the development of tile two thickened nasal placodes located at the ventrolateral regions of the frontonasal prominence. Neural crest-derived mesenchymal cells along the margins of the nasal placodes; proliferate rapidly to produce horseshoe shaped elevations around the placode, called the medial and lateral nasal prominences, whose continued rapid growth gradually forms the nasal pits, or early nostrils. The forward growth of each lateral nasal process forms the ala of the nose, whereas the medial nasal process contributes to the formation of the nose tip, columella, the philtrum, tuberculum and frenulum of the upper lip and the entire primary palate. Through the process of relative growth in this area, nasal placodes gradually "sink" to the depth of each nasal pit. A second important skin-brain interaction gives rise to localized thickenings of surface ectoderm, on each side of the embryo's head which

38

will form the eye's lens, retina, and optic nerve. Apparently, and as will be discussed later, these eye fields are first located on the lateral aspects of the embryo's head and progressively migrate to the frontal midline at about the time the facial prominences are consolidating into the complete face. Selective differentiation and proliferation of mesenchymal cells cause the maxillary prominences to enlarge and migrate medially toward each other and Lateral and medial nasal prominences. This migration is associated not only with patterns of cellular growth within the maxillary prominences, but also with the migration of the eye fields from the lateral to the frontal regions of the embryo's face during the fifth through eight weeks. Disturbances in normal eye field formation have been suggested as one possible cause of median facial clefting and the conditions of hypoand hypertelorism. Continued medial migration of the maxillary prominences on both sides also moves the medial nasal prominences towards the midline and each other. By the end of the sixth week, each maxillary prominence blends, or merges, with the lateral nasal prominence along a line, which demarcates the future nasolacrimal groove and duct. This event then establishes the continuity between the sides of the nose, or alar region, formed by the lateral nasal prominence with the thick region formed from the maxillary prominence. A combination of reduced cell numbers and abnormal migration of mesenchymal cells can lead to the abnormal merging or consolidation of the maxillary and lateral nasal prominences. Although seen infrequently, this can lead to facial defects involving oblique facial clefts, persistent nasolacrimal grooves, and failure of the nasolacrimal duct to develop. Between the fourth and eighth weeks, the medial nasal prominences merge with each other, small lower portions of the lateral nasal prominences and with cells in the larger maxillary prominences. This subsurface merging of cells, especially between the medial nasal and maxillary, prominences, results in the continuity of upper jaw and lip. As part of this consolidation of the medial nasal and maxillary prominences in upper lip formation, two important morphologic events need to occur: There is a deepening and downward growth of the nasal pit toward the oronasal cavity as a blind-ending sac whose floor eventually degenerates through programmed cell death, resulting in the formation of the primitive choanae,

39

which, allows a continuity between the spaces of the primitive nasal cavity and the common oronasal cavity. An event occurring concomitantly with nasal pit morphogenesis is the formation of the seam between the intermaxillary segment and the maxillary prominence. As these two segments come together in the sixth week, the developmental surface seam of cells between them also elongates as the nasal pit elongates, deepens, and moves downward. This developmental seam, called the nasal fin, essentially forms the floor of the nasal pit and progressively degenerates by increased activity among phagocytic cells on either side of the seam. Once the programmed cell death of the nasal fin is essentially completed at about the seventh week, mesenchymal cells from both the

intermaxillary and maxillary prominences intermix leading to fusion of the upper lip segments into the upper lip and its cupid's bow. The completion of the embryonic lips generally occurs about I week earlier than the formation of the palate. Thus, the lips and palate have different "developmental critical periods," and teratogens might affect the lips or palate either separately or in combination. The intermixture of mesenchymal cells within the consolidated lip segments gives rise to connective tissue components and muscle fibers within the orbicularis oris ring of the upper lip. Complete or incomplete failure of the nasal fin to degenerate has been associated with unilateral and bilateral clefts of the upper lip which variously involve abnormalities of the orbicularis oris muscle in terms of the number and distribution of its muscle fibers as part, of the orbicularis ring. Lateral clefts of the lip may, or may not be associated with clefts of the palate. Mesenchymal cell deficiency that results in partial or complete failure of the two medial nasal prominences to consolidate into a philtrum can contribute to the formation of such defects as a bifid nose or the rare median cleft ("hare lip") of the upper lip, as characteristically seen in the autosomally recessive Mohr syndrome. As the consolidation of facial processes progresses through the embryonic period, neural crest-derived mesenchymal cells within the maxillary prominences proliferate rapidly and differentiate into tissues which form mesenchymal cell fields from which the muscles of facial

40

expression develop, and whose myofibers are innervated by the cranial nerve to the second arch (i.e., the facial nerve). Similarly, crest-derived mesenchyme in the maxillary and mandibular portions of the first branchial arch differentiate predominately into the muscles of mastication which are innervated by the trigeminal nerve of the first branchial arch. Cells within the mandibular prominence give rise to muscle and connective tissue structures of the lower lip, chin, and lower cheek regions. With the reshaping and consolidation of the five major facial prominences, a recognizable human face is evident by the end of the eighth prenatal week. Morphogenesis of the mammalian palate is an even more complex process, which depends heavily on a balance of genetic, hormonal and various growth factors. As the face nears the completion of its developmental critical period, the lateral palatine processes, which form the secondary palate, grow out from the walls of the still common oronasal cavity. The developmental critical period for the palate is from the end of the sixth week through the eighth intrauterine week, or 1 week longer in duration than that of the lip. These palatine shelves first grow medially, then, become oriented inferolaterally to lie on either side of the tongue, which is quite precocious in its own development as a muscle-filled epithelial sac that fills much of the oronasal cavity. Nearing 8 weeks, the vertically oriented palatine shelves are progressively repositioned above the tongue mass. This repositioning of the shelves is thought to involve a combination of concurrent events, including a downward contraction of the tongue, an amoeboid-like reshaping of the shelves which gradually places them over the tongue surface, an increases in extracellular shelf "forces" (or shelf fluid turgor) which reposition the shelves in a horizontal position and a downward repositioning of the lower jaw. In reality, normal or abnormal horizontalization of the palatine shelves is related to a combination of these three events. Palatal shelf elevation begins in the posterior regions of the shelves, depressing the tongue downward and forward. This allows the more anterior regions of the shelves to first contact one another near the posterior edge of the primary palate, or in the region of the future incisive canal. Once the shelves are in a horizontal position, the shelves contact each other, and essentially stick together by a combination of interlocking shelf surface microvilli and a

41

proteoglycans surface coating. Once the shelves make contact, there is a degeneration (i.e., programmed cell death) of epithelial cells along the abutting shelf linings, and a directed movement of crest-derived mesenchymal cells from one shelf to the other. This process of epithelial degeneration along with intershelf bridging of mesenchymal cells is called fusion. The embryonic palatine raphe, or future midpalatine suture, marks the line of fusion between the palatine shelves. From the site of first shelf contact and fusion near the future incisive foramen, fusion of the more posterior regions of the shelves takes place over the next 2 weeks. Fusion also occurs between the shelves and the inferior edge of the nasal septum, except in the more posterior regions where the soft palate and uvula remain free. Once fusion of the shelves of the secondary palate is complete, their mesenchymal cells differentiate into osteogenic cells, which form the skeletal elements of the premaxillary, maxillary, and palatine portions of the palate. Formation of the soft palate and uvula follows a slightly different course than that of the regions of the secondary palate, which give rise to the hard palate. The soft palate and uvula develop from two separate masses found at the most posterior portions of the secondary palatine shelves. Unlike the fusion mechanism, which is in place along much of the length of the palatine shelves, the consolidation of these two separate masses is brought about by a selective proliferation of mesenchymal cells located deep in the valley between the masses. As that proliferation, called merging, continues the valley between the two distal shelf masses is obliterated, which results in a smoothening of the contour of the soft palate and uvula. Failure of the merging process in soft palate and uvula development can result in complete or partial clefts of the soft palate and uvula. Clefts of the palate, with or without clefts of the lip, are relatively common depending on the population group of the individual. Whereas occurrence figures for cleft of the- lip (with or without cleft palate) are about I in 1,000 live births, clefts of the palate (with or without cleft lip) occur once in 2,500 live births depending on the population group of the individual. Most clefts of the lip and palate generally correlated to interplay of genetic and environmental factors (i.e., multifactorial inheritance).

42

Although animal studies have provided some insight into the molecular and cellular bases of these defects, precise explanations, especially involving teratogens in the etiology of clefts of the human lip and palate are still wanting. Some clefts of the lip, with or without cleft palate, are seen regularly in a number of single mutant gene syndromes. Other clefts are associated with chromosomal syndromes, especially in trisomy. A complete cleft palate represents a maximum degree of clefting and is a birth defect in which the cleft extends from the incisive foramen region through the soft palate and uvula. The incisive foramen region is the demarcation used in distinguishing the two major groups of cleft lip and palate. Anterior cleft types include cleft lip, with or without a cleft of the alveolar region of the maxilla. Complete anterior cleft extends through the lip and alveolar region to the incisive foramen region. The pathogenesis of anterior clefts is related to a deficiency of neural crest-derived mesenchymal cells, chiefly within the intermaxillary segment of the lip. The posterior cleft type of birth defect generally includes cleft of the secondary palate that extend from the incisive foramen through the soft palate and uvula. The observation that the female secondary palate has longer developmental critical period than the male embryo (by approximately I week) offers some explanation of why isolated cleft palate is more prevalent in females (66%) than males (34%). In general, the pathogenesis of posterior palatal clefts is related to abnormalities in a combination of events ranging from deficiency in mesenchymal cell numbers to perturbation in the shelves' extracellular matrices to abnormal elevation and fusion of the shelves, or lack thereof, as complicated with a number of hypothesized teratogens, like excess doses of retinoic acids, glucocorticoids and dioxins. In summary, the understanding of the natural historical clinical delineation, and clinical management of defects involving the face and palate has progressed significantly over the last 20 years and will continue to do. Though human craniofacial morphogenesis is clearly a culmination of a very complex series of diverse overlapping developmental events, all of these events can be categorized into four fundamental happenings, which span mammalian development.

43

Cell differentiation, the process through which the myriad of building block cell types invoked in facial morphogenesis, are generated from the single-celled zygote Morphogenesis, the process or set of processes through which the complex form of the face and its constituent cells, tissues, and organs will emerge in a timely fashion along patternable individual land population lines. Growth, the collective results of differentiation and morphogenesis Dysmorphogenesis and abnormal growth.

The most exciting challenges we face today as we strive to understand how environmental influences interact with and cause changes in the expression of the genetic factors governing the behavior of the cells that will give rise to the entire human body, especially the face and palatal regions. The treatment of defective genes is very much a part of the clinical agenda dealing with craniofacial defects. Although the basic scientist, the Dysmorphologist, the clinician, and, importantly, those with natural or acquired craniofacial defects have gained significantly from the critical use of available information coming from classical and experimental studies of human morphogenesis These approaches should and will increase our knowledge base on the patterns and underlying causes of normal and abnormal craniofacial morphogenesis.

The velopharynx10,16 is a musculomembranous valve extending from the caudal margins of the oral cavity to the posterior pharynx. The anterior opening of the velopharynx, the oropharyngeal isthmus is bounded on either side by the palatoglossal arches and inferiorly by the dorsum of the tongue. The anterosuperior limit of the velopharynx is the line of attachment of the soft palate along the posterior margin of the palatine bones. The notion of the soft palate as forming the true roof of the pharynx is best appreciated if the soft palate is considered in its elevated position.

44

In this position, the oral surface of the soft palate is continuous with the posterior and lateral walls of the pharynx. The superior limit of the velopharynx thus becomes defined as the line of apposition of the soft palate with the posterior pharyngeal wall. Cineradiographic studies indicate that the level of velar apposition with the posterior pharyngeal wall lies about I cm above the level of the atlas, very close to the plane of the pharyngeal tubercle on the basilar part of the occipital bone. In its relaxed position, the posterior border of the soft palate defines the anterior limits of a large aperture in the velopharynx, the oropharyngeal isthmus or hiatus nasopharyngeus. The lateral borders of the nasopharyngeal isthmus are defined by the ridge produced by the palatopharyngeus muscle proper (the so-called palatopharyngeal sphincter) and posteriorly by the pharynx above the pharyngeal ridge (of Passavant). Jones suggested that the ridge of Passavant itself was the true posterior limit of the nasopharyngeal isthmus, although studies in living subjects indicate that the line of apposition of the soft palate is normally above the ridge. This superior limit approximates the level of the tori tubarii and thus includes the "true" pharyngeal part of the nasopharynx in the velopharynx. Identification of the soft palate with the roof of the pharynx excludes the space behind the choanae traditionally referred to as the nasopharynx. Various terms have been suggested for this region, including epipharynx, although that suggested by Negus- posterior nasal cavity-seems most appropriate.

Basic Structure of the Velopharynx Excluding the vascular and nerve plexus, the pharyngeal part of the velopharynx consists of four layers: Internal layer of mucous membrane Internal fibrous layer Muscular layer External fibrous layer.

45

The internal fibrous layer is continuous superiorly with the pharyngobasilar fascia, whereas the external fibrous layer is usually termed the buccopharyngeal fascia.. Mucous Membrane: The velopharyngeal mucous membrane is typical oral rnucosa consisting of nonkeratinizing, stratified squamous epithelium, with a well-developed lamina propria. Along the border of the nasopharyngeal isthmus, there is a transition from the typical stratified squamous epithelium of the velopharynx to the respiratory type of ciliated columnar epithelium. Inferiorly, the velopharyngeal mucosa is continuous with the mucosa of the remainder of the pharynx and oesophagus. The palatoglossal arch contains the palatoglossus muscles and associated connective tissue. The palatopharyngeal arch contains connective tissue and vertically running muscle fibres traditionally referred to as part of the palatopharyngeal muscle. These fibres are called as Palatothyroideus. On the posterior wall of the pharynx, a horizontal ridge (Ridge of Passavant) can be observed in some subjects. This ridge may be produced by the fibres running horizontally from the palate to the superior pharynx, which is referred to as part of the true palatopharyngeus muscle. In the region of the torus tubarius, three ridges are usually apparent. Running almost anteriorly from the lateral ledge of the torus is the small salpingopalatal fold. From below the opening of the auditory tube, a ridge formed by the levator palati muscle (the torus levatorius) runs anteromedially into the soft palate. Also, from the opening of the auditory tube medial to the torus levatorius, the salpingopharyngeal fold runs almost vertically downward. Internal and External Fibrous Layers of the Velopharynx: Though generally thin, they constitute a supporting framework for the velopharynx. Superiorly, the internal fibrous layer extends beyond the superior border of the superior constrictor muscle and is considerably thickened. This thick layer, generally termed the pharyngobasilar fascia, is firmly attached to the basilar part of the occipital bone, the pterygoid tubercle, and the adjacent surface of the petrous part of the temporal bone.

46

The internal fibrous layer is thin over the constrictor muscles, particularly over the inferior constrictor, and its extent is difficult to discern in gross dissection. The palatine, or velar, aponeurosis is a sheet of fibrous connective tissue extending to about I cm posterior from the posterior border of the hard palate. Generally, its posterior limit lies along a line joining the hamuli, but medially its fibers thin out gradually and pass more posteriorly than this limit. Although commonly referred to as the aponeurosis of the tensor palati, the palatine aponeurosis receives contributions from the epimysial coverings of the velar musculature and the salpingopharyngeal fascia. The external fibrous layer, or buccopharyngeal fascia, is thinner than the internal fibrous layer, and its precise extent is difficult to discern. Superiorly, it merges with the pharyngobasilar fascia and laterally with the carotid sheath and fascia overlying the buccinator muscle.

Velopharyngeal musculature: In the broadest terms, the musculature of the velopharynx consists of four U-shaped muscular slings that converge on the soft palate (the levator palati, the palatoglossi, the palatothyroidei, and the palatopharyngei), and a paired muscle mass (the musculi uvulae) lying on the soft palate. Associated with these muscles are paired longitudinal muscles running from the auditory tube (the salpingopharyngei), a U-shaped muscle sheet forming the superior pharynx (the superior constrictors), and a pair of L-shaped muscles contributing to the palatine aponeurosis (the tensors palati). Physiology of the Velopharynx Primary velopharyngeal movements can be divided roughly into two groups: Movements of the velum toward the posterior pharyngeal wall Mesial movements of the lateral pharyngeal walls.

47

Fig. 7: Primary components of palatopharyngeal function.

Anterior movements of the posterior pharyngeal wall and bulging of the nasal surface of the velum are also often considered while discussing velopharyngeal function. Numerous techniques, including ultrasound, cineradiography, endoscopy, and observation of anatomic relationships have been employed to study the contributions of velopharyngeaI muscles to these movements. However, the majority of these reports utilized electromyography (EMG) to relate muscle activity to velopharyngeal movement patterns. Although it might seem intuitively attractive to relate muscle activity directly to movement of structures, interpretation of such data must be made with some caution. Velar Elevation During breathing at rest and nasal sound production, the velum is maintained in a lower position to allow for the movement of air between the oral and nasal cavities. During attempts to produce oral speech sounds, the normally functioning velum moves posteriorly and superiorly to contact the posterior pharyngeal wall. The elevated velum is typically highest at its middle segment, whereas contact against the posterior pharyngeal wall is accomplished in its third quadrant. Velar height and displacement will, of course, vary during connected speech as a function of phonetic context. It is generally well accepted that the muscle primarily responsible for velar elevation is the levator palati. It is suggested that the superior constrictor, palatopharyngeus (palatothyroideus), and palatoglossus muscles may influence velar elevation in some subjects. Velar Lowering

48

Given that levator muscle activity results in movement of the velum toward a closed position, it would seem logical to assume that velar lowering would involve a cessation, or at least a reduced level, of levator muscle activity. This pattern has, in fact been observed by all investigators studying velar movement. There is, however, some disagreement about the precise mechanism, involved in lowering the velum. In her study of three subjects, Bell-Berti suggested that in addition to cessation of levator activity, velar lowering was accomplished by the natural tendency of tissue to return to its rest position, and not from increased activity in any muscle. This possibility is supported by the observation of elastic fibers in the anterior faucial pillars. An alternative explanation for velar lowering involves muscle activity. Historically, increased activity in two muscles has been associated with velar lowering. It was suggested that the tensor palati is favorably situated to pull the palate down and forward. More recent study, however, has cast doubt on the role of the tensor palati during speech production. Fritzell found that the tensor was consistently active during swallowing and chewing only. During speech, the muscle was typically inactive, and when active, it bore no relations to speech. Tensor palati activity does appear to be related to respiration. The second muscle thought by some to contribute to velar lowering is the palatoglossus. Anatomically, the palatoglossus is in a position to lower the palate Fritzell and Lubker et al found the palatoglossus to be active during palate lowering. They asserted that opening involves more than simple gravitational forces following cessation of levator palati activity and that the palatoglossus pulls the palate down for nasal sound production and at the end of phonation.

49

Fig. 8: Schematic view of sphincteric mechanism of velopharyngeal closure. Dotted lines show palatal and pharyngeal position at rest, while the solid lines are the same structures during velopharyngeal closure.

Lateral Pharyngeal Walls It is well established that mesial movement of the lateral pharyngeal walls contributes to velopharyngeal closure. Much less established is a description of how this is accomplished. Early reports attributed lateral pharyngeal wall movement to the salpingopharyngeus muscle. However, its contribution to such movement has since been discounted. Current explanations for lateral pharyngeal wall movement center on two muscles: the levator palati and the superior constrictor Posterior Pharyngeal Wall In the mid-1800s, Passavant described a bulging forward of the posterior pharyngeal wall in a cleft palate subject. Passavant's ridge has since been reported in normal subjects as well. Delineation of the exact mechanism by which this ridge is formed is not clear. However, it is most

50

likely to be caused by the horizontal fibres of the palatopharyngeus. It is also believed by some, that the superior constrictor might contribute to the ridge. It has been found that Passavant's ridge does contribute to velopharyngeal closure in some patients who demonstrated the ridge. This is especially true in patients with repaired palatal clefts. However, others have concluded that in normal speakers the observed magnitude of anterior movements of the posterior pharyngeal wall is probably not significant in the production of speech. Velar Bulging Until recently, much less attention has been focused on the musculi uvulae relative to the other velopharyngeal muscles. Historically, it was believed that the contraction of the musculi uvulae shortened the velum, an action that might oppose velopharyngeal-closing movements. Others have proposed that the musculi uvulae contribute to the convexity of the nasal surface of the soft palate and according to them the primary role of these muscles was to add bulk to the dorsal surface of the soft palate, which would aid in occlusion of the velopharyngeal part during speech and deglutition. Two possible roles for the musculi uvulae have been proposed: a stiffness modifying mechanism and a velar extensor mechanism. As a stiffness modifying mechanism, the musculi uvulae would act to control the velar-distorting forces of the levator palati muscle. That is, levator contraction in association with compliant musculi uvulae might result in distortion of the velum by stretching the top layer upward instead of moving the entire velum. The velum must be stiff enough to avoid such distortion but at the same time have enough compliance to allow it to stretch in reaching the posterior pharyngeal wall. As a velar extensor, the musculi uvulae might act as either a flexible beam or a pulling force about a boundary. The curved beam model is based on the fact that the musculi uvulae lie in the top half of the curved velum and are attached anteriorly to the palatal aponeurosis. On contraction, a compressional force is exerted along the nasal side of the velum. Because the oral side of the velum is relatively compliant, the compressive force would act to straighten the curved vellum and extend it posteriorly. The pulling force model is based on the fact that the musculi uvulae extend across the dorsal aspect of the levator sling. The sling acts as a boundary around

51

which the musculi uvulae can exert a force, thereby extending the velum posteriorly.

PATTERNS OF CLOSURE OF THE VELOPHARYNGEAL COMPLEX17

Nasal endoscopy has provided a perspective from above about the velopharyngeal portal, which has led to the refinement of the 4velopharyngeal closure patterns initially described by Skolnik from base view video fluoroscopy. 1. Coronal Pattern: The majority of the valving is palatal and accomplished by the full width of the soft palate contacting the posterior wall. The lateral walls exhibit limited movement to contact the lateral walls of the velum. There is no posterior wall movement. 2. Sagittal Pattern: The majority of the valving is pharyngeal. The lateral walls move extensively to the midline and approximate each other. The velum does not contact the posterior pharyngeal wall but elevates to contact the approximated lateral walls. The posterior pharyngeal wall does not contribute to the closure. 3. Circular Pattern: There is essentially equal participation from the soft palate and the lateral pharyngeal walls, with the contracting musculus uvulae acting as a focal point. The lateral walls contact the musculus uvulae as it contracts and contacts the non-mobile posterior pharyngeal wall.

4. Circular Pattern with Passavants ridge: The same pattern is followed as the circular closure, except that the posterior pharyngeal wall (Passavants ridge) moves forward to complete the closure pattern around the musculus uvulae posteriorly.

52

Fig. 9: Velopharyngeal closure patterns.

SPEECH 17,97,125

The development of the vocal sound into meaningful speech was one of the major accomplishments, which enabled man to reach the pinnacle of the animal kingdom, and speech as the basic and fundamental means of communication became the cornerstone for the establishment and organization of society. Speech is a learned process, which makes use of the anatomical structures designed primarily for respiration and deglutition. The production

53

of speech requires the selective modification and control of the outgoing air stream. Most girls master normal articulation by 6.5 years of age whereas boys require an additional year.

AGE AT WHICH TYPE OF SOUND AVERAGE CHILD HAS MASTERED IT Vowels Labials Dentals and gutturals Labiodentals Complicated tongue sounds Sibilants and blends During 7th year During 6th year 3.5 to 4 years 5 years. During first year 3 years

Components Of Speech: Speech has been divided into the following components1. Respiration 2. Phonation 3. Resonation 4. Articulation 5. Neurologic innervation 6. Audition. Respiration: During respiration the inhalation and exhalation are approximately equal but during speech, the inhalation phase is shortened while the exhalation phase is prolonged and not repetitive. Prolongation of exhalation is achieved by the valve mechanisms along the laryngeal,

54

pharyngeal, oral and nasal components of the respiratory tract. These, valves impede the expired air and help to create speech signals. Subglottic pressure is maintained by the balanced elasticity between the inspiratory intercostal musculature and the expiratory abdominal musculature. If the vital capacity of the lungs is compromised like in emphysema, speech will be perceived as breathy. The poor projection of voice in such cases is due to the reduced volume and pressure of the expired air. Phonation: The larynx provides the first level of constriction for controlling the respiratory air stream. The primary function of the vocal folds is to protect the lungs and the lower respiratory tract from inhalation of particulate matter. This, protective mechanism requires a simple, forceful approximation of the vocal folds. Speech conversely, requires a multitude of positions varying from tensions and vibratory cycles and an intricate coordination of the vocal cords with other structures. If the vocal folds are partially or completely adducted, they impede the expired air. With the proper degree of tension and sufficient subglottic pressure, the vocal folds may be set in vibration and thus impart phonation to the airstream. Whereas phonation is required for certain sounds, others do not need phonation; hence the vocal cords are left open or abducted. In the production of low-pitched sound the vocal folds are flaccid and thick while for high-pitched sounds the margins of the approximated folds are thin and tense. Resonation: The sound produced during phonation is augmented and modified by the chambers and the structures above the glottis i.e. the pharynx, oral cavity and the nasal cavity. These act as resonating chambers and amplify certain frequencies while muting others, thus refining the tonal quality. The dimensional changes in the pharyngeal tube like cavity due to the action of the constrictor muscles of the pharynx influence the resonant characteristics of the pulsating air stream, as it emerges from the larynx. The velopharyngeal mechanism proportions the sound and /or airstream between the oral and nasal cavities and influences the voice quality (basic sound) that is perceived by the listener. If the velopharyngeal closure is compromised, or if the structural integrity or relative size of the oral,

55

pharyngeal or nasal cavities has been altered, voice quality can be compromised. Articulation: Amplified, resonated sound is formulated into meaningful speech by the articulators namely the lips, tongue, cheeks, teeth and palate, by changing the relative spatial relationship of these structures. The tongue is considered to be the most important articulator of speech as it is able to affect rapid changes in movement and shape. The tongue may impede, selectively restrict, and channel airstream with precise contact against the teeth and palatal areas thus, articulating the basic laryngeal sound or the non-phonated air stream into recognizable speech. If the oral structures like the tongue, jaws or lips are surgically altered surgically and/ or neurologically, articulation may be compromised, Neural Integration: Speech is integrated by the central nervous system both at the central and peripheral levels. The sequential and simultaneous movements required throughout the speech process demand precise coordination. It is estimated that at least 17,000 motor patterns are required during speech. Neurologic impairments may compromise a specific component of the speech mechanism, such as the vocal folds, soft palate or tongue, or it may indirectly affect the entire speech system. A cerebrovascular accident may compromise the ability of the patient to comprehend and / or formulate meaningful speech, even though all the structures are individually normal. Audition: It is the ability to receive acoustic signals is vital for normal speech. Hearing permits reception and interpretation of acoustic signals and allows the speaker to monitor and control speech output. Compromised hearing can preclude accurate feedback and hence, affect speech.

Phonemics: A phoneme is a unit of speech by which we distinguish one utterance from another and which collectively make up the phonemics of the language. There are about 44 phonemes in the English language. Speech is further classified into Surds, Sonants and Consonants.

56

Surd: is any voiceless sound and is produced by separation of the vocal cords (glottis open) with no marginal vibration. The friction of the airstream makes the sound as it passes through the appropriate cavities. The initial h sound as in huh and the voiceless sibilants s, z, zh pronounced initially are examples of surds. Sonants: These are voiced sounds and include all vowels and vowel like sounds. They are produced by the vibration of some portion of vocal folds to establish the original sound wave, which is augmented by cavity resonation. The vowels require minimal articulation and are classified according to the tongue position in the oral cavity (i.e. high, mid or low) and the position of the lips. Vowel combinations are called Dipthongs e.g. ie Consonants: These are articulated speech sounds, and all require articulation to impede, constrict, divert or stop the airstream at the proper place and time to produce the desired sound. Consonantal articulation: Consonants are classified according to the type of articulation into Stops, Fricatives, Affricatives and diversions of the airstream. a) Stops: These are characterized by the stoppage and sudden release of the airstream and require complete occlusion of the articulators involved. The plosives p and b produced by the closure of the lips to permit momentary buildup of the airstream, followed by a sudden explosive release. The tongue contacting the hard palate to stop the airstream before suddenly releasing it produces the t and d sounds. The k sounds are produced by the tongue and soft palate closing the oral cavity at the same time the soft palate and the pharynx close the nasal cavity to stop the airstream prior to plosive release. b) Fricatives are produced by the airstream being forced through loosely closed articulators or a narrow passageway.

57

For the labiodentals f and v, the lower lip articulates with the maxillary anterior teeth to constrict the airstream. The linguodental th is produced by incomplete articulation of the tip of the tongue and maxillary incisors to constrict the airstream. The sibilants s, z, sh, and zh are produced by the tongue blade articulating with the lateral aspects of the hard palate, permitting the airstream to be forced through the groove created in the tongue apex. c) Affricates j and ch are produced by a combination of stop and friction, accomplished by the articulation of the tongue and the anterior hard palate.

d) Diversion of the airstream is characterized by stoppage at one point to permit escape at another. The nasal m is produced by the lips occluding to seal the oral cavity and permit emission through the nose. The nasal n is produced by the articulation of the tongue and the hard palate closing the oral cavity while the sound escapes through the nasal cavity. The nasal ng is produced by the tongue and soft palate closing off the oral cavity to permit nasal emission. For the lateral l, the tongue apex occludes the anterior portion of the oral cavity while the sound escapes the lateral portion.

PLACE PLOSIVE p(pole) Bilabial Labial Dental Lingual Dental b(bowl)

MANNER OF PRODUCTION FRICATIVE AFFRICATIVE SEMIVOWEL w(watt) NASAL M(sum)

f (fat) v (vat) 0(thigh) (thy)

58

Lingual Alveolar Palatal

t(toll) d (dole)

s(seal) z(zeal) (ash) z(azure) ch(choke) J(juke)

l(lot)

n(sun)

Velar

k(coal) g(goat)

ng(sing)

Fig. 10: Relative positions of the soft palate and tongue in the formation of the consonant sounds indicated by the letters.

LOCUS OF OBSTRUCTION

DEGREE OF OBSTRUCTION COMPLETE OBSTRUCTION ORALS PARTIAL OBSTRUCTION NASALS

VOICELESS VOICED VOICELESS VOICED (VOICED) BILABIAL LABIODENTAL /p/ /b/ /wh/ /f/ /w/ /v/ /m/

59

LINGUODENTAL ALVEOLAR POST ALVEOLAR PALATAL VELAR GLOTTAL /k/ /g/ /t/ /ch/ /d/ /j/j

/th/ /s/ /sh/

/th/ /z/,/l/ /zh/,/r/ /n/

/y/ /ng/ /h/

Speech and Maxillofacial Prosthetics:

Velopharyngeal incompetence is the functional inability of the soft palate to effect a complete seal with the posterior or lateral pharyngeal wall. It can be due to a variety of causes apart from cleft palate and these includes traumatic injuries to the neuromotor systems or the peripheral efferent cranial nerves, cerebrovascular accidents, brain stem tumours, neuromuscular disease such as multiple sclerosis and cerebral palsy. The prime clinical effect of this incompetence is an escape of air resulting in nasal speech that may be unintelligible. Patients with acquired defects or congenital malformations of the soft palate may exhibit excessive nasal resonance, because, without surgical and/or prosthodontic intervention, they are unable to control and divert sufficient airflow into the oral cavity. Whereas the degree of velopharyngeal closure remains the major determinant of resonance balance, other factors such as tongue position relative to assistance in velar elevation and structural resistance within the nasal cavity influence the perceived oral-nasal resonance balance. Resonance defects manifest as: Excessive nasal resonance (Hypernasality, nasality and/or rhinolalia aperta) In this excessive air escapes into the nasal cavity and the patient sounds as though he/she talking through his/her nose.

60

Insufficient nasal resonance (Hyponasality, denasality or rhinolalia clausa.) Patient shows insufficient airflow through the nasal cavity. This condition may occur due to use of obturator. Articulation deficiencies are primarily seen in patients with the acquired defects of the mandible. Congenital cleft lip and palate patients may exhibit errors both in articulation and resonance. Errors in articulation may be classified as three types: a. Errors of distortion- most commonly occurring problem. Commonly known as whistling /s/. Some types of lisping are these defects. Also patients with dysarthria, paralysis and prosthodontic patients show this. b. Errors of substitution- in this one sound is replaced by another. May be seen in a prosthodontic population. Patient might say /th/ instead of /s/; a sort of lisp. c. Errors of omission- Children, in developing speech skills, will often show omissions when they have failed to learn the sounds. Also persons learning a new language and people suffering from hearing problems. For example- Ink for sink /s/ is omitted wrong word. Cleft palate patients may show all three types of articulatory disturbances. When hypernasality and articulatory deficiencies coexist, resonance and articulation are difficult to differentiate. The speech considerations that need to be observed in constructing the prosthesis are as follows: I) Construction of the prosthesis a) Palatal Section: Should establish occlusion between the anterior maxillary and mandibular teeth to aid in the production of the labiodental, linguodental and linguoalveolar sounds. Should be free from obstructions (such as protruding malpositioned teeth), which would interfere with the free movement of the tip of the tongue. Should be vaulted to produce an oral cavity of as near normal size as possible.

61

Should provide adequate retention so that the movements of the appliance will not interfere with speaking. b) Velar section: Should be constructed to compensate for lateral movement of velar tissue in unoperated or redivided cases in order to prevent leakage of air or sound into the nasal cavities during speaking. Should be placed as high as is anatomically and prosthetically possible to avoid interference with tongue movements and to restore an oral cavity of normal size. Should provide a sturdy support for the pharyngeal section. c) Pharyngeal section: Should be located at the point of maximum constriction of the pharynx as determined by muscle trimming during deglutition. Should be large enough for the pharyngeal musculature to grasp during deglutition and to approximate during speech production. Should not be over-infraextended, i.e. it should not extend inferiorly into the oropharynx and, thus, reduce the size of this important resonating cavity, nor should it be oversupraextended. Should be constructed of some readily modifiable material, which will permit adjustment as muscular development results from speech training. II) Age factor in prosthesis. The prosthesis can be employed to prevent the development of serious speech defects. The speech pathologist recommends that temporary prosthesis be made for children as soon as the deciduous teeth have erupted sufficiently to provide retention and the child will cooperate. III) Management of postoperative cases Before prosthesis is constructed for a patient whose palate is insufficient or immobile, a thorough study of the lingual and mandibular movements employed in speech production should be made by a speech pathologist.

62

Skilled diagnosis and treatment planning are essential for adequate treatment of the patients handicapped by congenital and acquired maxillofacial defects. The maxillofacial prosthodontist serves, primarily as a member of a team and must cooperate with the other members in planning rehabilitative treatments for patients. The other team members include the surgeon, paediatrician, workers. speech pathologist, psychologist, psychiatrist, physiotherapist, radiologist, orthodontist, otolaryngologist and social

The maxillofacial prosthodontist must be acutely alert towards the medical health of the patient because of the ever-present possibility of recurrence, or the modified nature of tissues due to age, therapy or disease itself. Further, the maxillofacial prosthodontist must be familiar with the operating rooms, recovery rooms and various hospital protocols. He/she may advise the surgeon about the natural history, any existing dental pathology and advise about the preservation or excision of tissue for the benefit of the subsequent prosthetic treatment. He/ she may assist in the surgery and fit the immediate surgical obturator. Similarly, the maxillofacial prosthodontist must interact with the radiotherapist to render opinion on extraction of teeth, maintenance of the irradiated area, because at a later stage the irradiated tissue may alter the design of the prosthesis. The prosthodontist can contribute immensely towards preventing the unnecessary radiation to surrounding structures by making Brachytherapy appliances.

The psychologist and sometimes even the psychiatrist need to be consulted while dealing with the patents with defects and even the parents of children with congenital defects need counseling.

63

The clinical social worker and vocational rehabilitation counselor can provide solutions regarding finance, family and reemployment problems. This helps to allay fear, misconception of the patient and goes a long way in effecting social rehabilitation.

The pediatrician must be consulted for cleft lip and palate prosthesis. The pediatrician along with the obstettrician is usually the first to make the diagnosis and to discuss the deformity with the parents. The health of the cleft patient must be assessed and the nutritional status of the patient maintained under the guidance of the pediatrician. The otolaryngologists role is to prevent or treat those middle ear problems, which are uniformly present in these children.

An orthodontists role is very important in cleft palate and lip patients for arch correction and the orthopedic correction in procedures like presurgical nasoalveolar moulding. In addition, the prosthodontist may call upon the services of co-specialists like periodontist and pedodontist towards the successful management of these patients. Last but not the least is the role played by the speech pathologist. It is very important that the prosthodontists interact with speech pathologists to gain knowledge about the mechanics and physiology of speech so that the prosthesis can be designed in a way, which can fulfill requirements of resonance, phonation and articulation. It is highly imperative that a maxillofacial prosthodontist

understands the various diagnostic procedures used in the assessment of speech and their application. procedures is presented. Diagnostic Procedures Used In The Assessment And Treatment Of Speech Defects 15,17,140 Therefore, a detailed account of these

To define the severity of the dysfunction and to identify the most appropriate treatment plan, the pattern(s) of speech production should be evaluated by the speech pathologist.

64

An oral assessment is made to identify possible problems related to structural anatomy; an assessment of palatopharyngeal function for speech cannot be made from a functional assessment. Special tests, which have been described, are used. A standard speech sample is used to assess. Turner and Williams have described this standard sample. According to them, the selection of a clinical speech sample should include phrases that would normally require the palatal port to be completely closed and other phrases that would require the palatal port to close, open and close again. The sample used is the sentence In the evening, Connie watches TV with me. This sentence contains 10 oral consonants and 6 nasal consonants requiring the rapid opening and closing of the palatopharyngeal port for normal sentence production. The palatal port opens four times for the nasal consonants (/n/ of In, /n/ and /ng/ of evening, /n/ of Connie, and /m/ of me). In addition, there are three points of closure that are associated wit the oral consonants. The proximity of /n/ and /ng/ in the word evening and the two /n/ s in the word Connie result in a single opening of the palatal port during the production of each of these words. Knowing the pattern of production for this sentence as demonstrated by normal speakers provides a baseline to compare the pattern produced by individuals with suspected palatopharyngeal dysfunction. 1. Articulation Tests: These are used to record sounds that are produced correctly as well as errors in speech including omissions, distortions and substitutions of normal or compensatory sound errors. Rating of the speech sample is done for intelligibility and acceptability. Intelligibility is how well an individuals speech can be understood by others while the acceptability is the pleasing ness of sound and the appearance of speech. Both these ratings range from normal (1) to the unintelligible/ unacceptable (5/7). 2. Cephalometrics: Velopharyngeal valve in three dimension and its attributes cannot be captured on a midsagittal view alone. Also it can be filmed at a single point in speech production and there is no information gained about the lateral pharyngeal wall.

65

Cephalometrics is used to define the structures and growth pattern of pharynx, velum and lymphatic tissue and to determine skeletal characteristics and growth disturbances in pathologic conditions.

3. Cine videofluoroscopy: Cine fluoroscopy (X rays recorded on motion picture film) and videofluoroscopy (X rays recorded on videotape) with simultaneous voice recordings are done to assess the velopharyngeal mechanism. The key to the development of the motion x-rays was the advent of image intensification. Video recording involves lower radiation dosage than does cine fluoroscopy. 4. Multiview videofluoroscopy: Skolnick introduced it. Fluoroscopic X ray technique allows the visualization of velopharyngeal port or valve during speech in several different planes. This is important as speech involves movement of the soft palate, lateral and posterior pharyngeal walls. It includes lateral, base, Townes, frontal, Waters and oblique views. Not all views are required in all patients. View selection depends upon the information needed, anatomy of skull and the anatomy and function of the vocal tract. Generally three views are taken Lateral view Base or Townes view Waters or oblique view These are recorded and maintained on videotape with audio recording of the speech sample for the purpose of interpretation and comparison by the radiologist and the speech pathologist. Radiation dose is kept minimal by the following measures Videofluoroscopy rather than cinefluoroscopy is used. X ray coning is done to localize it to the minimal possible area Minimum amount of radiation required to produce image is used Lead shields are used to protect other areas. Technique:

66

To enhance the velopharyngeal area high-density barium is instilled into each nostril using a syringe and plastic tip. This results in barium coverage of the soft palate, lateral and posterior pharyngeal walls and the posterior aspect of the tongue. Standard speech sample is used during each view.

Lateral View: Patient is sitting upright and the judgment made about the length and thickness of soft palate, depth of the pharynx, size and location of adenoids and tonsillar tissue. The anteroposterior excursion of the soft palate and anterior movement of the pharynx and the velopharyngeal contact during speech is assessed. The disadvantage is that the velopharyngeal contact along its width cannot be studied but the lateral view provides excellent visualization of the tongue and is helpful in differential diagnosis of the compensatory errors. In some cases the tongue is observed to elevate soft palate to effect velopharyngeal closure for velar stop sounds /k/ and /g/. Abnormal laryngeal elevation and abnormal movement of the glottis are also seen in this view. Frontal View: It is used to determine the degree and location of mesial movements of the lateral pharyngeal walls. The lateral pharyngeal wall movement may occur at a specific location in the vocal tract or in an extensive area. This information is useful in planning approximate width of the pharyngeal flap or designing the speech aid prosthesis. Technique: The patient is upright facing the image intensifier with head in a position that the Frankforts Horizontal plane is parallel to the floor. Coating of the nasopharynx is done with barium and standard speech sample is used. When the overlying bony structure obscures the lateral pharyngeal walls, Waters view is the alternative in which the head is tilted up by 45 degrees from the Frankforts horizontal plane to prevent bony overlapping. Base and Townes Views: These views outline the shape of the velopharyngeal valve, pattern, symmetry and consistency of

67

velopharyngeal valving movements and the size and location of velopharyngeal gaps during speech. Townes view is more useful than base view when soft palate approximates the adenoid tissue during valving creating oblique areas of velopharyngeal closure or when patients have large tonsils or posterior compensatory tongue movements. In the base view the patient lies prone on the X ray table in a sphinx like position with the head hyper extended. In the Townes view the patient is seated upright with his/her head in the horizontal plane. The camera is then rotated in relation to the face until the velopharyngeal valve is visualized. During these procedures a standard speech sample is used and Multiview videofluoroscopy can be performed in patients as young as 3-4 years of age. 5. Ultrasonography: It is a device that has been employed for lateral pharyngeal walls. Not suitable for displaying motion of velum as there is problem in transmitting the waves through the bone overlying the structures under observation. 6. Video Nasopharyngoendoscopy: It involves inserting a flexible fibreoptic tube through the nose to obtain a direct superior view of the velopharyngeal valve and the vocal tract during speech. It is used to determine and test the following Anatomy and function of the velopharyngeal valve during speech. Relative size, location and consistency of the velopharyngeal gaps. Function of the posterior aspect of the tongue during speech to determine the differential. Diagnosis of the compensatory articulation errors. Anatomy and function of the laryngeal structures. Useful in identifying pulsations in the pharynx which may be indicative of abnormally placed carotid arteries which is seen in Velocardiofacial Syndrome that might preclude pharyngeal flap or sphincter pharyngoplasty surgery.

68

Used to assess the outcome of surgery, prosthetic aid or speech therapy. Used for Biofeedback therapy to enhance velopharyngeal

movements during speech and correct some compensatory articulatory errors.

For young children flexible nasopharyngeal endoscope of the distal tip diameter of 2- 3.7 mm is recommended. Technique: Topical local anesthetic is applied to the nostril to allow easy passage of the scope through the nostril into the middle meatus of the nasal passage to first visualize the velopharyngeal area to document the anatomy and function and to check for any pulsations. Scope is then passed down to the vocal tract to document the anatomy and function of the tongue and larynx. A standard speech sample is used and audiovisual recording done. However, false positive or negative results can come if the distal end of the scope not placed directly over the velopharyngeal port. 7. Nasometer: It is a computer-based instrument produced by Kay Elemetrics which is designed to measure the relative amount of nasal acoustic energy compared to oral acoustic energy during continuous speech production. The instrument uses sound separator placed on the patients upper lip. Microphones on either side of the sound separator sense oral and nasal acoustic energy during speech and this energy is filtered and digitized by the custom electronic module. Computer with the special software processes the information and produces a Nasalance score. This score is a ratio of nasal to oral acoustic energy multiplied by 100. Nasal and oral acoustic energy is averaged during the production of vowels and consonants in test sentences to produce nasalance score. Interpretation: An abnormally high nasalance score during production of non nasal consonants suggest velopharyngeal inadequacy and

hypernasality while abnormally low nasalance score during production of nasal consonants is suggestive of Hyponasality and/or nasal airway impairment, The disadvantage is that it is less useful in patients who exhibit velopharyngeal inadequacy and nasal airway impairment.

69

8. Aeromechanical Measurements: These aerodynamic studies are based on a modification of a theoretical hydraulic principle, which assumes that the smallest cross sectional area of a section, can be determined if the differential pressure across the structure is measured simultaneously with the rate of airflow through it. Warren & Dubois Technique: Measurement of nasal airflow and difference in air pressure above and below the velopharyngeal port may be used to estimate area of the velopharyngeal orifice during the production of stop consonants and also the resistance of port to the airflow. These pressure flow measurements provide information about the coupling of the oral and nasal cavities during speech and about the resistance in the system. The disadvantage is that it does not describe the movement of particular structures, such as the velum or the lateral or posterior pharyngeal walls or the location and configuration of any opening that is present. PERCI- Palatal Efficiency Rating Computed Instantly Warren introduced PERCI. It records and displays the difference in air pressure in the mouth and the nose. Warren studied 75 patients and concluded that patients with differential pressure reading greater than 3.0 on PERCI had velopharyngeal orifice areas of 10 square millimeters or less. PERCI readings of less than 1.0 had areas greater than 20 square millimeters. PERCI readings between 1.0 and 2.9 associated with velopharyngeal orifice of area between 10 and 20 square millimeters. TONAR The Oral and Nasal Acoustic Ratio Introduced by Fletcher and Bishop. They advanced the study of oral and nasal sound intensity measures as indices to study hypernasality. The instrument prints out voltages associated with nasal and oral signals and also a trace reflecting the ratio of the voltages from the sound detected in the oral and nasal chambers. Based on these tests lot of findings have been made about:

70

Velopharyngeal orifice size: it has been found that the velopharyngeal orifice should be less than 0.2 square cm during the production of plosive and fricative sounds. If the opening is greater than this then, the respiratory effort has to be increased to compensate for it and provide improved oral pressure for speech. Oral pressure greater than 3 cm of water is considered adequate for plosive and fricative phonemes. Increase in oral pressure along with velopharyngeal inadequacy may improve articulation but the nasal airflow is increased which in turn, may increase the perceived level of nasality. Nasal resistance: the resistance to nasal airflow may contribute to increased oral pressure and consequently improve the effectiveness of speech for patients with large velopharyngeal orifices. It is the sum of the resistance provided by the velopharyngeal mechanism, nasal resistance and the increase in the respiratory effort that determines the oral pressure. Warren studied the airflow and found that cleft palate patients had significantly greater nasal resistance to airflow. But, patients with repaired bilateral clefts of lip and palate have larger airway, less nasal resistance and consequently less effective speech articulation as compared to patients with unilateral clefts. Therefore, a nose that is good for breathing may be bad for speech under these circumstances.

Nasal valve: The valve is considered to be the area between the upper and lower lateral cartilages, the piriform aperture and the anterior terminus of the inferior turbinate. In physiologic terms, the nasal valve is considered as the regulator, with the smallest cross sectional area within the nasal cavity based on the anatomical and flow resistive characteristics. The nasal valve dilates during inspiration and both active and passive flattening occurs during expiration. Therefore, the nasal valve is an active participant in the breathing process rather than a passive conduit of airflow.

Oral versus nasal breathing also depends on the average cross sectional area of the nasal valve, which is 0.63 square cm +/- 0.17 square cm. When it is lesser than 0.40 square cm it is an impaired airway and patients will be predominantly oral breathers.

71

It can then be summarized that there is not a direct linear relationship between velopharyngeal orifice size and the level of perceived nasality. This is understandable when the number of variables including the nasal resistance and timing, which can impact the aerodynamic characteristics of the speech mechanism, are understood

72

Psychological Considerations9,17,29,135

The assessment of the patients demeanor is important to the success of the treatment. It determines whether the proposed treatment can be performed efficaciously or understood and appreciated by the patient once it is completed. The prognosis for a successful treatment outcome is dependent upon the prosthodontist making a correct diagnosis and anticipating issues beyond the realm of dentistry alone. This is even more important while dealing with patients having oro facial defects as the maxillofacial region is of crucial importance during ones early development. It is involved in all interpersonal relationships and relates to some of our deepest needs. During the earliest stage of development, the most salient portion if the infants existence is oral. It is because of this that Freud and subsequent analysts termed the first year of life as the oral stage it is with the mouth that the self is first revealed to the environment. Psychological Classification and interpretation: Routine classification to categorize the mental status of patients fall short in classifying those patients with life threatening diseases or those who have suffered recent traumatic events. Additionally, those patients in whom the face is disfigured and/or those who have lost an important biological function such as speech or swallowing will experience changes in social acceptance that impact the psyche and sense of well being. As the maxillofacial patients quality of life is altered and social integration becomes difficult, the patients expectations to return to normalcy often collapse. Underlying emotional issues that were subconsciously buried may come to the surface, or unachievable expectations and unreasonable demands may arise that hinder the prosthodontists ability to provide adequate treatment. Further, in such a case it is critical to assess whether treatment should be carried out at all, delayed until the patients demeanor is more conducive to treatment and/or coordinated with services of supportive professionals like social workers and psychologists. The prosthodontists goal is a successful treatment outcome, but not at the expense of ones emotional and mental well being or that of the staff. A health care provider is not required to heal every patient that

73

walks through the front door. It means that if at the examination level one recognizes a patient with underlying psychological conditions or confounding emotional factors, it may be best not to treat until these are addressed. There must be an unconditional commitment to the same treatment goals by both doctor and the patient. Therefore, it becomes paramount that the prosthodontist understand the various psychological diagnoses, ranging from subtle emotional nuances to overt psychological disorders that potentially undermine prosthetic treatment. Psychological impairments are characterized by disturbances in a persons thoughts, emotions or behavior. These impairments can range from those that cause mild distress to those that severely impair a persons ability to function, individually, in family or in a community. International surveys have demonstrated that from 30 to 40% of people in a given population experience a mental illness during their lives. They also reveal that anxiety disorders are more common than depression. In children and the elderly, rates and forms of mental illness change with age and gender. Depression and anxiety occur at the same rate among girls and boys until mid adolescence, when girls account for more. Among prosthodontic patients, children most often present with congenital defects or alterations in growth and development whereas adolescents and young adults often present with developmental defects or trauma. Mental illness has grown in the elderly as greater portion of the population live beyond the age of 65. Dementia, characterized by impaired intellectual functioning and memory loss, occurs mostly among the elderly, and may overlap with the ablative cancer patient groups. The highest rates of mental illness occur in people in the lower socioeconomic classes and rates of all mental illnesses decline as levels of education and income increase. Therefore, the ability of maxillofacial patients to integrate into society and to be employable will be critical to their mental status. The overall prevalence rates between men and women are similar, however, men have much higher rates of antisocial personality disorder and substance abuse. The acquired maxillofacial cancer/defect population correlates with this group of substance abuse. Women suffer anxiety disorders and depression more than men. 1. Anxiety Disorders:

74

These involve excessive apprehension, worry and fear. The disorders included in this group are panic disorder, obsessive compulsive disorder (OCD), posttraumatic stress disorder (PTSD), social phobia and generalized anxiety disorder in which people experience constant anxiety about routine events in their lives. Phobias are fears of specific objects, situations or activities. Panic disorder is an anxiety disorder in which people experience sudden, intense terror and physical symptoms like tachycardia and dyspnoea. Panic disorder typically strikes in young adulthood. Women are twice at risk and it is likely to be seen with depression and substance abuse. Obsessive-Compulsive Disorder is a condition in which the patients experience intrusive thoughts or images (obsessions) or feel compelled to perform certain behaviours (compulsions). Posttraumatic Stress Disorder (PTSD): In this condition, patients relive traumatic experiences from their past and feel extreme anxiety and distress about the event. PTSD can develop at any age including childhood and more commonly seen in women. This occurs frequently in people who have spent time in war zones, after violent personal assaults like rape, mugging, domestic violence, terrorist attacks, natural disasters and accidents. Depression and substance abuse generally accompany PTSD. Social phobia is seen more in women. The disorder typically begins in childhood or early adolescence and is often accompanied by depression and may lead to substance abuse. 2. Mood Disorders: Depression and Mania. These are also called affective disorders, which create disturbances in a persons emotional life. Depression is a serious condition frequently seen after heart attack, stroke, diabetes and cancer but is treatable. Depression increases the incidence of other somatic illnesses like myocardial infarction. Symptoms of depression include feelings of sadness, hopelessness, and worthlessness as well as complaints of physical pain and changes in appetite, sleep patterns and energy level. In mania on the other hand an individual experiences an abnormally elevated mood, often marked by exaggerated self-importance, irritability, agitation, and a decreased need for sleep.

75

In bipolar disorder or manic-depressive illness, a persons mood alternates between extremes of mania and depression. 3. Schizophrenia and other psychotic disorders: People with these disorders lose contact with reality. Symptoms include delusions and hallucinations, disorganized thinking and speech, bizarre behavior, diminished range of emotional responsiveness and social withdrawal. Men and women are equally affected. 4. Personality Disorders: Generally these patients have poor perceptions of themselves or others. They may have low self-esteem or overwhelming narcissism, poor impulse control, troubles social relationships and inappropriate emotional responses.

5. Cognitive and Dissociative Disorders: Cognitive disorders such as dementia and delirium involve a significant loss of mental functioning. Dementia is characterized by impaired memory, difficulties in speaking, abstract thinking and ability to identify familiar objects. These occur due to medical conditions, substance abuse or as adverse reactions to medication or poisonous substances. Dissociative disorders include disturbances in a persons consciousness, memories, identity and perception of the environment. These include amnesia that has no physical cause, dissociative identity disorder in which a patient has two or more distinct personalities that alternate in their control of the patients behavior, depersonalization disorder characterized by a chronic feeling of being detached from ones body or mental processes and dissociative fugue that is an episode of sudden departure from home or work with an associated loss of memory. These disorders also include possession states or trances. 6. Somatoform and fictitious disorders: These are characterized by the presence of physical symptoms that cannot be explained by a medical condition or other mental illness. These include conversion disorder or hysteria in which a person experiences blindness, deafness or seizures though the physicians cannot find an organic cause in the person. Hypochondriasis is one condition in

76

which a person feels a constant fear that he/she will develop a serious disease and misinterpret minor physical symptoms as evidence of illness. People with factitious disorders intentionally produce or fake physical or psychological symptoms in order to receive medical attention and care. 7.Substance Related disorders: These result from the abuse of drugs, side effects of medication or exposure to toxic substances. These are regarded as behavioral or addictive disorders. 8. Eating Disorders: These are disturbances in eating behavior occurring most commonly in young women. These include, anorexia nervosa in which people have extreme fear of gaining weight and refuse to eat adequately and Bulimia nervosa in which people repeatedly engage in episodes of binge eating followed by self induced vomiting or the use of laxatives, diuretics or other medications to prevent weight gain. 9.Impulse control disorders: In these people cannot control an impulse to engage in harmful behavior such as explosive anger, stealing (kleptomania) etc.

After this brief review of the common psychological impairments the psychological changes in the maxillofacial patient are as follows. Maxillofacial patients are classified according to the aetiology of their diagnosis i.e. acquired, congenital and developmental defects. Patients with acquired maxillofacial defects have had ablative cancer surgery or trauma. These two groups are similar in that in both situations a person who had a relatively normal anatomy and physiologic function and subsequently lost them overnight. Cancer patients differ from trauma

77

patients and they express why me? and are often faced with the possibility of recurrence, more surgery, chemotherapy or radiotherapy and the futility of the process. Patients with smaller defects are generally more demanding with higher expectations than the ones with larger, more debilitative defects. The trauma patient is usually younger than the cancer patient, particularly when the trauma is self-inflicted. It is noticed in the cases that attempted suicides that their demeanor is relatively but superficially upbeat. Additionally, with the self-inflicted trauma patient, there is a la belle indifference demeanor when confronted with the upward struggle of multiple, difficult procedures to restore the patients face. Congenital defect patients intuitively understand that they are different from the norm and may believe that they are genetically damaged or subhuman as they may not fit in with their peer or age groups. They also face the knowledge that there may be a genetic predisposition to recurring incidence in their own progeny. Parents may have difficulty in accepting their child or blame themselves for the birth defect, resulting in family dysfunction and loss of family unity. Congenital maxillofacial patients usually face multiple and sequential surgeries, defects. Anomalies in growth and development may not be readily apparent at first in the developmental defect patient but will ultimately become so. The developmental defect patient may display emotional responses similar to the congenital defect patients but as the defect becomes apparent over a period of time, the patient may or may not learn to deal with the evolving process. Loss and Grief in Maxillofacial Defects: Once patients realize they have cancer, or have experienced any other debilitating crisis creating a loss, they perceive it as both an immediate and future loss. This may manifest itself in the form of anxiety, depression or a posttraumatic stress disorder. In any event a cycle of loss, grief and reintegration must be completed by the patient and understood by the prosthodontist. orthodontics and prosthodontic procedures over several years in an attempt to correct their

78

Fig.11: Overlapping psychosocial concerns of the head & neck cancer patient.

Loss has been defined as a state of being deprived or being without something one has had and valued(Peretz 1970). The loss of a facial feature or other body part due to cancer can be one of the most painful experiences in life. This loss not only includes the deprivation of the feature but also subsequent deprivation of some of lifes experiences.

Patients will be subject to possible rejection by their spouses, friends, business associates and their community. In addition, a loss of a maxillofacial feature may mean a loss in social groups or in ones career. If patients cannot develop successful psychological and physical coping skills, they may experience severe psychological trauma, even if the loss appears minimal. Peretz has divided loss into four categories: loss of a significant person, loss of a part of the self, loss of material objects and developmental loss. The meaning of loss depends on the one who feels the effect. Loss can threaten the integrity of ones self esteem, which will remain easily damaged for sometime after the fact. Even the threat of loss can be emotionally devastating. It can trigger the fear of death at the deepest level. Grief:

79

Stages of the grief process include Shock and denial: Changes occurring in sleeping pattern and eating, often symptomatic of depression. The past is idealized. Patients are at risk for suicide if their depression is severe. Guilt, anger, and a search to find ways to discharge emotional pain: The feeling of anger at this stage is really secondary to the driving feeling of fear of the unknown and unfamiliar. The patient may be subject to possible substance abuse. Adjustment, acceptance and growth: the patient comes to realize that the past had its faults and the future may not be so bad. This stage signals acceptance of loss, healthy adjustment and new life patterns. Integration of the prosthesis is possible. The reaction of grief is an adaptive function to assure group cohesiveness in species where a social form of existence is necessary for survival. Unfortunately, our society emphasizes competency, adequacy and strength; this often prevents patients from sharing their feelings. A prosthodontist needs to empathize with the patient. A prosthodontist will not have had to experience the same level of loss as the patient, but remembering losses of loved ones, friends and property will help the practitioner to be empathetic with the patient and to be in a better position from which to gauge the patients psychological progress. This, empathy will assist the prosthodontist to make a decision regarding the referral to a psychotherapist. At the same time the prosthodontist needs to be wary of any unresolved grief that may be triggered in response to the patients grief experience. Regardless of how effectively grieving is done, it cannot be rushed. Grieving requires time out from routine living and often makes the one grieving appear disturbed. Improper recognition of this can cause prosthodontists to misinterpret behavior and add confusion to the suffering. This can create lack of self-confidence in patients, weaken their sense of self, bring despair, or trigger self-destructive behavior. Grief is the opposite of mental health, which is the ability to cope, to love and to work. Grief can cause physical illness, poor judgement, weakened inhibition, clouded intellect, and blurred perception. Patients who experience traumatic losses will experience great ambivalence between wanting to be active and passive, dependent and independent,

80

exploitive and helpless. Grief is so overwhelming that it has often been viewed as an illness that may end only in partial recovery. This partial recovery or unresolved grief can be triggered even after a significant amount of time following the initial loss, by other losses or become the impetus for a range of physical or mental disorders. Therapy for children in such cases is strongly indicated. Children often grieve their losses openly and dominant emotional response is anger. Also due to their egocentricity children can blame themselves for losses and feel guilty. Improperly guilt and anger can set the stage for later emotional difficulties s adolescents and adults. The maxillofacial patients quality of life is impacted which predisposes him or her to a variety of psychological impairments. Quality of life (QOL) surveys are done in patients suffering from various diseases to measure the differences occurring due to the disease process. There are ways to evaluate the psychological impairment status by psychometric testing like Minnesota Multiphasic Personality Inventory, Cornell Medical Index, Eysenck Personality Inventory and the Social Adjustment rating scale but the Prosthodontist should limit the evaluation by sensing the patients presentation attitude, demeanor, appearance, emotional state, mood, manner of speech, cognitive processes and then make the appropriate referral. The disorders mentioned earlier have varying effects on the patients ability to withstand surgical procedures or to accept prosthesis. The prosthodontist should consult a social worker, psychologist or psychiatrist as a part of the treatment team to aid in preparing a plan that will achieve the desired goal of the patient. Also, the quality and content of communication between the patient and the prosthodontist significantly affects the patients ability to accept the prosthesis and the successful out come of the treatment plan. Family Support and patient centered treatment involve knowing how to enlist the support of the patients family and significant others in the treatment and the aftercare process. Support from family and friends can be a great help in coping with trauma. Patients feel isolated and lonely; communications with people who care and try to understand help the patient overcome this isolation. Patient centered treatment planning needs to be done which is the highly individualized process designed to respond to the expressed needs

81

and desires of the individual. The patients choices and preferences should always be considered if not granted. The patients cultural background must be recognized and valued in the decision making process. Referral to Mental Health Services: Before referring, the prosthodontist must know whether the patient is at a stage of acceptance of their maxillofacial deficiencies to accept referrals. Referrals can be made to the following professionals: social workers who tend to involve the family and the environment of the patient, psychologists who are more

psychodynamic or individual focused and the psychiatrist who are specialized physicians who can prescribe medication.

Suggestions for the prosthodontist for dealing with patients with maxillofacial defects: i.) Recognize the existence of the emotional component of illness for the patient as well as for the health care worker. The patients resistance to follow the recommended treatment plan may be caused due to psychological barriers. ii.) Make an effort to listen to what the patient does and does not say. Do not assume that no difficulty exists because the patient offers none. iii.) Establish a routine office practice of referring the patient to a clinical social worker or other qualified therapeutic agent for psychosocial referral. Psychological health and spiritual well-being are integrated and related states. In addition, a traumatic incident can itself aid in improving the patients outlook toward life. Loss can often build strength of character. Benefits of adversity to trauma patients include changed life priorities, increased sense of self-efficacy, enhanced sensitivity towards others, improved personal relationships and increased spirituality. However, maxillofacial patients will not see the benefits of adversity till they are able to attach a meaning to the adverse event. Once a patient is able to apply meaning to the life threatening traumatic event, the evaluation and treatment and consultation services as needed. Talk to the worker personally in making the

82

introduction of benefit related concepts could be attempted and discussed. This is a technique of psychotherapy called Reframing, where an event is relabeled to search for the positive aspects in relation to the patients ability to face serious problems. If this can be achieved, the patient can be urged to think about ways that they have benefited, making the traumatic event seem more palatable and easier to think about and cognitively process. Positive outcomes of prosthetic treatment would be anticipated at this point because patients have stopped seeing themselves as victims and instead as capable human beings. Therefore, if health care professionals subscribe to the premise that the treatment goal is to maximize function, bio-behavioral interdependence follows as a necessary corollary. Recognition of this relationship may aid in making comprehensive dental health care a reality rather than an abstract ideal.

Review Of Materials Used in Maxillofacial Prosthetics 17,29

A number of materials are available and have been for maxillofacial prostheses. These include wood, wax, metals, and, recent times, polymers. While the new materials have exhibited some excellent properties, they also have exhibited frustrating deficiencies. As yet, a material has not emerged that does not possess distinct and important undesirable characteristics. Much effort has been expended recently in studying existing materials in the hope of ameliorating them. A discussion follows of desirable physical, biologic, and clinical properties, emphasizing those properties most important for achieving clinical success and patient acceptance. IDEAL PROPERTIES OF MAXILLOFACIAL PROSTHETIC MATERIALS Proposed Specifications: Maxillofacial Elastomeric Requirements And

IDEAL PHYSICAL AND MECHANICAL PROPERTIES 1. Dynamic properties comparable to tissues 2. High edge strength

83

3. High elongation 4. High resistance to abrasion 5. High tear strength 6. High tensile strength 7. Low coefficient of friction 8. Low glass transition temperature 9. Low specific gravity 10. Low surface tension 11. Low thermal conductivity 12. Odourless, 13. Non-inflammable 14. No water sorption 15. Softness compatible to tissue 16. Translucent 17. Variable flexibility without addition of leachable plasticizer. IDEAL PROCESSING CHARACTERISTICS 1. Adjustability 2. Chemically inert after processing 3. Dimensionally stable during and after processing of colorants 4. Ease of mold fabrication 5. Ease of processing 6. Ease of repair or refabrication if needed. 7. Fidelity of detail reproduction 8. High enough viscosity for maintaining even dispersion of colorants 9. Long shelf life 10. Long working time 11. Low enough viscosity for ease of processing 12. Low processing temperature 13. Low sensitivity to contamination during processing 14. Non-inflammable 15. No polymerization by-products 16. Non-toxic components 17. Non-porous after processing 18. No color change after processing

84

19. Odorless before and after processing 20. Reusable molds 21. Retain intrinsic and extrinsic coloration during use 22. Short processing time

IDEAL BIOLOGICAL PROPERTIES 1. 2. 3. 4. 5. 6. 7. 8. 9. Non allergenic Compatible with supporting tissues Non toxic Cleansibility without loss of detail at surface or margins Cleansible with disinfectants Color stability Dimensionally stable Flexibility comparable to tissue Flexibility stable at extreme of temperatures (- 40 to 140F) 10. 11. 12. 13. 14. 15. 16. Fabrication: Materials that are easily processed with available instrumentation offer distinct advantages. Polymerization, or conversion from liquid to solid, occurring at temperatures low enough to permit reusability of molds (epoxy, dental stone, etc.) is desirable. Blending of individual components should be easy, allowing some margin for error. Suitable working time is likewise beneficial. The material should be adaptable to intrinsic as well as to extrinsic coloration. Physical properties: Ideally, the prosthesis should possess sufficient flexibility for use on movable tissue beds. The materials should be dimensionally stable, be Inert to solvents and skin adhesives Resistance to growth of microorganisms Softness maintained during use Usable life of 2 or more years Inexpensive Permeable to moisture release from underlying tissue Resistance to environmental discoloration

85

light in weight, and possess suitable edge strength to permit thinning or feathering of margins. Variations in temperature should not affect physical properties, and thermal conductivity should be sufficiently low to permit comfortable use in cold environments. Biologic and chemical properties : The material should remain stable when exposed to environmental assaults, such as ultraviolet rays, oxygen, secretions (sebaceous, perspiration, nasal, and salivary), and adhesives and their solvents. The material should not be toxic, allergenic, or carcinogenic, and it must be biocompatible. Last, it is highly desirable that the prosthesis be durable and have the capability of being used for at least 6 months without significant compromise of esthetics and physical properties. CLASSIFICATION OF MATERIALS AVAILABLE: 1. POLY (Methyl Methacrylate) Palamed 2. Vinyl Polymers and Copolymers Dicor Geon 121 (Prototype 1, II, III) Prototype III Soft Chloronated Polyethylene 3. Polyurethane Elastomers Epithane Dermathane Isophorone Polyurethane 4. Silicone Elastomers HTV Silicones ES-4524U Q7-4635 Q7-465081 Q7-4735 Silastic 4-4514 Silastic 4-4515

RTV Silicones A-0102 A-2186 Cosmesil MDX 4-4210 MDX 4-4210 (Modified) Silastic 382 (Opaque White) 86 Silastic 386 (Foam) Silastic 399 (Translucent)

Acrylic Resin: Heat polymerizing methyl methacrylate is preferred over the autopolymerizing form because of the presence of free toxic tertiary amines in the latter. Rigidity is the primary disadvantage of acrylic resin. Its usefulness is compromised in highly movable tissue beds leading to local discomfort and exposure of margins. Its relatively high thermal conductivity may precipitate discomfort in cold climates. Duplicate prostheses are not possible because of the destruction of the mold during removal from the flasking apparatus. Also, it is easily repaired or relined with either a tissue conditioner, or temporary denture reliner, and it can be quickly and easily processed. Light Activated Denture Base Resins: The dental community has known a visible light cure denture base resin system for years. It is a composite having a matrix of urethane dimethacrylate, microfine silica, and high molecular weight acrylic resin monomers. Acrylic resin beads are added as fillers,. Visible light is the activator, while camphoroquinone serves as the initiator for polymerization. Its use has been advocated in maxillofacial prosthodontics as a denture base, reliner and tray material by a lot of authors because of its ease of use and much lesser polymerization shrinkage compared to autopolymerizing or heat cured acrylic.37,38,68,110,127,128,144 Soft denture liners: Plasticized resins, which are chemically activated, are generally used as denture liners. These polymers are supplied in powder form and mixed with liquids containing 60-80 % of a plasticizer, which is generally dibutyl pthalate. The distribution of the large plasticizer molecules minimizes the entanglement of the polymer chains, thereby

87

permitting individual chains to slip past one other, resulting in the flexibility of the material. However, the liquid does not contain acrylic monomers, hence these material are short term. Heat activated liners are more durable and are available as powder liquid system. The powder contains acrylic resin copolymers and acrylic resin polymer. The liquid contains monomer and plasticizers. When mixed these form pliable resins with glass transition temperature below mouth temperature. However the plasticizer leaches out over time. Acrylic copolymers Acrylic copolymers are soft and elastic but have not received wide acceptance because of a number of objectionable properties. They possess poor edge strength, poor durability, and are subject to degradation when exposed to sunlight. Processing and coloration are difficult. The completed restorations often become tacky, predisposing to dust collection and staining. A well-documented discussion of the properties and fabrication of prostheses with Palamed (a plasticized methyl methacrylate) is provided by Cantor and Hildestad. Development of a new generation of acrylic monomers, oligomers, and macromeres was reported by Antonucci and Stansbury. They reported that these materials can be polymered easily by using different polymerization methods: thermal, chemical, photo-initiated, or even dual-cure initiators. Their approach is to incorporate highmolecular-weight acrylic polyemers with molecular blocks of other types of polymers (e.g., poly-etherurethane, -hydrocarbon, -fluorocarbon, or -siloxane) that can eliminate the shortcomings of traditional acrylic copolymers and meet the requirements of a maxillofacial elastomer. A wide spectrum of physical and mechanical properties which may satisfy the requirements in maxillofacial application can be obtained by varying modes of polymerization. However, the results of laboratory and clinical tests of potential polymers have not yet been published. Silicone liners are more durable as they do not contain leachable plasticizer but the ahesion to acrylic is difficult and hence, rubberpoly(methyl methacrylate) cements have to be used which serve as chemical intermediaries that bond to both soft liner and resin base. Silicone Elastomers

88

Silicones are a combination of organic and inorganic compounds. The first step in their production is the reduction of silica to elemental silicon. Then, by various reactions, the silicon is combined with methyl chloride to form dimethyl dichlorosiloxane which, when it reacts with water, forms a polymer. These polymers are translucent, watery, white fluids whose viscosity is determined by the length of the polymer chain. Polydimethyl siloxane, commonly referred to as silicone, is made from these silicon fluid polymers. Most rubbery forms of silicone are compounded with fillers that provide additional strength. Additives are used to provide color. Antioxidants and vulcanizing agents are used to transform the raw mass from a plastic to a rubbery resin during processing. The long-chained polymers, when tied together at various points (cross-linked), create a network that can be separated only with difficulty. This network makes the silicones especially resistant to degradation from ultraviolet light exposure. The process of cross-linking the polymers is referred to as vulcanization. Vulcanization occurs both with and without heat and depends on the catalytic or cross-linking agents utilized. Using a chain of silica and oxygen atoms, and attaching suitable side chains or organic radicals to them, a material evolves with the inertness of quartz and the flexibility of the organic plastics. The silicone elastomers are available in 2 forms: those requiring heat to effect vulcanization (HTV) and those that vulcanize at room temperature (RTV).

Silicones are classified into 4 groups, according to their applications. 1. The first classification is Implant Grade, which requires the material to undergo extensive testing and must meet or exceed FDA requirements. Recent health problems caused by silicone breast implants have created controversies regarding the safety of the material to be implanted interstitially. 2. The second classification is Medical Grade, which is approved for external use only. This is the material most commonly used in fabrication of maxillofacial prostheses. Adverse reactions caused by direct contact between Medical Grade silicone and human skin have not been reported. Very often, the term. medical grade. creates confusion among clinicians. 3. Clean Grade.

89

4.

Industrial Grade, which is mostly used for industrial applications.

HTV silicones Designed for higher tear resistance in engineering applications, this type of polymer requires more intense mechanical milling of the solid HTV stock elastomer compared with the soft putty RTV silicone, especially for incorporating the required catalyst for cross-linking, and for pigmentation. The prosthetic device is cured at elevated temperature in a heat-transferring metal mold. Pigment - elastomer milling represents a significant advance in the state of the-art overcoming the problem of hand mixing pigments in viscous, air entrapping RTV silicone stocks. The HTV silicones processed by milling compared with RTV silicones are generally most prominent in industrial silicone technology, particularly for long-term mechanical durability and chemical resistance. Silastic 370, 372, 373, 4-4514, 4-4515 HTV silicone is usually a white, opaque material with a highly viscous, putty-like consistency. The material may be supplied as a 1-component or 2 component putty. The catalytic, or vulcanizing, agent of the HTV silicones is dichlorobenzoyl peroxide or platinum salt, depending on the type of polymerization used (condensation reaction or addition reaction, respectively). These silicones can be preformed into various shapes for alloplastic implantation or facial prostheses. Varying amounts of filler are added to these polymers, depending on the degree of hardness, strength, and elongation desired. Generally, the more filler, the harder and less resilient the compounded rubber will be. The filler is usually a very pure, finely divided silica with a particle size of about 30. In addition. the copolymerization of silicone with small amounts of methyl vinyl, or methyl phenyl siloxy radical, varies the relative softness and tear strength. Processing of heat-cured silicones requires sophisticated

instrumentation and high temperature. An excellent description is provided by Chalian. These silicones exhibit excellent thermal stability, are color-stable when exposed to ultraviolet light, and are biologically inert. However, they do not possess sufficient elasticity to function in movable tissue beds. Polydimethylsiloxane oligomer (Electronic Fluid 200, Dow Corning) may be added to reduce the stiffness and hardness of the

90

prostheses. Also, the material itself has low edge strength and may require nylon reinforcement at the margins. Important objections are their opacity and lifeless appearance. They do not readily accept extrinsic coloration. so the internal colorants must be incorporated into the gum stock with a milling device. Because high temperatures are required for vulcanization, metal molds are necessary. PDM siloxane A HTV silicone was developed by the Veterans Administration. Results of studies by Lontz show that the material exceeded values considered clinically acceptable and is used intra orally.133 Q7-4635, Q7-4650, Q7-4735, SE-45240 A new generation of HTV silicones evaluated by Bell were shown to have improved physical and mechanical properties compared to MDX4-4210 (a RTV silicone) and MDX 4-4514. The processing characteristics of Q7-1635 and SE-45240 were particularly favorable because of their single component system with unlimited shelf life. In general HTV silicones have better physical and mechanical properties than do RTV silicones. The drawback of the material is its opacity, difficulty in intrinsic coloration, high superficial surface hardness, and difficulty in processing. RTV Silicones Designed for rapid room temperature curing, the RTV silicones continue to serve the needs of the maxillofacial restorations but with some limiting aspects. With some grades, owing to the white source elastomer, internal coloring is difficult. In mixing stock elastomer with the catalyst for the curing (vulcanizing), air entrapment persists in the finished cured prosthesis, which tends to initiate tear and accumulation of skin exudates. Tear resistance of RTV grades is generally inadequate to maintain edge resistance. Once started at an edge void or a nick, tearing propagates gradually across the prosthetic device, requiring skilled repair by applying proprietary silicone adhesive or reinforcement with fabric. RTV silicones formulated with silica fillers to enhance tensile strength and to mask yellowing or discoloration sacrifice considerable translucency, making it difficult to attain proper internal (intrinsic) coloration. Also, discoloration in

91

some RTV grades of silicone introduces a negating feature esthetically. To correct for these deficiencies, a transparent proprietary RTV-grade silicone (Dow Corning MDX 4-4210) is an improved alternative but requires considerably longer curing time of up to 16 hours at ambient temperature. The curing time can be reduced by heating up to 150 C for as little as 5 minutes, which would require forming special expensive metal molds. The improvement in tear resistance is significant, but nick tear sensitivity under tension prevails, as does the propensity to entrap air during blending and pigment mixing Silastic 382, 399 This viscous silicone polymer includes a filler, a stannous octoate catalyst, and a orthoalkyl silicate cross-linking agent. The polymerization is by condensation reaction. Fillers, usually diatomaceous earths. are used to improve strength. The properties of the original RTV silicones (Silastic 382, 399) are similar to the HTV types. They are color-stable, biologically inert, and retain their physical and chemical properties at wide temperature ranges. They are available as clear solutions that enable the fabrication of translucent prostheses. The RTV are much easier to process than the heat-cured forms. Molds of dental stone can be used. The RTVs share some of tile undesirable properties of the HTV silicones in that they have poor edge strength and are difficult to color. In our experience, at delivery, the cosmetic appearances of these materials is inferior to that of the polyurethanes. acrylic resins, and polyvinylchlorides. Silastic 382 is used for intraoral use.133 MDX4-4210 This medical-grade silicone elastomer has shown to be the most popular among clinicians. Moore reported that it exhibits improved qualities relative to coloration and edge strength. This material is not heavily filled, making it translucent. It has a chloroplatinic acid catalyst and hydramethylsiloxane as a cross-linking agent. The polymerization reaction is an addition reaction with no reaction by-products. The cured material has been shown to exhibit adequate tensile strength. More importantly, increased elongation and resistance to tear have reduced the need for reinforcement of the thin edges of the prosthesis. In addition, the surface texture and Shore A hardness measurements are well within the range of human skin. Modifications of the physical properties can be accomplished

92

by the addition of silicone fluid. In the study by Moore, the material was found to be nontoxic, color stable, and biologically compatible. Early clinical testing reveals Silastic MDX 4-4210 to be quite desirable and it appears to be compatible with most skin adhesive systems. Shade guides for intrinsic coloration have been developed. Accelerated aging testing have shown that the elastomer is very color stable. Extensive testing on the physical and mechanical properties of MDX 4-4210 has been documented. Results indicate that, even though it is not the ideal material, MDX4-42 10 has shown many improvements when compared to earlier materials, and it possesses many desirable characteristics. Processing is simple, as molds of dental stone are acceptable. A 5% solution of mild soap can be employed as a releasing agent. Care should be taken to avoid contamination of the mold with petrolatum or clay residues. The prepared molds are placed in a dry heat oven at 50C for approximately 30 minutes prior to their use. Warming all the mold segments will assist in retaining the position of the custom colors used for intrinsic shade matching. After appropriate surface detail has been reproduced, a syringe is loaded and used to fill the mold parts with the material that has recovered its viscosity after mixing. The mold is closed with finger pressure and a web clamp is secured in position to hold the sections together tightly. The mold is returned to the dry heat oven and the temperature is elevated to 80C. The mold is left in the oven for 1 hour. Surface characterization can be achieved with pigments immersed in a silicone adhesive. Using unflasked gypsum mold in dry heat for multiple processing will dehydrate the gypsum and cause loss of surface detail or disintegration of the mold. Flasking of the mold and using moist heat will increase the longevity of the mold. Research on porosity and density of both RTV and HTV silicones, using various processing techniques by Kent, indicates that de-airing the fluid silicone prior to packing, using a controlled injection packing technique, and soaking of a flasked mold in slurry water prior to moist heat application will result in a dense and porosity-free prosthesis. Superior cosmetic results are achieved with this material. Silastic 891 Udagama and Drane first reported the use of this material, also

93

known as Silastic Medical Adhesive Silicone Type A, for fabrication of facial prostheses. It has gained popularity among clinicians. Twenty-five percent of clinicians surveyed use this material". It is a translucent, non-flowing paste which polymerizes at room temperature on contact with moisture in the air. It can also be processed in a gypsum mold. Metal molds are not recommended because its surface may react with acetic acid, which is liberated as a by-product of polymerization. The advantages of the material are no catalyst is required and it is compatible with a wide range of colorants. However, the material does share some of the disadvantages of RTV silicones. In 1987, Udagama reported improving the edge strength of silicone prosthesis fabricated by Medical Adhesive Type A by bonding the prosthesis to a prefabricated polyurethane film using primer, S2260 (Dow Corning Corp.). Farah studied the mechanical properties of mixtures of Adhesive Type A and uncatalyzed MDX 4-4210 base elastomer. It was reported that different mechanical properties can be obtained by varying the amount of MDX 4-4210 base elastomer to Medical Adhesive Tune A to allow for better simulation of facial tissues. Cosmesil Cosmesil is a RTV silicone which can be processed to varying degrees of hardness as described by Wolfaardt. The material was shown to have higher tear strength at failure than MDX 4-4210. Studies on surface texture, wettability, and hardness were also reported by Veres. A-2186 A-2186, a recently developed material (Factor II Inc., Lakeside, Ariz.), initially showed Improved physical and mechanical properties when compared to MDX 4421093. However, Haug reported that, after subjected to environmental variables, the A-2186 elastomer did not retain its improved physical and mechanical properties when compared to MDX4-4210. Foaming silicones: Silastic 386 A form of RTV silicone that has limited use in maxillofacial prosthetics is the foam-forming variety. The basic silicone has an additive so that a gas is released when the catalyst, stannous octate, is introduced. The gas forms bubbles within the vulcanizing silicone. After the silicone is

94

processed, the gas is eventually released, leaving a spongy material. The formation of the bubbles within the mass can cause the volume to increase by as much as sevenfold. The purpose of the foam-forming silicone is to reduce the weight of the prosthesis. However, the foamed material has reduced strength and is susceptible to tearing. This weakness can be partially overcome by coating the foam with another silicone. This coating adds strength but increases stiffness. Siphenylenes Siphenylenes are siloxane copolymers that contain methyl and phenyl groups. The catalyst is similar to that of Silastic 382 and 399. These polymers possess many desirable properties of RTV silicones, including biocompatibility and resistance to degradation on exposure to ultraviolet light and heat. In addition, they exhibit improved edge strength, low modulus of elasticity, and colorability over the more conventional polydimethyl siloxanes. Clinical testing will determine whether this compound represents a significant improvement. New materials: Silicone block copolymers Silicone block copolymers are new materials under development to improve some of the weaknesses of silicone elastomers, such as low tear strength low-percent elongation, and the potential to support bacterial or fungal growth. It has been found that silicone block copolymers are more tear-resistant than are conventional cross-linked silicone polymer. The type of block copolymer being investigated is one that incorporates Poly Methyl Methacrylate (PMMA) into siloxane blocks-. Various methods of synthesis are under investigation. Data on physical and mechanical properties of silicone block elastomers have not been reported. Polyphosphazenes Polyphosphazenes fluoroelastomer has been developed for use as a resilient denture liner (Novus tm Hygenic Corp.) and has the potential to be used as a maxillofacial prosthetic material. Modifications of physical and mechanical properties of this commercially available elastomer may be needed to satisfy the requirements for fabrication of maxillofacial prostheses.

95

Polysar: It is a thermoplastic material that is malleable at 80 degrees centigrade either in hot water or against hot-pulsed air. It belongs to the polyisopren (rubber) family and is available in the form of 61 cm X 45 cm X 3 mm thick smooth sections. Didier has described its use for the fabrication of a hollow surgical obturator. 42 Metals for framework of definitive obturators: 117 Metal frameworks for obturator prosthesis are typically made of Co-Cr alloy; however, Ni, Co or Cr may sometimes cause sensitivity, including not only local responses such as gingivitis and stomatitis but also generalized manifestations like eczema or dermatitis with or without mucosal lesions. By contrast Titanium and its alloys have very high biocompatibility and excellent corrosion resistance in the oral cavity as titanium oxide that is formed on its surface is highly stable and inert. Commercially pure titanium has been in use for over a decade and has been recommended for the fabrication of complete denture & overdenture frameworks and removable partial dentures. Titanium is less dense than conventional alloys, which is of key importance in view of the large size of obturator prostheses. Titanium frameworks have been reported to be 40 % lighter than Co-Cr frameworks and 60 % lighter than Ni-Cr frameworks.

96

PROSTHETIC MANAGEMENT OF THE DEFECTS OF HARD AND SOFT PALATE A rewarding area of prosthodontics is the rehabilitation of patients with congenital and acquired maxillary defects. The dentist contributes to all facets of patient care from diagnosis and treatment to rehabilitation. Resection of the hard and soft palate and related structures result in a variety of anatomic and functional defects in the oral cavity and Oropharynx. Such defects are inconvenient to the patients because of the loss of oro-nasal separation, which substantially interferes with the important functions of speech swallowing and appearance of the patient. The region is susceptible to lesions like epidermoid carcinoma, salivary gland tumours, lymphoepitheliomas, lymphosarcomas, Wegeners

granulomatosis, mucormycosis and aspergillosis which require resection of the palate, maxilla and some facial structures. The extent to which an ablative technique may reasonably be applied in this anatomic region is determined by the degree to which restorations of satisfactory function and acceptable appearance may be achieved. Teamwork between the head and neck surgeon and maxillofacial prosthodontist is necessary to provide a solution to these problems. Methods of Resection: Palatectomy: The mucosal incisions are outlined to give 5- 10 mm margin around the tumour, depending upon the histopathology observed in the biopsy. The incisions are made through to the periosteum and sufficient bone exposed. If the soft palate is also involved a generous margin or the entire soft palate is resected. After soft tissue resection the bone is resected using a power saw or osteotome. If the nasal septum or medial wall of maxillary sinus is involved, they are included in the resection.

97

If the lesion approaches the greater palatine foramen, then the posterior alveolar ridge and the pterygoid plates should also be resected.

After resection, the bony edges are smoothened and contoured, then covered with the periosteum and mucosa. The raw tissues in the surgical defect are covered with split- thickness skin grafts. Packing is placed in the defect and an immediate surgical obturator is inserted and wired to the teeth or alveolar ridge. Maxillectomy: It is required if the tumour is very malignant and invades the nasal cavity or paranasal sinuses. Complete exposure of the maxilla is obtained by the Weber- Fergusson Incision in which the lip is split and the incision extended around the nose up to the orbit and along the eyelid. The mucosal cuts on the palate are as described above. The periosteum is raised and the bone is resected using osteotome, power saw or Gigli wire saw. The orbital rim is spared if the orbital contents have not been invaded. The pterygoid plates and the soft tissues of the pterygomaxillary space are resected at the base of the skull using a curved osteotome. A split thickness skin graft is placed under the soft tissue flap to line the surgically produced cavity. The wound is packed, the immediate surgical obturator is placed and the Weber- Fergusson incision closed.

Fig. 12: Bony cuts for maxillectomy.

The high potential for recurrence is a strong argument for the need for follow up and observation of the margins of the defect instead of surgical reconstruction.

98

Total maxillectomy is the complete resection of one of the two maxillae or resection to the midline, whereas partial maxillectomy is a bony resection, which is less than a total maxillectomy. Post-surgical anatomy of the region: Resection of the maxilla results in a continuity of at least the oral, nasal and maxillary sinus cavities. If the tumor involves the roof of the antrum (floor of the orbit) then the orbital contents will also be exenterated creating a continuous defect from the oral cavity that extends through the orbit to the facial surfaces. The anatomic defect of maxillectomy, may be bounded medially by the nasal septum, posteriorly by a vertical plane through the anterior border of the soft palate, laterally and inferiorly by the inside of the graft-lined cheek, superiorly by the floor of the orbit and cribriform plate, inferiorly by a horizontal plane extending from the residual hard and soft palate to the fibrous contraction band which forms at the juncture of the buccal mucosa and skin graft which corresponds to the superior region of the mucobuccal fold on the resected side. It is important that the prosthodontist knows what structures are in and around deformity, which is to be restored. The prosthesis should not impair the function of the adjacent tissues or produce undesirable changes in the tissues.

When the bony margins of a defect are sharp and the overlying tissue is thin, a resilient material can be utilized to aid retention. When the bony margins of the defects are covered with a generous amount of overlying tissue, it may not be necessary to use a resilient restorative material. The turbinate bone should not be utilized to absorb stresses transmitted through the prosthesis. A less prominent post dam is indicated on the final prosthesis when a tissue seal cannot be obtained.

99

CLASSIFICATION OF MAXILLECTOMY DEFECTS94

Defect classification systems enable surgeons and prosthodontists to use the characteristics of a particular defect to establish a functional prognosis. 1. Ohngrens classification system (1933) for maxillectomy defects. Following this, a number of oncologically oriented classification schemes have served to describe the anatomic boundaries of the maxillectomy defect. 2. Aramanys Classification (1978)7 addresses removable partial framework design and prosthetic rehabilitation of the partially edentulous maxillectomy patient in six categories. 3. Spiro et al proposed a classification in 1997 that focuses on infrastructure defects; however, it does not specifically address the involvement of adjacent structures such as the orbit and the zygoma. Defects are termed as limited or subtotal on the basis of the number of maxillary walls involved in the resection. 4. Davison et al (1998) proposed a reconstruction algorithm based on a review of 108 patient treatments involving prosthetic obturation, non vascularized bone grafts, local flaps, regional flaps and microvascular free tissue transfer. Davison divided patients in two broad categories of complete and partial maxillectomy defects. Davison proposed a wide range of reconstructive techniques, but the lack of a specific defect oriented classification system outlining the remaining portion of the hard palate, dentition, orbit and zygoma make such an algorithm difficult to apply as a reconstructive guide. 5. Brown (1996) was the first to discuss a multidisciplinary (surgical and prosthodontic) approach to palatomaxillary reconstruction. His more useful defect classification scheme is based on both the vertical and horizontal dimensions of a defect. The vertical component of the defect ranges from minor resections with no oro-antral fistula to radical maxillectomy defects with orbital exenteration. The horizontal component ranges from a small hard palate defect without the involvement of dentition to a total palatectomy defect. According to Browns scheme, the classification of the horizontal dimension of the defect is based upon the remaining palatal surface. Although the residual palatal surface plays an important role in determining the best form of reconstruction for the edentulous patient, the dentate patient can rely not only on the remaining surface but also on the remaining dentition for

100

retention. Furthermore, the state of the orbital floor and zygoma, which play an important role in both the function and the cosmetic results of the midface, are not specifically addressed in the Browns system. Defects involving either of these areas are poorly managed by prosthetic rehabilitation and often require hard tissue reconstruction.

6. A classification system of defects for the prosthodontic guidelines for the surgical reconstruction of the maxilla was been proposed by Okay et al (2001)94 by reviewing 47 consecutive patient treatments of palatomaxillary reconstruction at the Mt. Sinai Medical Center. All patients were rehabilitated with a tissue borne obturator, a local advancement flap, a fasciocutaneous free flap or a vascularized bone containing free flap. Palatomaxillary defects are divided into 3 major classes and 2 subclasses.

Probably, the most common of all intraoral defects of the maxilla are in the form of an opening into the nasopharynx. needed to repair the defect is termed as an 'obturator'. The prosthesis

The term obturator is taken from the Latin meaning "to stop up". More specifically, from a dental standpoint obturator is defined as a disc or plate, natural or artificial, which closes an opening of the hard or soft palate, or both. FUNCTIONS OF OBTURATOR17 i. ii. iii. iv. v. It serves to close the defect. It can serve in lieu, of a naso-gastric tube for feeding purposes. It can be used to keep the wounds or defective area clean and it also enhances the healing of traumatic or post-surgical defect. It helps to reshape and contours the soft and hard palate and also improves lip and check position. It reduces the flow of exudates in the mouth and improves deglutition and mastication if impaired. vi. vii. viii. It can be used as a stent to hold dressings or packs post surgically. It improves speech in some cases. It can benefit the morale of the patients with maxillary defects.

101

CLASSIFICATION OF OBTURATORS According to Rahn and Boucher112, obturators may be broadly classified according to : A) The origin of discrepancy: a) b) Congenital defect obturator. Acquired defect obturator.

B) The location of the defect a) b) c) d) e) Labial or buccal reflex obturator. Alveolar obturator Hard palate obturator Soft palate obturator Pharyngeal obturator

C) The type of obturator attachment to the basic maxillary prosthesis a) b) c) Fixed obturator Hinged or movable obturator Detachable obturator

D) The physiologic movement of the oral, nasal and pharyngeal tissues adjacent to or functioning against the obturator a) b) Static obturator Functional obturator

Prior to surgery the prosthodontist should examine the patient thoroughly, make impressions for diagnostic casts, obtain a jaw relation record and appropriate dental radiographs (IOPA, OPG, Lateral oblique, Dental CT SCAN) and photographs of the patient. Interaction between surgeon and prosthodontist is necessary for achieving optimum

rehabilitation post operatively by considering certain modifications of surgery that may improve the prognosis for prosthetic rehabilitation.

102

Surgical modification enhancing prosthetic prognosis

i)

An attempt should be made to save as much of the maxilla as possible consistent with tumor control. The premaxillary segment if saved can improve the prosthesis, prognosis immeasurably by enhancing stability and support for the prosthesis.

ii)

At times in resections extending posteriorly, it may be advisable to remove the coronoid process of mandible since it might interfere/impinge upon the distobuccal aspect of the obturator.

iii)

The surgeon can improve the tolerance and retention of the obturator if he lines the reflected cheek flap with a split thickness graft. Such a graft is more flexible and resistance to abrasion. The graft also contracts about 50 % of its volume. Contracture is mainly affected by the amount of residual bony support and ancillary therapies such as radiotherapy.

iv)

Scar band formed at a skin graft - mucosal junction often creates a sizeable lateral undercut superiorly. and support. Engaging the scar band superiorly and inferiorly with prosthesis enhances stability retention

v)

Retention of key teeth may lead to improved function. the tooth adjacent to the resection.

The

transalveolar resection should be made as distant as feasible from

Fig. 13: Transalveolar resection done through the middle of the socket of extracted tooth to save bony support for the adjacent tooth.

103

vi)

If the surgeon can save some of the palatal mucosa normally included in the resection and reflect this tissue during the bony resection of the palate, it can be used later to cover the cut bony margins of the palatal bones, because the defect which is covered with keratinized mucosa is a better denture bearing surface and can provide lateral stability.

vii)

In cases where only posterior portion of the soft palate remains post surgically, it should be removed along with the entire soft palate because it may contract superiorly and thus hinder prosthesis reconstruction by blocking access to the area of greatest motion of the lateral and posterior pharyngeal walls. An exception has to be made for edentulous patients and even posterior third of the soft palate left behind, as the extension of the obturator prosthesis onto the nasal side of the residual palate is an advantage that outweighs the possible speech and leakage problems that might occur due to the contraction.

Fig. 14: The remainder of the soft palate is subject to rapid contraction anteriorly and superiorly during the first three weeks after surgery and can compromise velopharyngeal closure.

viii)

Access to the superior and lateral portions of the defect should be provided by excision of the turbinates and the oral mucosal bands. Maintaining the turbinate precludes the extension of the medial wall of the obturator bulb into the nasal cavity, and the hence, it cannot prevent the rotation of the prosthesis during function. Engaging the

104

lateral nasal side of the orbital floor provides support for the obturator. ix) Implants can be placed during the resective surgery in the premaxillary segment or the tuberosity region. The use of implants within the defect should be discouraged, as it is very difficult to maintain hygiene around them. Also the use of pre or post operative radiation does not preclude the use of implants it has been found that radiation doses above 5000 centigray, compromise the remodeling of bone around the implant and thus predispose to bone recession and premature implant loss.

General Outline For Prosthetic Rehabilitation Of Hard Palate Defects

The prosthodontic therapy for patients with defects of the maxilla can be arbitrarily divided into two phases of treatment with each phase having different objectives. I) II) I) First phase/initial phase - surgical obturator construction Second phase - Definitive prosthesis construction. Surgical Obturator : These prosthesis initially is limited to the

restoration of palatal integrity and the reproduction of palatal contours. It entails the placement of a prosthesis at surgery or immediately there after. This prosthesis must be modified at frequent intervals to accommodate for the repaid soft tissues changes that occur within the defect during organization and healing of the wound. Surgical obturators are of two types according to Beumer & Curtis17 Immediate surgical obturator Delayed surgical obturator / Treatment obturator/Transitional

i)

Immediate surgical obturator - It is placed at the time of surgery. It can be of utmost importance in the successful post-operative management of person who will have resulting oral and facial deformities.

105

Advantages of immediate surgical obturation Provides a matrix on which the surgical packing can be placed. The prosthesis reduces oral contamination of the wound during the immediate post surgical period. Enables the patient to speak more effectively

postoperatively by reproducing normal palatal contours and by covering the defect. The prosthesis permits deglutition, thus the nasogastric tube may be removed at an earlier stage. The prosthesis lessens the psychologic impact of surgery by making the postoperative course easier to bear. The prosthesis may reduce the period of hospitalization,

Construction of immediate surgical obturators: Beumer and Curtis17 have given several principles relative to the design of immediate surgical obturators. The obturator should terminate short of the skin graft mucosal junction. As soon as the surgical packing is removed, extension into the defect may be accomplished with tissue treatment, or interim soft reline materials. It should be simple, lightweight, and inexpensive. The prosthesis for dentulous patients should be perforated at the interproximal extensions with a small dental bur to allow the prosthesis to be wired to the teeth at the time of surgery.

Fig. 15: the cast is modified as per the out line of resection decided by the surgeon.

106

Fig. 16: The holes for interdental wiring and recesses made

Fig 17: Inserted surgical obturator with interdental wiring.

Normal

palatal

contours

should

be

reproduced

to

facilitate

postoperative speech and deglutition. Posterior occlusion should not be established on the defect side until the surgical wound is well organized. incorporated at times for esthetics. In some patients the existing complete or partial prosthesis may be adapted for use as an immediate surgical obturator. However, the Anterior teeth may be

flange of the prosthesis corresponding to the proposed defect should be reduced and the posterior denture teeth removed prior to surgery.

Procedure of surgical obturator construction for dentulous patients: Rahn and Boucher112 have described this. The patient is seen

preoperatively, and an alginate impression is made of the maxillary arch. The impression should involve area of soft palate as well as overextension into the buccal vestibule. This amount of tissue coverage is necessary because the resection usually involves the pterygoid area side of the tumor. The stock impression tray may be altered by addition of wax or

107

removal of portion of tray to cover all desired areas or when the tumor protrudes orally respectively. The impression is border molded in the soft palate area by asking the patient to bend forward and then turn slowly from side to side, causing the functional limits of the palate to be recorded. The impression is poured in artificial stone. The area to be

resected should be determined by the surgeon and sketched onto the cast. The teeth are removed in the designated area and eighteen gauge wrought wire retainers or ball-type retainers are constructed on the teeth so as to give proper retention to the completed restoration. Most of the time a retainer is given on tooth adjacent to the defect. If conservation of time is essential, an autopolymerizing acrylic resin can be added to the cast by using sprinkle on technique and the cast is placed in a pressure cooker for 10 min. If time is not a factor, the obturator should be waxed up, to two thickness of base plate wax. Artificial anterior teeth can be placed, if further esthetic qualities are desired and the teeth are expected to not cause trauma to the defect area. The obturator can be invested and processed for nine hours using hear cure acrylic resin. A clear, heat-cure acrylic resin is usually desirable because the pressure areas can be easily detected and relieved when the obturator is placed immediately after surgery in the operating room. Surgical obturator for edentulous patients. These obturators can be constructed very easily and the procedure is almost the same as for dentulous patients. But, since the retention is sought from a source other than the teeth, by the technique of pinning the obturator to maxilla using a palatal screw, suturing into surrounding mucosa or using ligature wire around the zygomatic arch and through the obturator is often used. This requires additional time. Some surgeons would prefer to wait at this stage until the pack is removed and then recommend a treatment obturator.

108

Fig. 18: Surgical obturator for edentulous patient with holes for transalveolar wiring and recesses for the ligature wire.

Fig. 19: Obturator in place with transalveolar wiring.

Bone screw retention for a surgical obturator in an edentulous patient can be achieved by using a 13-16mm long self-tapping bone screw (made of titanium or stainless steel). It is placed through a predrilled hole in the acrylic resin plate in the mid-palate at the anterior peak of the palatal vault and screwed into the vomer. The hole in the acrylic plate should allow free movement of the screw before placement into the bone and must have a countersink to hold the head of the screw. If the vomer is resected, two screws placed at conflicting angles through the denture at the lateral hard palate at the junction of the alveolus and palatal vaults should be used. The contralateral maxillary sinus may be entered with the screws. A small plug of tissue conditioner or silicone added over the head of the screw to keep the screw attached to the plate, in case the patient dislodges the surgical obturator. In an irradiated patient, the placement of bone screw is avoided and sutures placed at the periphery of the prosthesis may be secured into the soft tissues at the height of the vestibule, against the bone of the remaining maxillary alveolus, while the surgical side is secured against the cheek. The patients existing denture should not be used as maintaining the occlusion while securing the obturator with bone screws, wires or sutures is almost impossible. The patients need to be instructed to discontinue use of the mandibular denture due to these occlusal

109

discrepancies. As facial contracture occurs, the anterolateral border of the denture requires significant reduction, which involves the facial reduction of teeth or even their removal. If it is not done then the lips unseat the prosthesis. Therefore, the patient must be counseled to accept a baseplate without dentition for surgical obturation. Revision of the surgical obturator: After the gauze pack is removed, the obturator generally needs revision. This is accomplished by building up the defect side of obturator in modeling plastic and border moulding the area. After this, the obturator is invested and modeling plastic is removed and replaced with autopolymerizing acrylic resin. In order to reduce the weight, the newly added bulb portion may be hollowed out superiorly. This type of revision can be performed quite easily without the patient having any discomfort. Another technique is to do chairside incremental addition and shaping of a tissue conditioner material. The viscous mix of the material is placed at the periphery of the surgical obturator, arbitrarily shaped, then placed in the mouth and patient is asked to do the movements as described later in the impression procedure for definitive obturator. Excess material is cut away, and after sufficient adaptation is achieved a wash type of impression can be made by a thinner consistency of the tissue conditioner. ii) Delayed surgical obturator/Treatment obturator:

An alternative to the placement of prosthesis at surgery is the placement of a delayed surgical obturator 7 to 10 days post surgically. If the patient is edentulous and the surgical defect is extensive this approach may be the treatment of choice. It is constructed, right after the surgical pack is removed, and about seven days post operatively. Irreversible hydrocolloid impression is made in a stock metal tray very carefully after covering all the margins of the tray with beading wax. The obturator is fabricated and inserted before the patient leaves the hospital. In dentulous patients as healing progresses, posterior occlusal ramps can be established with the addition of autopolymerizing acrylic resin. In edentulous patient the delayed obturator is regularly relined. can be constructed. This restoration is used until the defect area has Because, depression develops in many patients healed sufficiently, usually about 3 months, and a more definitive obturator

110

during this post-operative period, a surgical obturator can have far reaching psychological value. Treatment obturators for dentulous and edentulous patients These techniques have been described by Rahn and Boucher112. If the patient has an existing denture, it can be utilized in the construction of a treatment obturator. If there is excessive underextension an alginate impression can be made over the denture while it is in place in the mouth. A plaster cast is made from the impression. Cold cure acrylic resin is added to the periphery of the old denture on the cast. The tissue surface is cleaned and covered with resilient adhesive. The resilient denture lining material is placed on the tissue surface and readapted. fabricated Procedure :After a satisfactory impression is made, it is poured in artificial stone. On the stone cast a pencil line can be drawn slightly inferior to where the oral mucosa and skin graft meet on the cheek. This area can be easily palpated on the patient as a fibrous band running horizontally on cheek and at the height where the buccal vestibule would have been. This band will generally extend posteriorly and become part of the posterior portion of the defect. After this retainers are constructed if the patient is dentulous. The retainers should be placed as close to the defect as possible and at maximum distance from each other135. This is different from the earlier concept that the clasps should be placed as close to and as far from the defect as possible (Desjardins
40

This type of

obturator can be used until a more effective treatment obturator can be

). Such a configuration might not

necessarily place clasps as far apart as possible and might in fact, place a clasp on a tooth that serves as an indirect retainer, rendering the clasp nonfunctional. The resin portion of the obturator prosthesis should contact the axial surfaces of the remaining teeth whenever possible to provide maximum stability and wider stress distribution. The addition of teeth should be limited to satisfying esthetic needs and assisting in speech production. Occlusal function should not be restored.

111

Two thickness of baseplate wax is adapted over the designated area. All undercuts alone the walls of the defect side are blocked and the prosthesis is processed in a conventional manner. The prosthesis after processing is checked in a patients mouth. The acrylic resin cavity on the palatal side of the obturator is filled with wax until proper contour of the palate is established. This procedure is carried out in order that an

artificial or false palate can be added to the prosthesis. A thin layer of separating media is placed over the wax and onto the acrylic resin. A plaster cast is then poured over the wax and extended onto the acrylic resin to a point where reorientation of the core can be easily done. The wax is removed from the defect side and an acrylic resin separating medium is placed over the superior portion of the core. Over this core is sprinkled auto-polymerizing acrylic resin to a thickness of 1-2 mm. The core is then invested and pressed into contact with the

prosthesis and hold firmly till resin has set properly. All excess acrylic resin is trimmed away and the obturator is polished. Some dentists may prefer to wax the defect side so that it will be processed entirely of resin and then hollow it out as a port of revision procedure. The patient is examined periodically and instructed regarding maintenance and cautioned that further adjustments are likely as the surgical area heals and contracts. Interim Obturation: bridges the gap between immediate surgical obturator and the definitive prosthesis. There is very little distinction as both immediate and interim obturators provide comfort and function to the patient till definitive obturation can be done. The reasons for fabricating a new prosthesis are: The periodic addition of interim lining materials increases the bulk and weight of the obturator and the temporary material become rough and unhygienic with time. Addition of teeth to the obturator provides great psychological relief to the patient.

112

The retention and stability can be made better than the immediate obturator. The interim prosthesis may prove useful as a backup prosthesis to the definitive one.

Instructions to patients for delayed surgical and interim obturators: The patient should be instructed not to keep the obturator out for more time than is required to clean the prosthesis or the surgical defect area as ensuing tissue edema may alter the fit of the prosthesis. Denture adhesives can be used with acrylic resin dentures not lined by tissue conditioner. Patients must be instructed and made to practice the placement & removal of the prosthesis and instructions for cleaning the prosthesis must be given before the patient leaves the office. Patients should be told that the head- upright position during swallowing would decrease the leakage of fluids into the nose. Patients should be instructed not to use effervescent denture cleaners when tissue conditioner material is used to reline.

II)

Definitive Obturation Three to four months after surgery consideration may be given to the construction of definitive obturator prosthesis. The timing will vary depending on the size of the defect, the progress of healing, the prognosis for tumor control, the effectiveness of the present obturator, the use and timing of post surgical radiation therapy and the presence or absence of teeth. The defect must be engaged more aggressively for edentulous patients to maximize support, retention and stability. Therefore the recovery period is extended for these patients, as changes associated with healing and remodeling continue to occur in the border areas of the defect for at least one year, but are primarily related to the peripheral soft tissues rather than to the bony support areas. If osseointegrated implants are placed at the time of the tumour resection, fabrication of the definitive prosthesis is delayed until the implants are exposed and peripheral soft tissues around them have healed. Also the information regarding the prognosis of the tumour control as well as general health and desires of the patient need to be considered.

113

A patient's poor prognosis, or poor health does not preclude the construction of definitive obturator prosthesis, but the treatment plan should reflect the possible altered needs of such a patient. Treatment Concepts Regarding The Definitive Obturator Prosthesis:17 Following factors should be considered. i) Movement of the Prosthesis: The obturator prosthesis will be displaced superiorly into the defect with the force of mastication and will tend to drop without occlusal contact. The degree of movement will vary with the number and position of teeth that are available for retention as well as with the size and configuration of the defect. ii) Tissue changes: Dimensional changes will continue to occur for at least a year secondary to scar contracture and further organization of the wound. Movement of the prosthesis, during function may, itself contribute to tissue changes. Hence, the obturator portion should be made in acrylic resin so as to facilitate reline or rebasing to compensate for these changes. iii) Oro-Nasal Partition: Obturators for acquired defects of the maxillae are basically covering prosthesis serving primarily to re-establish the oral nasal portion. The obturator prosthesis is extended into the defect in order to enhance retention, stability and stability. The contours of the defect are relatively static during function, aside from the movement of the soft tissue displaced by the movement of the coronoid process, the anterior border of the ramus, elevation of the soft palate and slight movement of the lips and cheeks. In contrast, obturators that restore palatopharyngeal incompetency must function in concert with tissues exhibiting extensive functional movement. iv) Extension into the defect: is dependent on the requirements of retention, stability and support. If adequate maxillary structures are

present, extension into the defect need not be extensive. In addition the extension of the prosthesis into the defect will vary according to the configuration of the defect and the character of its lining tissue. Extension of the prosthesis superiorly along the nasal septum offers little mechanical advantage. In addition its lining mucosa is not amenable to tolerate stress.

114

In comparison, extension superiority along the lateral margin of the defect will enhance, retention stability and support. Stress is well tolerated by the skin graft and the oral mucosa lining the cheek surface of the defect. v) Teeth: The presence of teeth enhances the prosthetic prognosis.

Every effort should be made to maintain and enhance the longevity of teeth, or even roots of teeth, to assist in the retention, stability and support of the prosthesis. vi) Implants: The placement of osseointegrated implants dramatically improves the function of obturator prosthesis. Implants can be placed either at the time of tumour resection or at some appropriate time thereafter. vii) Weight: Bulky areas should be hollowed out to reduce weight so that teeth and supporting tissues are not stressed unnecessarily especially when the obturator prosthesis is suspended without bony or posterior tooth support on the defect side. Wu and Schaaf153 have found that hollowing the obturator prosthesis reduces weight by 7-33% depending on the size of the defect. The superior surface can either be left open or closed. Clinicians who prefer closed top state that if the obturators are left open, nasal secretions accumulate leading to bad odour and added weight. Advantages of leaving the top open are that the weight of the obturator is further reduced as there is no lid, it is easier to adjust and speech is better. The effect of length of extension into the defect and top configuration (open/closed) was studied by Aramany and Drane (1972) and Oral96; and they found that the speech quality using the limited extension prosthesis was better than with the maximally extended obturator prosthesis. The lengthy superior extension along the lateral and disto lateral aspect of the defect is essential for stability, support and retention. If a lid is added to the hollow obturator, the obturator bulb occupies significant portions of the nasal and maxillary sinus cavities. Sharry(1962) has stated that it is not necessary for the obturator to occupy the entire defect superiorly for effective obturation. If a closed bulb is used, then it may change the configuration, resonance balance and airflow characteristics of the nasal cavity. The

115

open obturator design may be less obtrusive in the nasal cavity and permits more normal airflow, nasal resonance and speech. Though Chalian29 recommends closed top obturator, Beumer and Curtis17 advocate the open top obturator and have experienced that occasionally a patient may be required to be converted to closed top bulb. Also, a drainage channel for the collected secretions may be made. A diagonal opening may be made in the inferolateral floor of the open obturator through the cheek surface for drainage154. The cheek will close against the opening and hence, the seal will not get compromised. A pipe cleaner can be used to maintain patency and cleaning this channel. Definitive Prosthesis construction for hard palate defects is divided into A) a) b) B) a) b) For Edentulous patients For Dentulous patients For total Maxillectomy For Partial Maxillectomy

PROSTHETIC CONSIDERATIONS FOR EDENTULOUS PATIENTS WITH TOTAL MAXILLECTOMY DEFECTS It is a prosthodontic challenge to restore such patients as air leakage, poor stability and support, reduced bearing area compromise adhesion, cohesion and peripheral seal. Therefore, the contours of the defect must be used to maximize retention, stability and support. The prosthesis exhibits a lot of movement about the axis of rotation, which is located along the medial palatal margin of the defect. In a posterior maxillary defect, where the premaxilla is preserved, the axis of rotation shifts posteriorly. This is a favourable situation as more support is available. Remaining palatal structures determine the available support and stability. An ovoid or square arch form provides better support than the reduced amount and undesirable angulation of the palatal shelf found in tapering arches. If pendulous soft tissues are present, they should be excised to improve the prognosis. The undercut above the scar band at the junction of the split skin graft with the oral mucosa should be engaged to enhance retention and

116

support of the prosthesis. Since, the lateral portion of the obturator exhibits greatest degree of movement, retention can be improved by appropriate obturator tissue contact supero-laterally. Additional retention gained by extending the prosthesis along the nasal surface of the soft palate or anteriorly into the nasal aperture. The lateral portion of the orbital floor can also gain support if it has been lined by skin graft. Impressions are made as described later. Jaw relations may need to be recorded on processed bases as described by Curtis
35

& Jacob

61

as support and stability are difficult to

achieve with a conventional temporary base. Temporary base can be used if stability and support is adequate. Trismus complicates the recording of vertical relation. It can be countered by the use of flexible baseplate type of plate made of silicone as described by Lauciello. However, it is subject to rapid deterioration and fungal infections, it needs to be replaced frequently. Extreme trismus can also be managed in a way described by Taylor in a patient with a contiguous orbital defect. The prosthesis is button shaped and fabricated in silicone. It is snapped in position from the top to plug the defect. It is possible only when the orbital defect is large. Normal parameters are used to adjust the maxillary rim and the vertical dimension. Compensation for the contracted lip and cheek has to be done on the surgical side. Often it may be necessary to gradually create a negative horizontal overlap or end-to-end occlusion extending from the midline to the posterior dentition. Lip closure may be a problem due to contracture and shortening of the upper lip. It can be compensated by reducing the vertical dimension slightly or by the adjustment of buccolingual placement of teeth. The latter should be preferred as if the former technique is employed; there might be tongue or lip biting on the normal side. Due to the size of the maxillary cast a high post articulator such as TMJ articulator is recommended. Transfer should be done with a face bow record. Graphic centric records by intra or extra oral tracing are contraindicated as the lack of support introduces inaccuracy. Use of bite registration paste to record the centric relation is advocated along with stabilization of the record bases by the operator during closure.

117

The maxillary base should be carefully observed for movement or shifting during interocclusal record making. Teeth should be arranged using Monoplane teeth with reduced size to minimize stress
25

. Monoplane teeth also allow negative horizontal

overlap on the surgical side. Roberts advocated balanced occlusion while according to Beumer & Curtis nonanatomical and /or functional posterior teeth are arranged according to neutrocentric or lingualized occlusal concepts as these minimize lateral forces and deflective occlusal contacts and thus improve stability. The teeth are set in centric relation and all lateral interferences eliminated. The trial denture is checked and jaw relations verified. At the try-in appointment the palatal contours must be evaluated. The vault may be too high or low. It can be evaluated easily by sweeping the thumb across the palate from one side to the other. Palatograms can be used to evaluate further. Pressure indicating paste is streaked across the palatal contour and then the patient is asked to swallow and speak. Heavy contact areas should be trimmed while the deficient areas built up in wax. If there is heavy tongue contact on the palatal surface of the teeth on the defect side, tongue space should be regained by reducing the width of the occlusal surfaces. The denture can be made hollow, with a closed or open top, or have a silicone obturator section as described later in the different techniques that are used. Denture processing should be done at 165 F for 15 hours to prevent porosity if thicker sections of acrylic are present. If the processed bases were used then the prosthesis can be cured at a lower temperature than the first curing .The clinical significance of the distortion created with multiple processing of the resin is negligible. During denture delivery pressure indicating paste should be used to delineate areas of excessive tissue displacement. Clinical remount should be done to perfect occlusion.

Instructions to the patients: Patients should continue to wear the maxillary prosthesis at night as the sinus secretions and saliva cannot be managed without it. If not

118

worn then tissue edema at the periphery of the defect will cause difficulty in placement of the prosthesis. Patients should be instructed to masticate from the nonsurgical side of the arch in cases where the surgical defects are very large. Patients should be taught how to use denture adhesives and to maintain hygiene of the prosthesis. PROSTHETIC CONSIDERATIONS FOR EDENTULOUS PATIENTS WITH PARTIAL MAXILLECTOMY DEFECTS These are similar to the total maxillectomy patients, however the prognosis is better as more of the hard palate remains and hence, the prosthesis has more stability and support. However, the retention may be compromised as the access to and use of the defect is more limited. Implants are especially useful for this group of patients as the premaxillary segment is available for placement of implants and as the access to the defect may be difficult.

PROSTHETIC CONSIDERATIONS FOR DENTULOUS PATIENTS WITH TOTAL MAXILLECTOMY DEFECTS Treatment concepts These are concepts that are unique for dentulous patients and should be considered by the prosthodontist. i. Location of the defect The tumour location and size will dictate the type of remaining arch following resection of maxillary tumors. Invariably, the surgical resection includes the distal portion of the maxilla and rarely does a distal abutment tooth remain after surgery. The extent of the surgical resection anteriorly does vary considerably. Therefore, a Kennedy class II partial denture with an extensive lever arm is required for most patients. ii. Movements of the prosthesis With resection of the maxilla the mucosal and bony support are compromised or may be lacking completely. Hence, the defect must be employed to minimize the movement of the prosthesis to reduce the stresses on the abutment teeth. In most defects, if forceful mastication occurs on the defect side, the prosthesis can be displaced significantly into the defect, which causes the abutment teeth to be

119

exposed to damaging lateral torquing forces. The lateral portion of the obturator exhibits the greatest motion; retention can be improved by appropriate obturator tissue contact supero-laterally.

Fig. 20: Illustration showing the greatest motion in the lateral portion of the obturator.

iii.

Length of the lever arm In conventional prosthodontics, the most common Class II removable partial denture involves an edentulous area distal to the cuspid. However, considerably longer lever arms are encountered in patients with intraoral surgical defects. It is not uncommon for the defect to extend form the middle anteriorly into the soft palate area posteriorly.

iv.

Arch form Square or ovoid arch forms possess more palatal bearing surface perpendicular to occlusal stresses. This results, in a more stable prosthesis during function. This support area must be utilized by the prosthodontist in the same manner as the buccal shelf is used for support for the mandibular partial prosthesis. Tapering arch form provides less palatal support area; therefore, support is compromised possibly leading to

120

significant rotation and subsequent movement of the prosthesis up into the defect, during mastication. v. Teeth Preservation of the remaining teeth is of particular importance, because retention of the prosthesis is far less in the corresponding edentulous patient. Partial denture designs must anticipate and

accommodate to the movements of the prosthesis during function without exerting pathologic stresses on the teeth. Maximum retention, stability and support should be derived from the defect and close attention should be directed to the occlusion on the defect side to minimize occlusal forces. vi. Partial denture design: The basic principles should be followed. Major connectors should be rigid. Occlusal rests should direct forces along the long axis of teeth. Guide planes on the palatal surfaces facing the defect to be used to facilitate stability and bracing on maximum teeth possible as it resists the rotational dislodgement of obturator. The longer the guide planes, better is the resistance to rotational dislodgement. These can be incorporated in the cast crowns, casted bonded metal contours or bonded resin contours. Retention should be within physiological limits of the periodontal ligaments of the remaining teeth. The retainers should be placed as near to the defect and as far away from each other. Maximal support and stability should be gained from the residual soft tissue denture base area including the defect. PROSTHETIC CONSIDERATIONS FOR DENTULOUS PATIENTS WITH PARTIAL MAXILLECTOMY DEFECTS These are similar to those for total maxillectomy patients, but these have better prognosis as the margin of resection moves posteriorly. With the preservation of the canine or even the lateral, the advantages are dramatic as the fulcrum line shifts posteriorly. As this happens the

distolateral extension of the obturator should be lengthened for better mechanical advantage as it will be at a right angle and most distant to the fulcrum line. Indirect retainers should be placed as far anteriorly as possible from the fulcrum line. Retainer placed on the tooth adjacent to the defect increases stability and retention. The construction for the

121

prosthesis is similar to total maxillectomy patients, however when the defects are very small, they should be packed with gauze, to prevent escape and lodgment of the impression material. surgically before the prosthesis is made. Occasionally, edematous turbinates extend into the oral cavity, which should removed

CLASSIFICATION OF PARTIALLY EDENTULOUS DENTAL ARCHES WITH MAXILLECTOMY DEFECTS: Defects of the partially edentulous patients have been categorized into 6 groups by Aramany (1978)7 based on the relationship of the defect area to the remaining abutment teeth. Class sequence reflects the frequency of occurrence in a patient population of 123 patients treated during a period of over 6 years. Class I: The resection in this group is performed along the midline of the maxilla, with the teeth maintained on one side of the arch. This is the most frequent occurring defect and most patients falls into this category. Class II: The defect in this group is unilateral, retaining the anterior teeth on the contra lateral side. This type of surgical resection is favoured more rather than the classical maxillectomy. The central incisors and sometimes all the teeth anterior to canine or premolar are saved. Class III: The palatal defect occurs in the central portion of the hard palate and may involve part of soft palate. The surgery does not involve and remaining teeth. Class IV: The defect crosses the midline and involves both sides of maxilla. Class V: The surgical defect in this situation is bilateral and lies posterior to the remaining abutment teeth. Class VI: It is rare to have an acquired maxillary defect anterior to the remaining abutment teeth. This occurs mostly in trauma or congenital defects rather than as a planned surgical intervention. This classification excluded patients who have large palatal defects involving both sides of the dental arch and those who have only one tooth remaining. For these patients, the principle of design is similar to that for edentulous maxillectomy patients. The remaining teeth or tooth are reduced in height to improve the crown- root ration and support is derived primarily from the residual soft tissue. These teeth are either covered by an overdenture or clasped with a flexible wrought wire clasp.

122

DESIGN

OF

THE

METAL

FRAMEWORK

FOR

PARTIALLY

EDENTULOUS MAXILLECTOMY DEFECTS- ARAMANY (1978) 8 The design of the metal framework obturator will vary greatly is each group. However, the design objective is to select most suitable

components to resist various forces without applying undue stress on remaining teeth and soft tissues. The patterns of forces affecting the obturator prosthesis are complex because of their concurrent occurrence. These forces may be categorized as vertical dislodging forces, occlusal vertical force, torque or rotational lateral force and anterior posterior forces. The weight of the nasal extension of the obturator exerts dislodging and rotational forces on abutment teeth. Obviously, then it would be desirable that the nasal extension superiorly helps resist such forces. Occlusal vertical force is activated during mastication and swallowing. Wide distribution of occlusal rests will help counteract such forces. Preservation of teeth or part of residual ridges across the midline will greatly improve obturator stability. Maximum support should be planned through utilization of full palatal coverage. Lateral forces are minimized by proper selection of an occlusal scheme, elimination of premature, occlusal contact, wide distribution of stabilizing components, and covering medial wall of the defect with palatal flap, can help resist lateral forces. Guiding planes on the proximal abutment teeth help resist anterior-posterior movement. Properly designed retainers will reduce stress transmitted to the abutment teeths while maintaining obturator in place. Stabilization and indirect retention components must be strategically positioned to effectively retard movement of the nasal extension portion away from its terminal position, which in turn will reduce stresses on the abutment teeth. CLASS I The design can be either linear when the remaining anterior teeth were not to be used for retention and support and a tripodal design when the anterior teeth were used. Class I Curved arch form: Support: It is provided and shared by the remaining natural teeth, the palate and any structure in the defect that may be contacted for the purpose. The goal is to ensure that the functional load is distributed as equally as possible to each of these structures via a rigid major connector. The natural teeth are aided in this action, when the support regions of the

123

palate and the defect are loaded to their maximum without physiologic overload.

Fig. 21: Class I

A broad square or ovoid palatal form aids by providing greater tissue bearing surface to resist upward force (occlusal force) and a greater potential for tripodization to improve leverage. A tapering arch is less of an aid. Rests are placed on the most anterior abutment (closest to the defect) and the mesio occlusal surface of the most distal abutment tooth when the alignment and occlusion will permit. The mesio-occlusal posterior rest, most often located between adjacent posterior teeth, is accompanied by a rest on the disto-occlusal surface of the more anterior adjacent tooth. This additional rest will prevent wedging and separation of the two adjacent teeth and will decrease the possibility or periodontal damage from food impaction. The completed obturator often requires a compound path of insertion as undercuts and support regions within the defect will be negotiated before the teeth are engaged. Guide planes will assist in the precise placement of the prosthesis once the teeth are contacted. They will also ensure more predictable retention and add a greater stability to the prosthesis. Guide planes on the anterior abutment should be kept to a minimum vertical height (1-2mm) to limit torque to the abutment teeth and should be physiologically adjusted. This is important as movement can be expected during function because of the extensive lever arm provided by the defect and the dual nature of the support system. This consideration becomes more important as the curvature of the arch decreases and the potential mechanical advantage of the indirect retainer is decreased. In this instance, it is especially important to use the palatal surfaces of the posterior teeth for additional bracing and stability. An indirect retainer is usually located perpendicular to the fulcrum line (which connects the most anterior and posterior rests) and as far forward

124

as possible. This is usually a canine or a first bicuspid. Strategically placed indirect retainers allow maximum use of leverage to resist movement of the prosthesis in a downward direction by the pull of gravity acting on the defect side. Retention: It is supplied by direct retainer designs that allow maximum protection of the abutment teeth during functional movements. On the anterior abutment, a 19 or 20 gauge wrought wire clasp of the I- bar design is often used to engage a 0.25 mm undercut on the midlabial surface of this abutment or a gate design. Additional protection is afforded to this tooth by splinting it to one or two adjacent teeth with full crowns whenever possible or acid etch composite resin techniques when crowns are not possible. Other possibilities include a variety of cast clasp assemblies located on the height of contour for frictional retention only. The posterior retainer is most often a cast circumferential clasp utilizing a 0.25 mm undercut on the buccal surface. The placement of posterior clasps facing in both anterior and posterior direction will aid in retaining both anterior and posterior portions of the prosthesis.

CLASS I : LINEAR ARCH FORM The linear design is used for a class I defect when one does not desire to use the anterior teeth, when the arch form is linear and the remaining posterior teeth are in a relatively straight line.

Fig. 22: Class I

Support: in the linear design the remaining posterior teeth and the palatal tissues provide support. The palate becomes more important in the linear

125

design because the use of leverage to resist vertical dislodging forces is decreased. Miller states that a unilateral design requires bilateral retention and stabilization on the same abutment teeth. A diagonally opposed retention and stabilization system can be used. Retention: is provided by the combined use of buccal premolar retention and palatal molar retention. Stabilizing components are placed on the palatal surfaces of the premolars and buccal surfaces of molars. CLASS II DESIGN : In this, the design is similar, to Kennedys class II removable partial denture. A bilateral tripodal design is recommended. Primary support is placed on the tooth nearest the defect, as well as the most posterior molar on the opposite side. Double rests are used on adjacent posterior teeth. Guide plane location and size is similar to the class I situation with full use of the palatal surfaces of the posterior teeth. Guiding planes are located proximally on the distal surface of anterior tooth and the last molar. Retention and stabilizing components are placed on buccal and palatal surfaces of abutment teeth respectively.

Fig 23: Class II

The abutment tooth closest to the defect is critical to for retention and should be engaged with a direct retainer design that resists downward displacement but tends to rotate, disengage or flex when upward forces are applied. A cast circumferential clasp or an I-bar clasp is frequently used in a 0.25 mm undercut when the retentive terminus can be located on the fulcrum line. A 19 gauge wrought wire clasp in a 0.5 mm or less mesiofacial undercut is also a frequent choice. Additional protection can be provided for this tooth by splinting it to one or two teeth adjacent to it. The posterior retainer is most frequently a cast circumferential clasp using a 0.25 mm distobuccal undercut. The placement of posterior clasp

126

assemblies facing in both an anterior and posterior direction will aid in retaining both the anterior and posterior portions of the prosthesis. The anterior facing clasp will also serve to aid any additional clasps placed opposite to the fulcrum line from the defect. The canine is frequently the location of an indirect retainer and also serves as an additional (optional) retentive site, engaged with a 19 gauge wrought wire clasp in a 0.25 mm undercut. The canine is important in resisting occlusally directed forces and will receive severe stress. If an additional clasp is required on the canine, it should be a more flexible clasp in less than the normal amount of undercut or a less flexible clasp on the height of contour so that frictional retention will be supplied. A combination of buccal and palatal retention is almost never indicated for this classification for the following reasons: a. Additional bracing and cross arch stabilization will be lost when palatal retention is engaged. b. Increased rotation will be noted with an actual decrease in retention because of the short length and shallow gingivally located curvature of the palatal surfaces of the molar teeth and disengagement of the lingual undercut on slight displacement. c. The location of palatal retentive clasps often results in a major connector that has multiple small regions that trap food or irritate the tongue. Occlusion on the defect side is important because the occlusally directed forces can be destructive. Occlusal schemes with fewer, smaller teeth, located further toward the anterior side and devoid of premature or deflective contacts is desirable. CLASS III DESIGN : The design is based on quadrilateral configuration. The remaining natural teeth via widely separated and bilaterally located rests supply support. The canines and molars are usually selected to generate the largest quadrilateral shape possible while avoiding alignment, occlusion and hygiene problems and providing good aesthetics. Little or no support is derived from the palate or the defect. Bilateral symmetry of the major connector design and avoidance of the rugae area is desirable when possible.

127

Guide planes are usually short because they are located on the palatal surfaces of the posterior teeth. The proximal surfaces may be liberally used if edentulous spaces are present. Very little movement of the prosthesis should occur in function, therefore these guide planes may be long and physiological adjustment may not be necessary.

Fig. 24 Class III

Indirect retention is not required because a direct retainer supports each terminus; therefore, rotation around a common fulcrum should not occur. Retention is often provided with cast retainers using 0.25 mm undercuts on the facial surfaces of the teeth. These may be circumferential retainers, I bars or modified T-bars depending on the location of the retentive sites, the esthetic requirements and the presence of tissue undercuts. Combination type retainers can be used to an esthetic advantage because they can engage a deeper undercut and may thus be placed in a less conspicuous zone. CLASS IV DESIGN : The design is linear, Support is located on the centre of all remaining teeth. Channel rests or multiple mesio-occlusal and disto occlusal rests are designed. The defect should also be engaged to use, as much as possible, any sites within the defect that may be contacted. These are the midline of the palatal incision, when palatal mucosa has been preserved to cover this region, the floor of the orbit, the bony pterygoid plates and the anterior surface of the temporal bone. If these regions are covered by respiratory mucosa, little added support can achieved. Retention is located buccally on the premolars and palatally on molars. Stabilizing components are palatal on premolars and buccal on molars. This leads to loss of bracing, increased rotation and the creation of small irritating spaces in the major connector. (As discussed in Class II design)

128

Fig. 25: Class IV

Retentive sites should ideally be located on teeth and the lateral wall of the surgical defect via the superolateral extension of the obturator section in the engagement of the lateral scar band. Reduced posterior occlusion (size and number of teeth) is also useful. If no lateral scar band exists, because a split thickness skin graft was not given or because one could not be maintained, the prosthodontist may have no choice but to use a combination of buccal and palatal retention.

CLASS V DESIGN :

In this, splinting of at least two terminal abutments on each side is suggested. Rests located on the mesio occlusal surfaces of the most posterior abutment provide support. These rests define the fulcrum line around which most of the expected movement will take place. If adjacent posterior teeth are involved, double rests are used. Stabilization and bracing is provided by broad palatal coverage and contact with the palatal surface of the remaining teeth.

129

Fig. 26: Class V

Indirect retention is provided by rests located as far forward of the fulcrum line as possible. This usually places them on central incisors, which often presents an occlusal problem that may require minor occlusal equilibration. The location of the indirect retainer essentially converts the design to an efficient large tripod that uses leverage to resist downward movement of the prosthesis. Positive rest seats are a critical necessity to eliminate the strong labial force generated by the downward movement of the prosthesis. Retention: I-bar clasps are placed bilaterally on the buccal surfaces of the most distal teeth. Located in a 0.25 mm midbuccal undercut very close to the fulcrum line, it provides for resistance to dislodgement and rotation in function. When the remaining soft palate is scarred and relatively immobile it can also be used to provide added retention for the posterior portion of the prosthesis. A gate prosthesis is a viable alternative for these patients

if they can tolerate splinting of all of the remaining teeth.

CLASS VI DESIGN : In such defects, two anterior teeth are splinted bilaterally and connected by a transverse splint bar. A clip attachment may be used with out an elaborate partial framework. If the defect is large, or remaining teeth are in less than optimal condition, a quadrilateral configuration design is followed. In this the support is derived from rests located on the anterior and posterior abutment teeth. Greater stability is provided by placing additional rests as far posteriorly as possible. The most posterior rests, similar to the Kennedy Class IV situation, may be considered as indirect retainers,

130

resisting the vertical downward movement of the anterior segment of the prosthesis.

Fig. 27: Class VI

In extremely large Class VI situations indirect retention may not be possible. The remaining natural teeth provide all of the support with little support derived from the defect. Guide planes are usually located on the proximal surfaces adjacent to the defect and should be kept of minimal length (1-2mm) to avoid trauma to the abutment teeth during expected movements of the prosthesis. Retention is most often provided simply with cast retainers using 0.25 mm of facial undercut. I bar or combination retainers can be used on anterior abutments. Effective accessory retention can be achieved by extending the prosthesis anteriorly into the nasal aperture. Cosmetic support of the nose and upper lip is also possible when adequate retention is present.

131

OTHER

DESIGN

CONSIDERATION'S

FOR

PARTIAL

DENTURE

FRAMEWORK FOR OBTURATOR PATIENT i) Stress breaker concept Since the maxillofacial prosthetic patient has an added problem of movable basal seat, which is made up of grafted bone and skin covering over it (instead of mucous membrane). So there is more movement of the base in function than severely resorbed alveolar ridge. Also, the restoration of the lost parts is usually heavy and bulky, and this adds to the load on the remaining teeth. The remaining teeth in these patients are extremely valuable to them and stress breaking should be considered. a) When relatively few teeth are left and a partial denture is indicated, the combination clasp that Applegate described with one arm consisting of a flexible wrought wire and the opposing arm consisting of a rigid cast arm should be considered. The wrought arm supplies gentle retention and the cast arm is kept out of the undercuts and serves only to stabilize the appliance against lateral movements. b) A double or split-bar type of stress breaker is effective where the abutment teeth are all posterior to the denture base. This design

prevents rotation about the anterior rest. The great advantage of such a split bar is in its ability to transfer the fulcrum or center of rotation to the most posterior tooth. c) The truss bar retainer is indicated, where a large number of healthy teeth remain and maximum retention is needed to support an obturator or other large appliance.

132

II)

SWING

LOCK

PARTIAL

DENTURE

FRAMEWORK

DESIGN

CONCEPT - Javid & Dadmanesh (1976) 63 The lack of a residual alveolar ridge and soft palate in hemimaxillectomy patients complicates the design of removable partial dentures for these patients. With conventional clasp design, because of the lack of the supporting residual alveolar ridge the prosthesis moves towards the tissue more than the conventional removable partial dentures. Also during masticatory function, depending on the magnitude of forces, kind of food and the size of the occlusal table, the retentive clasp arm might be bent or broken. As a result, the prosthesis may lose its retention and stability, affecting speech as well. A swing lock - design for clasp retention of the obturator prosthesis is suggested. A gate clasp was first described by Ackerman in 1955 and swinglock concept was introduced by Simmons in 1963. The design should include multiple retentive bar clasps engaged in the appropriate undercuts (0.010 inch) utilizing as many teeth as possible. This kind of design may have an orthodontic effect, depending on the size of the occlusal table, degree of masticatory forces, and the number of teeth involved in retention. The reduction of the amount of masticatory force is not possible but the resisting force should include as many teeth as possible. This concept has been used in the fabrication of a surgical obturator by William Black (1992) 19 Technique: On the preoperative casts the outline of resection is marked. A 0.036 wire is contoured into a double arch wire across the buccal surfaces of the remaining teeth. Posteriorly the wire is passed through a 0.51-inch inner diameter steel tubing to provide a hinge axis. Anteriorly, the wire ends are looped to provide for elastic anchorage. After blockout, a custom swinglock gate of autopolymerizing acrylic resin is made. This is incorporated in the remaining prosthesis. At the time of surgery this is placed and gate retention is either obtained by elastics or wire. Even interdental or suspension wiring can be done to retain. After a week following surgery the prosthesis is relined, the interproximal holes are filled and the prosthesis is used as a removable prosthesis with gate retention

133

till a definitive obturator can be made. The advantage is that there is easier transition from wire stabilized to removable obturation. Marunick (2004)
80

described a hybrid gate design framework, which

incorporates both conventional retainers as well as the gate design concept.

Fig. 28: A hybrid gate prosthesis

III) DUAL PATH OF INSERTION CONCEPT King & Gay 49 Patients with an acquired maxillary defect, have essentially a unilateral support problem that is compounded by the need to support the obturator portion of the prosthesis. The use of facial and lingual retentive arms has been the classic way of designing unilateral removable partial dentures. The use of facial retentive and lingual reciprocating arms is based upon the premise that there will be cross-arch clasping. When it is impossible to provide cross-arch clasping, as in maxillectomy, a unilateral support situation exists, and the value of using both facial and lingual retention in the same arch becomes apparent. The obturator's downward movement can be resisted by the lingually placed clasps on the supporting teeth, as well as by the soft tissues that approximate its lateral border. The dual path of insertion is a reliable concept that can be of great value in obtaining retention with a guiding plane when that plane has access to an undercut before final seating of the prosthesis. When a lateral or central incisor is the posterior abutment on the defect side of a maxillectomy patient, the dual path may allow retention to be obtained with the guiding plane and obviates the need to clasp the teeth.

134

Application of Resin Bonding:

135

The discovery of resin bonding by

Rochette in 1973 has paved the way for a lot of advances in dentistry. The possibility of altering the tooth contours with techniques that do not require full veneer preparations have greatly reduced the cost of preparing the mouth for the complex removable partial dentures. Additive mouth preparation is appropriate for the creation of rest seats, guide planes, whether primary or associated with minor connectors and indirect retainers; retentive contours for conventional clasping and in carefully selected cases bonded precision attachments. Bonded contours can either be in composite or in metal that is microetched and then bonded.

Fig. 29: Wax up for bonded contours

Fig. 30: Spruing for the multiple contours.

Fig. 31: Lingual guide planes and cingulum rest bonded.

135

Fig. 32: Definitive obturator in position.

Precision & semi precision attachments: Bonded attachments are indicated in cases where the terminal abutment does not lend itself to conventional clasping. For e.g. when a central or lateral incisor is next to a large defect. Attachments that permit some measure of rotational freedom are most appropriately selected. The life of the attachment can be increased when the attachment does not become the rest s well as the retentive component. Milled rest seats developed on the casting that holds the attachment allow the stress to be transferred to the long axis of the abutment rather than to the cantilevered extra-coronal attachment.

Fig. 33: Wax up of multiple guide planes with CEKA attachment on central incisor.

Fig. 34: obturator casting seated on master cast. The plate of the framework rests on solid rest seats placed in the anterior bonded castings.

136

PROSTHESIS

DESIGNS

FOR

OTHER
29

ACQUIRED

MAXILLARY

DEFECTS as described by Chalian

1) Snap on prosthesis for marginal defects. When there is a marginal defect of the maxilla but with no associated palatal or vestibular communication with the maxillary sinus cavity, a snap on removable partial prosthesis may be constructed for retention and esthetic purpose. 2) Snap on Prosthesis for Anterior segmental defect. The versatile snap-on mechanism can also be adapted to provide transpalatal splinting when the anterior palatal defect is large. To minimize tilting, looseness, and occlusal stress on the remaining teeth, a clip attachment is centrally placed to engage the palatal rod. 3) Prosthesis for lateral segmental defects of edentulous maxilla with no palatal opening. Often trial dentures are made to permit the patient to have a positive experience of closure and centric stop for occlusion. prosthesis is fabricated. ADVANCES IN SURGICAL RECONSTRUCTION AND ITS IMPLICATION ON MAXILLOFACIAL REHABILITATION 94 New prosthodontic guidelines that relate to the surgical reconstruction of the maxilla seem to be mandated as a result of advances in microvascular surgical techniques. Microvascular free flap surgery allows the transfer of muscle, connective tissue, skin and bone to the recipient sites. A vascular supply to the graft can be provided after donor blood vessels are reanastomosed to recipient vessels of the head and neck region. Fasciocutaneous and osteomyocutaneous free flaps can provide closure of the oral cavity for acquired maxillary defects. Major factors in the prosthodontic rehabilitation decision-making process include whether a maxillectomy defect should be reconstructed; if so, what type of free flap should be employed; and how the chosen free flap will affect the patients oral function. Then, when facial symmetry and patient comfort have been achieved, the final

137

Okay et al state that soft tissue flaps can provide closure of the oral cavity in smaller defects but are unsupported and may not provide a stable palatal base for a removable prosthesis. If a removable prosthesis is planned along with surgical closure provided by a fasciocutaneous flap, the support of the prosthesis should be derived from the remaining palate and the dentition. For larger defects, the use of vascularized bone containing free flaps (VBCFF) for maxillary reconstruction can provide the restoration of a stable palatal base. The biomechanical principles relevant to prosthetic rehabilitation of maxillectomy defects should be utilized if surgical reconstruction is anticipated. Indications for the use of fasciocutaneous flaps and VBCFFs can be derived from the application of these biomechanical principles and from the anatomy of the remaining dental arch and palate. To assess the functional outcome and patient satisfaction that surgical reconstruction can provide a classification system of defects based on a selected patient population at the Mt. Sinai Medical Centre was established. All the defects reviewed were rehabilitated with a tissue borne obturator, a local palatal island flap, a fasciocutaneous free flap, or a vascularized bone containing free flap. Design considerations for surgical reconstruction and prosthodontic rehabilitation focused on 4 objectives: Closure of the oral cavity. Provision of a stable base for the restoration of function. Restoration of midface symmetry. Support of orbital structures. Palatomaxillary defects were divided into 3 major classes and 2 subclasses. Eight different defects of the hard palate and maxilla were characterized within this classification system. The size and location of the defect, remaining dentition, and palate influenced the design of the microvascular free flap and prosthodontic restoration. Maxillectomy defects involving the floor of the orbit and/or zygoma also played a role in the donor site selection and the design of the microvascular free flap.

Class I a: These are the defects involving the hard palate but not the tooth bearing alveolus. These could be rehabilitated with an obturator, a local advancement flap, or a fasciocutaneous free flap. In general, prosthetic rehabilitation is stable and well tolerated.

138

Fig. 35: Class Ia

But, local island flaps can also be used as a simple method to reconstruct if the defect covers less than one third of the hard palate. This obviates the need for a dental prosthesis. If a patient is radiated or the defect too large then a fasciocutaneous free flap should be used. Class Ib: Defects that involve any portion of the maxillary alveolus and dentition posterior to the canines or that involving the pre maxilla. These defects involve a small portion of the dental arch; the anterior sextant, and a unilateral posterior quadrant of teeth remain intact.

Fig. 36: Class Ib

As a result, the theoretic cantilever forces over the defect are minimized. The movement of the obturator around the fulcrum line can be stabilized due to the superior root morphology of the canine approximating abutment and the considerable arch length provided by a sound anterior sextant and a unilateral posterior quadrant. The ability to clasp teeth perpendicular to

139

the fulcrum line of the framework and the support afforded by the remaining palate further stabilizes the prosthesis and improves the prosthetic prognosis. If surgical reconstruction is planned, a soft tissue flap is indicated without osseous reconstruction because the remaining dentition and palate are able to support the occlusal contacts over the reconstruction with a removable partial denture. With a removable partial denture, the support is derived from the remaining dentition and palate and not the flap. A radial forearm fasciocutaneous free flap works well for closure of the oral cavity because of ample soft tissue of the donor site and low donor site morbidity relative to those of the other sites. In an edentulous patient, the bone of the remaining maxillary alveolus has to be sufficient to accommodate osseointegrated implants. Forgoing osseointegration of implants in the remaining natural maxilla and surgical closure of the defect with a fasciocutaneous free flap can result in a difficult or impossible situation for prosthetic rehabilitation. This is due to the inability to extend the obturator bulb into the defect and engage anatomic undercuts for stability and retention. Class II: Defects that involve any portion of the tooth bearing maxillary alveolus but includes only one canine. The anterior margin of these defects is within the pre maxilla. Also included within this class are anterior transverse palatectomy defects that involve less than one half of the palatal surface. Total maxillectomy comprises the majority of defects in this class in which an incisor serves as the terminal abutment.

Fig. 37: Class II

140

Prosthetic rehabilitation of class II defects is less predictable than class I defects. Factors that contribute to instability are fewer teeth for clasping, reduced arch size and form and a significantly reduced supporting palate. Further, an obturator alone is inadequate to restore cosmesis to the midface if the orbital floor or zygoma is resected. Some class II defects are best restored with VBCFFs. Vascularized bone offers the ability to re-establish the bony dental arch for the placement of osseointegrated implants which allows the distribution of the masticatory forces across an intact maxillary arch and thereby reestablishes a favourable biomechanical condition in the maxilla. Furthermore, VBCFF permit the primary reconstruction of the orbital rim and the prominence of the zygoma tic body with autologous tissue.

Class III: Defects that involve any portion of the tooth bearing maxillary alveolus and include canines, total palatectomy defects and anterior transverse palatectomy that involve more than half of the palatal surface.

Fig. 38: Class III

These defects leave little or no residual palate or dentition for the secure retention of an obturator, which leads to a poor prosthetic prognosis. Class III defects are best restored with VBCFF, although the soft tissue closure serves to effectively partition the oral cavity from the nasal cavities and maxillary sinuses, oro-dental rehabilitation is severely compromised. Bones containing free flaps however, serve to separate the cavities along with providing vascularized bone capable of retaining implants. Palatal reconstruction provides a stable base to oppose the restored mandibular arch.

141

Subclasses f and z: Defects that involve the inferior orbital rim are categorized as subclass f, where as defects that involve the body of zygoma are categorized as subclass z.

Fig. 39: Subclass f

Subclass z

. Extensive palatomaxillary defects commonly involve a vertical component of the maxilla. The creation of subclasses, relate to the status of the orbital floor and the zygomatic body and are essential to provide an accurate description of the palatomaxillary defect. The orbital floor and the zygomatic body play both functional and cosmetic roles as the ablation of the vertical maxilla commonly results in a significant disruption of the midface and orbit and has profound effect on function. Enophthalmoses and diplopia can occur if the orbital contents are not supported. In addition these patients may suffer from a cosmetic deficit that is impossible to restore with an obturator.

VBCFF serve best to restore bone to the load bearing palate by restoring bone to the orbital rim and the zygomatic body. It also permits the placement of osseointegrated implants for the retention of an orbital prosthesis.

142

This algorithm is used for functional reconstruction, midface restoration and oro-dental rehabilitation according to the palatomaxillary defect classification. Impression Making Procedure's: i) Conventional Impression: By Beumer and Curtis17 The objective of the preliminary impression is to record the remaining maxillary structures and the useful portions of the defect. An edentulous soft metal tray is selected according to the configuration of the remaining maxilla. The medical and anterior undercuts are blocked out with gauze lubricated with petrolatum. Adhesive is applied to the tray and wax. The irreversible hydrocolloid material is mixed and located in the tray with ample care to load the material laterally so as to record the lateral configuration of the defect and a diagnostic cast is obtained. The undesirable undercuts recorded in the cast are blocked out with suitable wax prior to constructing the custom tray. and the superior lateral aspect of the defect. Relief of one thickness of base plate wax is provided for the skin graft-mucosal junction The residual palatal structures are relieved in the customary way and the tray fabricated with self-cure acrylic resin. After checking the custom tray so that it extends 2-3 cm into the cavity and extends beyond the scar band and superior to the cut edge of the hard and soft palate, conventional border molding be carried out it is advisable, that border molding be completed initially on the unresected side since this serve to stabilize and orient the tray over the defect. The lateral, posterior and anterior aspects of the defect are recorded

143

sequentially in two sections. First the area below the skin graft mucosal junction is molded. Next, the area above the scar band is molded. In molding the posterolateral aspect the patient should be instructed to perform eccentric mandibular movements to account for the movement of the anterior border of the ramus, and the coronoid process of the mandible. The patient should be directed to use routine head and mandibular movements during the border moulding. The impression of the surgical site requires that the patient perform exaggerated head movements turning left to right with the head level, and then again with the neck flexed and extended. The mouth should be opened and closed, and the mandible moved laterally. Speech and swallowing evaluation should be done to check the seal before making the final impression. The patient should be made to speak m and b and if there is distinction then the seal achieved is adequate. If they are not distinct, then there is some air leakage present. The modeling plastic is relieved approximately 1 mm in all areas, prior to obtaining the final impression. Several perforations are made for escape of the impression material with at least three perforations being made along the median palatal margins. Prepare mixes of regular and light body rubber base impression material; spatulating the regular material slightly in advance of the light bodied material. The light body is injected into the defect and the regular body-containing tray is seated over it. If the anterior margin of the soft palate exhibits considerable elevation during speech and swallowing, the portion of the impression that engages the soft palate both superiorly and inferiorly is cut away with a scalpel and a functional impression is made with thermoplastic wax. If the patient exhibits extreme trismus, surgical obturator can be used for making final impression with tissue treatment material. For dentulous patients a preliminary impression is made in a stock tray with irreversible hydrocolloid in a suitably modified stock tray. The tray extensions can be extended in the defect area by using modeling compound. Same precautions are taken as in an edentulous patient. The design of the prosthesis is decided, necessary mouth preparation done and the final impression of the non-defect side is made for framework fabrication. This impression should include sufficient amount of the defect region so as to allow the extension of the framework into the defect without

144

interference from remaining anatomic structures. The final impression of the defect area is made only after the framework has been fabricated and physiologically adjusted in the mouth. Autopolymerizing resin is added to the retentive meshwork to serve as an impression tray for the obturator portion extending into the defect. A wax occlusal rim may also be added to assist in evaluation of facial support, tooth position and occlusal registration. It is difficult to make the impression as the incremental addition of impression or reline material increases the weight and causes incomplete seating or rotation of the prosthesis away from its original position. Adding an occlusal stop onto the occlusal rim, before the impression is made can prevent this. With each increment added the patient is instructed to bring the teeth together in maximum intercuspation, thereby reseating the framework in its intended position. After border moulding is done in the similar way as for edentulous patients, final impression can be made in light body silicone material and can be further refined by impression wax as discussed earlier. ii) A foam impression technique for maxillary defects- by J. Schmaman and L. Carr (1992). 121 TECHNIQUE: An intraoral impression of the maxilla and entry into the defect is taken in the conventional manner with alginate following which a special tray is fabricated on the cast. A mushroom shaped acrylic resin retention-

relocating button is added to the special tray. A 20 ml, disposable plastic syringe is modified to receive a latex-feeding nipple. The tip of the nipple is cut to widen the aperture to about 5 mm. The nasopharynx and orifices are blocked with gauze. After adhesive is applied silicone rubber impression material is loaded on to the tray while the button is excluded. An impression of the residual structures, including the perimeter of the defect is taken in the normal manner. The impression is withdrawn, checked and inserted back. The patient is instructed to breathe through the mouth. The desired

volume of silastic foam liquid is poured in the syringe & the catalyst added and rapidly mixed with a thin spatula. The plunger is replaced and nipple inserted into the nostril that is continuous with the defect. The foam is rapidly injected through the nostril into the nasal cavity, and the syringe is removed. The defect and nasal

145

cavity are filled with foam, which expands to 4 times its original volume and then extrudes from the nostril. After setting, this excess is removed with scissors. The tray with rubber impression is removed from the mouth, and the button is withdrawn from the extremely elastic foam. The foam

impression is removed by inserting a finger into the nostril and pushing the foam downwards and simultaneously, pulling the foam from inside the oral cavity, as it disengages from the undercuts. The foam impression of the defect is relocated onto the button and is luted with sticky wax. To fabricate the cast, the foam is initially painted with a thin coat of stone. conventional manner. When this sets, the cast is poured in The advantage of this technique is that the This disadvantage is that the rapid

impression can be easily removed from the severe undercuts and that it is easier when trismus is present.

reaction of the foam liquid to the catalyst limits the time.

Fig. 40: The defect.

Fig. 41: Special tray and silicone impression in position.

Fig. 42: Injecting foam with modified syringe and nipple.

Fig. 43: Withdrawing the impression.

146

Fig. 44: Recovered impression.

Procedure for two-piece hollow bulb obturator: 29

This technique is most frequently used although it is less hygienic and esthetic as compared to the one-piece technique. Once the master cast is obtained, clasps are placed in the appropriate area and the baseplate wax of 2 mm thickness is adapted over it. This includes the defect area, the base, and the medial, posterior and lateral walls, keeping open the palatal ridge side. Next, modeling clay is put into the defect area and with the patients normal palatal ridge being used as a guide, the false palate and ridge are shaped and contoured in the clay, leaving an approximately 2 mm thickness for the wax pattern on the reshaped palate and ridge. Next, the wax lid is prepared by keeping a tinfoil on the clay as a separating medium. The wax lid is then separated, the tin foil and modeling clay are discarded from the master pattern, setting of artificial teeth is done and wax pattern are flasked separately and processed in heat-cured acrylic resin.

The margins of the lid portion is perforated or undercut for retention and then sealed over the main base by autopolymerizing methyl methacrylate resin.

147

Fig. 45: A. palatal view of waxed up obturator. B. waxed up obturator with the modeling clay in the defect area. C. tin foil applied over the modeling clay. D. false palate-ridge is separated. E. false palate perforated and seated over processed base. F. palatal view of the finished temporary obturator. G. tissue side view of the hollow bulb temporary obturator. H. temporary obturator inserted in the mouth.

148

Obturator bulb fabrication for edentulous patient: - by Chalian29

After the final impression is obtained, a cast is poured and undesirable undercuts are blocked. A stabilized base plate is made and flowed in the defect area, at this stage; a wax lid is fitted over the defect area to leave it hollowed and to provide the effect of a complete palate. Then occlusal wax rim is adapted to prepare the cast for centric and vertical records. With resulting records the casts are mounted on the semi adjustable articulator. The teeth are selected, and arranged into the rims. Then the wax try in is done. Finally the case is ready for laboratory processing. The palatal defect is filled in with modeling clay and given a palatal shape. A false lid is made from autopolymerizing acrylic resin. This is set aside while the case is flasked and processed. The lid is then added to the master base to close the palatal portion of the hollow bulb, and is sealed with quick-curing acrylic resin. Usual finishing and polishing of the denture follow this. Procedure for One Piece Hollow Obturator Chalian After the wax try in of the trial denture, the denture is festooned and finally waxed as any conventional denture. The denture is flasked and boiled out in the usual manner. When the case is completely flushed with boiling water and thoroughly dried, a shim is constructed. The undercut areas in the defect are blocked out and the entire defect area is relieved with one thickness of baseplate wax. Three stops deep enough to reach the underlying stone of the master cast are placed in the wax to facilitate proper positioning of the shim. One thickness of base plate wax is also placed in the top half of the flask over the teeth and the palate area to form the top wall of the shim. This also allows for the thickness of heat cure acrylic on the palatal side of the denture. Autopolymerizing resin is mixed and rolled to about 2 mm in thickness after reaching the dough like stage. A layer of resin is then contoured over the wax relief in the defect side, with another layer on the wax in the top half of the flask. The flask is then closed and allowed to set for a minimum of 15 minutes.

149

Fig. 46: A schematic drawing of the construction of one piece hollow obturator.

After curing, the flask is opened and wax is flushed off the shim with stream of boiling water. The excess acrylic is removed and the shim is placed back using the 3 stops as a guide. Heat-cure acrylic resin is mixed and a layer is placed to the bottom of the defect, and shim is inserted for final processing. The heat-cure resin is placed in the top flask and the case is trial packed under pressure (1000 pounds). After the final

150

closure, the case is cured, deflasked, finished and polished in the customary manner. This technique has the following advantages: i. ii. iii. iv. There are no lines of demarcation on the denture to discolor. The undercut areas of the defect are thick enough to allow for adjustment if necessary. It is simple and consumes very little more laboratory time than a conventional denture. Accuracy is assured.

Other Important Methods Of Fabricating Hollow-Bulb Obturators:

I) THE SILICONE RUBBER OBTURATOR - Described by Rahn and Boucher.112 Before the advent of resilient denture materials hollow bulb obturators were used as a means of gaining additional retention and also as a means of carrying supplemental forms of radioactive materials for treatment of recurrent tumors. satisfactory. Most of the disadvantages can be overcome by fabricating the base portion of such prosthesis with one of the heat vulcanized medical grade silicone rubber materials. Their excellent dimensional stability and resilient character, aid in providing satisfactory retention, by permitting closer engagement of the undercuts areas, thus providing a seal for the palatal openings. These materials also ensure accurate delivery of brachytherapy tubes, which are to be placed, in closure and intimate relationship to the tumor site, unlike acrylic resin bulb, which cannot by pass the undercut areas easily. Method of fabrication: After duplicating the master cast. The crown portions of the remaining teeth are cut from the cast down to the gingival crevice. The wax pattern is formed to the design desired to be reproduced in the silicone rubber material. But, sometimes not all the available undercut areas in the defect could be utilized and retention was not always

151

When using silicone rubber, a flask should be used which can be bolted together. After flasking and boiling out the wax pattern, all the stone surfaces are treated with silicone rubber mold release material. There are two types of silicone rubber sheet material, depending upon specific needs. The material is available in varied durometer hardness, and may be used together when a different degree of firmness is needed in a specific area or a reinforcement is supplied by an inlay of a silicone rubber impregnated Dacron. The mold is packed in a similar fashion, as is acrylic resin. Polyethylene separating sheets are used during the trial packing phase to ensure separation and withdrawal of the flask halves. The flask halves are pressed together in a bench press slowly so that putty-like material has an opportunity to flow. The excess flash is cut away with a sharp instrument and necessary reinforcement if necessary, in areas like labial frenum, the portion distal to last tooth or any thick isthmus is done before the final closure. After final closure, the flask halves are bolted together and the entire assembly is placed in the processing oven, which should be a dry heat, natural air circulating type oven, with an accurate temperature control system. The air circulation provides for the escape of by products of vulcanization. The flask is left in the oven for one hour at 300oF. After removing, it is then allowed to bench cool, and is finally separated. The molded form may be trimmed off any excess flash at this time, but it must be returned to the over for a period of 4 hours at a temperature of 400oF in order to complete the curing process. It is during this later period of time, that the by-products of vulcanization the driven out from the rubber mold. Upon removal, from the oven, the rubber base is finished neatly and placed on the master cast and super structure of the denture is constructed in a conventional manner. The depth of the defect is filled with wax or plaster, so that base plate material could be adapted over it, bypassing the depression. Occlusal rims are constructed and the baseplate and rubber base are united together by application of pressure sensitive silicone adhesive. This procedure facilitates accurate intraoral recording of centric relation and vertical dimension. After mounting on the articulator, the occlusion unit areas is set and wax-try in is accomplished. If a wax plug is used to bypass the depression, it is adjusted at this time to form a collar, which fits into a portion of the concavity. This

152

provides additional support for the hollow bulb against lateral stress and also allows for greater surface contact for the bonding agent. The wax pattern superstructure is then removed, flasked separately and upon recovery, finished and polished. The base-contacting surface of the acrylic resin is ground, roughened and lined with a silicon primer. The rubber base is cleansed with ether or chloroform. Care is taken to see that both surfaces are not contaminated in any way by fingers or anything else. The permanent bonding material between resin and rubber base is another form of silicone rubber, which cures at room temperature. To ensure proper alignment, the lower complement of the articulator is used, making certain that incisal pin contacts the guide table and vertical dimension and centric relations are maintained. Upon closure of the articulator, the excess adhesive material will be pressed and will fill the space created therein. The excess is carefully removed. The articulator is held together with rubber bands to ensure that the two components do not shift their relationship. A minimum of 12 hours is required for the adhesive to set. After this, the components may be further finished with moist free pumice. II) INFLATABLE OBTURATOR PROSTHESIS- described by A.G.L.Payne W.G.Welton (1965) 105

It consists of a latex rubber balloon attached to a denture by means of a silicone rubber former, into which is incorporated an air valve. The balloon is inflated with air to fill the surgical defect. PROCEDURE Preparation of the denture; The upper denture is constructed in the usual way and finished with the solid acrylic resin obturator extending only about 3mm into the defect. By working form the fitting surface, the obturator is hollowed out as far as possible and a hole 1cm in diameter is cut through the labial flange over the lateral incisor tooth. This aperture will give

access to the air-retaining valve. A groove 2mm deep is cut out into the inner aspect of the periphery of the hollowed out portion, about 2mm below its edge.

153

The valve mechanism: The most suitable air-retaining valve is an automobile valve. In the completed assembly, the valve is subjected to torque when the inflator is connected. It is necessary, therefore to attach tags to the valve sleeve to prevent its displacement. As the valve is to be embedded freehand in silicone rubber, it is essential to decide the ideal position in order that no portion of the valve or its tagging will be exposed. The air exit aperture must be sealed with wax, and a wax column is extended vertically to give an indication of the position of the valve after the embedding is complete. With the valve supported from the front, silicone rubber is spatulated into the hollowed obturator so as to embed the valve completely. Care must be taken to fill the grooves previously made. When the silicone rubber has cured, it is smoothed and trimmed to the shape of the obturator base and the wax column is removed down to the valve exit. The inflator: The cap for the valve is reduced in length, and a hole 1mm in diameter is drilled through the center of the cap and its rubber washer. The washer is removed and a tube 5mm in diameter, about 1.5 cm long is soldered onto the valve cap. After the washer is replaced 2.5 cm of well roughened metal tube, 1.0 mm in diameter is passed through the valve cap until about 2mm of the tube is left extending above the washer. This tube is held in its central position inside the larger bore tube by self-curing acrylic resin. The projecting tube in the valve cap is reduced carefully till it just depresses the valve core when valve cap is screwed tight on the valve. Thus an easy passage of air, and restoration of seal immediately when the inflator is removed is assured. The modified cap is connected by means of a short length of rubber tubing to an air bulb having a simple one-way valve.

Fig. 47: Denture made with solid acrylic obturator that extends 3mm into the surgical opening.

154

Fig. 48: Obturator hollowed out to receive the silicone rubber former that will carry the air valve. The groove just below the top edge serves to lock the silicone former in place. The hole in the labial surface will accommodate the inflator.

Fig. 49: Valve shown in position with a wax column (C) that will maintain an airway from the obturator into a balloon while a silicone rubber former is made to fill the hollow obturator. Metal tabs are soldered to the valve housing to prevent its rotation in the silicone rubber former.

Fig. 50: the denture with the silicone rubber former. Note the groove on top that will lock it in position, while the hole in the top of the former that was maintained by the wax column.

Fig. 51: the inflator is connected to the valve cap through the aperture in the labial surface. The latex balloon is in position and inflated. The opening into the valve through the labial surface is closed with a silicone plug.

ASSEMBLY AND USE OF THE OBTURATOR A latex balloon is stretched over the silicone rubber former that contains the valve. The former is then pressed into the hollowed out obturator. The silicone rubber former is retained by the engagement of the silicone rubber into the groove initially made. Inflation of the balloon causes it to stretch and automatically seal itself to the acrylic resin of the obturator in the denture. The size of inflation can be adjusted and experience soon dictates the most advantageous size for each patient. The valve aperture on the labial surface is sealed with a small silicone plug. This appliance has following advantages. It provides a perfect oronasal seal and is self adjusting to changes in the shape of tissue after surgery The balloon may be inflated after insertion and therefore, this appliance may be used in cases with severely limited opening.

155

It is light in weight and its simple construction permits easy cleansing and maintenance.

III ) EMERGENCY TEMPORARY OBTURATOR - OSCAR E. BEDER (1968) 11 A temporary emergency type of obturator made for patients with acquired palatal, defect these obturators can be made in single patient visit, if necessary, since the speed of construction may be essential for some patients.

Fig. 52: Assembled cast and core to illustrate the funnel shaped hole and vent.

PROCEDURE i) ii) iii) Make a master cast from an impression of the maxillary arch. Contour strategically placed wire clasp on the teeth of the cast. Upon this cast adapt a softened sheet of easily manipulated wax, trim it to the correct border outline, and add wax for contour and thickness as indicated. iv) Cut index grooves in the master cast. Coat all exposed plaster with a separating medium and pour a plaster core over the wax, extending it to the master cast. v) vi) Immerse the cast and core in hot water until the wax is soft. Separate the core from the cast and peel out the wax. Cut a funnel shaped hole through the plaster core and extend it to the obturator region. Cut an air vent hole approximately 1/8 in diameter through the core over the intact vestibular area. Clean all plaster surfaces and coat them with a tinfoil substitute. vii) Pour a small amount of monomer in the mold and empty it out quickly. Pour some fluid cold cure acrylic resin into the obturator part of the cast. Reassemble the parts and pour an adequate

156

amount of the acrylic resin into the funnel-shaped hole in a thin stream until it flows out of the air vent. viii) ix) Place the entire complex into a pressure pot and raise the air pressure to 25 pounds. After curing, carefully remove the plaster and recover the prosthesis. x) IV) Trim excess acrylic resin, and polish before delivery.

FABRICATING A HOLLOW OBTURATOR USING TWO FLASKS WITH INTERCHANGEABLE PARTS. This technique has been described by A.S. El Mahdy'(1969). 45 PROCEDURE: Flasking the appliance: Two identical flasks are required [flask U-L and F1 - F2]. Their upper and lower halves should be interchangeable and they should fit accurately. The trial prosthesis is invested in flask U-L in the usual manner of investing an upper trial denture. Elimination of wax: Flask U-L is immersed in hot water, opened, and the wax is eliminated.

Fig. 53: A cross section of flask U-L shown after elimination of wax. U upper half, L lower half, A- obturator part, B conventional part of the prosthesis.

Waxing the impression surfaces of the prosthesis in the lower half of the flask [L]: An appropriate thickness of baseplate wax is added to establish the desired thickness of acrylic resin in part A of the obturator. This amount of wax should eliminate all undercuts if present. Add a thin layer of wax to part B. Cover the wax with a wet sheet of cellophane and make a trial closure of the two halves of flask U-L. There should be metal-tometal contact. Waxing the polished surfaces of the obturator in the upper half of the flask [U]: Add baseplate wax to establish the desired thickness of acrylic resin on the polished surfaces of the obturator part. This wax should contact the wax on the impression surface and make a seal at S. Again cover the wax

157

with wet cellophane and make a second trial closer. There should be metal-to-metal contact.

Fig. 54: A cross section of the second trial closure of flask U-L which shows wax up of both upper & lower halves S- wax seal Dot and dash line C-C cellophane sheet

Preparing the processing flask: Separate the two halves of flask U-L. The teeth of the conventional part of the prosthesis B in the upper half U are protected by two layers of thick tinfoil as indicated by the dotted line T. Coat the inner surface of the second flask F1-F2 with petroleum jelly to facilitate the separation F1 is related to L and F2 to U. The wax patterns in L and U are flasked using colored plaster.

Fig. 55: Flasking the wax patterns which represent the impression surfaces of the appliance in the flask F1- L and the polished surface of the obturator in flask U- F2. T (dotted) is the tin foil protecting the teeth in the conventional part of the appliance

PROCESSING THE PROSTHESIS: The wax patterns in flasks F1-L and F2-U are substituted with acrylic resin, which is cured in the first step of processing. This is done in the following manner. Eliminate the wax from flasks F1-L and F2-U. Pack acrylic resin and cure without removing the cellophane. The cellophane facilitates separation of F1 and F2. Any wrinkles in the acrylic resin from the cellophane will provide better union with added acrylic resin in the second processing procedure. The cellophane protects the acrylic resin from contamination by the flasking plaster. Separate flasks. Section F1 and F2 will come apart more easily than sections L and U.

158

Remove the colored investing plaster, which identifies F1 and F2, and also remove the cellophane from the cured acrylic resin. Remove the tinfoil (T), which was used to protect the teeth on the conventional part of the prosthesis. Do not disturb the contents of sections L and U. Make a trial closure of sections U and L and make sure metal-to-metal contact is achieved. Any acrylic resin in the seal area must be reduced to proper thickness. Clean the acrylic resin surfaces and prepare for the addition of a new mix of acrylic. Any excess thickness can be reduced at this stage to further reduce the bulk and weight.

Fig. 56: A cross section of the reassembled flask U-L, which contains the completed appliance with the hollow bulb obturator.

SECOND PROCESSING Join the two halves of flask U-L. This unites the two previously processed segments and will cure the remainder of the conventional part of the prosthesis. Make a new mix of acrylic resin and place it along the edges of the two parts and in area T. Make trial closure to ensure sufficient acrylic resin. Remove the cellophane and process. Remount and finish in the conventional manner.

Advantages of this method are: Control of thickness and weight are achieved. Accuracy is assured because the relationship of various components is maintained. The method is easy to learn and teach. It can be used in conjunction with a metal framework.

V)

A SIMPLIFIED TECHNIQUE FOR FABRICATING A LIGHTWEIGHT OBTURATOR. This technique was described by Yoshinobu Tanaka, Henry O Gold and Samuel Pruzansky (1977). 17

159

This procedure does not deviate from the usual technique of obturator fabrication until the waxed prosthesis has been flasked and the wax has been boiled out in preparation for packing with acrylic resin. They utilized polyurethane foam for the core-fabrication.

PROCEDURE The defect is covered with a single layer of base plate wax. Excessively deep undercuts are blocked out to facilitate removal of the polyurethane foam core and to allow for later adjustments without, risk of perforating the core. Several 2mm perforations are made through the wax in the top and the bottom of the flask in the region of the defect. 4mm sections of 2mm diameter heat cured acrylic resin rods are cut placed into the perforations and allowed to project approximately 2mm into the region of the defect. The projections attach to the polyurethane foam and acts as guide to centre the core. A liquid foil separator is applied to the wax surface. Polyurethane foam base is catalyzed and approximately one fifteenth of the chamber of the defect is filled and the flask is quickly closed. The flask is heated for 10 minutes at 120oC in a dry oven after which it is opened, and the wax is then peeled off the foam core. Boiling water should not be used to soften the wax over the core since it will destroy the foam. The foam core is coated with a waterproof separator to avoid direct contact with the acrylic resin monomer, which would soften the foam. The coated polyurethane foam core with its acrylic resin guides for centering the core is coated with thin layer of heat-cured acrylic resin of putty like consistency. A thin layer of the acrylic resin is placed over the defect in both halves of the flask, which has been treated with a foil substitute. The coated polyurethane core is pressed into position in the top half of the flask. Additional acrylic resin is packed in the remaining portion and the flask is then closed, the foam core is sufficiently rigid to withstand the intra flask pressure. The acrylic resin is then cured in a hot water bath following the manufacturer's specification. obturator is deflasked finished and polished. The completed

ADVANTAGES: i) It is not necessary to fabricate a hollow obturator to achieve a significant reduction in weight. Polyurethane core filler accomplishes the same result while providing greater strength.

160

ii) Economical because of the time saved and the ease of fabrication. iii) Ten fold reduction in weight compared to acrylic resin obturators. iv) Easy to repair. VI) HOLLOW SILICONE OBTURATOR ATTACHED TO A HOLLOW DENTAL PROSTHESIS- Described by Robert H. Wood & William Carl (1977) trays for making impression of the defect. PROCEDURE: A preliminary impression is made in alginate and a diagnostic cast is obtained. Custom trays are then made on diagnostic cast that will approximate the anteroposterior and buccal extent of the impression. An impression using irreversible hydrocolloid is then made and a cast is poured which is used to fabricate a flexible impression tray. Regular body rubber base is spatulated into the defect in the cast and allowed to set. The center is hollowed out with a scalpel and scissors to increase flexibility. The flexible tray is now coated with rubber base adhesive and the final impression is now made in low body rubber base material. Because of its flexibility, filling of undercut is easy and can be accomplished without the loss of any impression material. Minimal seating pressure is applied to avoid distortion and removal of final rubber impression is no problem. The cast obtained after pouring the impression made in flexible tray is used for making the all silicone obturator. A single layer of base plate wax is adapted across the palatal opening of the cast. The borders of the cast are notched and a stone cover is poured. The two halves are then separated and the wax is eliminated. Silicon rubber is mixed with catalyst and packed into the defect. The model is closed and rotated during polymerization. Before inserting the obturator all rough edges are trimmed with scissors and stones. This is used as temporary obturator.
151

described a technique for fabrication of, by utilizing flexible impression

Wood also described hollow obturator with acrylic resin palatal section. It consisted of silicone obturator attached to hollow palatal section of the denture.

161

Fabrication of silicone obturator: It is made in accordance with the technique described by Hahn54. A double thickness of baseplate wax is adapted into the defect surface within the cast without leaving internal undercuts and extended to the palatal borers. A thin ring of wax serving as a retentive lip is added to the inside just superior to the palatal border. Another keyed stone cover

extending into the wax up is poured for the master cast. Silicone rubber is mixed and placed in the cast and the cover is then seated and clamped or held with rubber bands until the silicon has cured. The resulting obturator is next reseated in the master cast and a plaster core is poured up to the retentive lip. Self-curing acrylic resin is sprinkled, poured or moulded over the palatal surface in a thin layer. The acrylic resin must be adapted under the retentive lip inside the obturator. The obturator section will be retained against the acrylic resin section in the undercut. Fabrication of hollow palatal section: The dental section of the prosthesis is an extension of the acrylic resin palatal section. Wax occlusal rims are added to the acrylic resin section. A rim of maxillary teeth may be pre-assembled in the laboratory in occlusion with a cast of the mandibular teeth. The obturator with a softened wax rim is inserted into the mouth and the assembled tooth rim is placed against the mandibular teeth and held while the patient closes gently into the wax. A vertical dimension of occlusion is determined by phonetics and esthetics. The wax trial prosthesis is completed with the palatal section hollowed out as much as possible to reduce weight. A ledge is carved in the palatal wax just lingual to the teeth. After processing of the denture one to one and a half thickness of base plate wax are adapted to the palatal ledge to provide normal palatal contour. The sheet of wax is processed and attached to the denture.

162

Disadvantages of this method are: i) It is large and heavy, making it difficult to insert. ii) Retention will be marginal at the best. iii) Vertical displacement occurs because of absence of superior stops. iv) Esthetically less pleasing. v) Discomfort from mucosal contact. VII) TECHNIQUE UTILIZING DOUBLE INVESTMENT PROCEDURE

PROCESSING AGAINST ICE: This procedure has been described by Aaron Schneider (1978) 122 PROCEDURE: Make a master cast in the usual manner and outline the borders. With plaster, block out undercuts created by surgery. Wax up of the base is done making sure to wax the internal part of the cavity as thin as possible. Invest the cast with defect in the lower half of the flask. Paint the plaster investment and the wax up with petroleum jelly and plaster of paris is poured in the upper half of the flask. After setting of plaster, separate the flask and set the second part aside, followed by covering the open part of the cavity and wax to complete a full palate. Pour the third part of the flask and separate when it hardness. Wash out all the wax, with boiling water and thoroughly clean the plaster and paint with a separating medium. Mix acrylic resin; pack the cavity in the first invested flask. Trialpack several times and remove all excess acrylic. Process in the usual manner. The next step can be performed in one of the following two ways. Fill the cavity with water and place in a freezer overnight or fill the cavity with crushed ice. Make another mix of acrylic resin and when dough stage is achieved pack it over the ice-filled cavity and process the resin. Remove the processed obturator from the flask, trim and polish it. Create a hole to remove water, which is later resealed with cold cure acrylic resin. Complete the denture, by making the jaw relation records and arrange teeth directly on the finished bases.

163

VIII)

COMPLETELY

HEAT

CURED

ACRYLIC

RESIN

HOLLOW

OBTURATOR USING A FILLER MATERIAL THAT IS ABSENT FROM THE FINAL PROSTHESIS. Described by Worley et al (1983) 152 PROCEDURE: It consists of conventional technique of teeth arrangement, festooning, flasking and wax elimination. The defect side is covered with baseplate wax on both sides of the flask. Damp asbestos strips mass is wrapped in a sheet of wet cellophane and placed into the waxed defect area and the flask is closed. The asbestos will conform to the shape of the waxed defect. The final form of the asbestos is preserved and the wax eliminated. A split pack technique is used for packing. The acrylic resin covering the defect should be as nearly as possible the same thickness as the wax blockouts and there should be no undercuts of acrylic resin existing on either side of the flask. Before packing the acrylic resin, tinfoil substitute is applied and allowed to dry. Acrylic resin is then packed and asbestos form with cellophane around it is gently placed into the defect area. Trial pack two or three times, with the asbestos form remaining each time to control the thickness of the acrylic resin on the walls of the defect. cellophane with a sheet of elastophane. Before final closure, remove the cellophane from the asbestos form and replace the Two sheets of elastophane between the flasks are placed to keep the two acrylic resin sections from curing together. The flask is final closed and the resin cured. After curing elastophane and asbestos are removed and a new mix of acrylic resins applied at the junctions of obturator section and the denture base and closed again for curing. The method besides being accurate also controls the thickness of hollow obturator prosthesis. IX) TECHNIQUE FOR THE FABRICATION OF CLOSED HOLLOW

OBTURATOR PROSTHESIS- by Minsley et al (1986). This technique allows for control of wall thickness of the obturator extension thereby minimizing the weight of the prosthesis. In addition, the junction between the lid and the palatal portion is remotely located in relation to the lid thus minimizing micro leakage. TECHNIQUE: -

164

After blocking out the undercuts in the defect, the cast along the defect is covered with two sheets of pink baseplate wax, which is processed in a conventional manner to obtain the acrylic base with obturator extension. A recess is cut around the palatal opening of the obturator extension to a depth of 1.5 mm. The interior of the hollow extension is filled with damp pumice to within 1-1.5 mm of the edge of the recess. An irreversible hydrocolloid impression of the entire palatal portion of the obturator excluding, the joining is made and is reinforced with plaster backing. The cast so obtained from above impression is then used for making autopolymerizing acrylic resin lid, which is then checked over the palatal opening of the obturator for fit and is fixed to the obturator opening with acrylic resin. A second ledge is then cut parallel to the flange of the obturator and across the posterior palatal seal. This ledge should be 4-5 mm below the top of the flange, 1 mm in depth ending in a but joint. Wax rims are then attached to the base of the prosthesis, maxillomandibular records, teeth arrangement is then carried out by conventional procedures.

X)

LIGHT CURED HOLLOW OBTURATOR: It was described by I.C.

Benington (1989)14

TECHNIQUE: i) Duplicate the obturator prosthesis. of the desired obturator. ii) Add impression compound to the immediate prosthesis to indicate the extent iii) In regular viscosity polysulfide rubber, record a final impression of the defect at the trial stage to procure the best fit possible for the new hollow obturator. iv) Pour a stone model and when hard, sandwich the mold between a plaster base and lid. The artificial teeth are invested in the superior plaster layer. v) Boil out the wax and remove the impression material. vi) Where the cavity undercuts are deep, section the master cast to facilitate accurate adaptation of the resin to the cast walls and for ease of removing the obturator after curing. vii) Coat the stone cast with sodium alginate separating medium and allow drying.

165

viii) Carefully adapt sheets of light-cure resin to cover the walls of the defect. When the individual cast sections are assembled on the plaster base, the obturator is complete except for the junctions. ix) Apply prescribed bonding agent to the margins of each section and firmly adapt thin cords of resin along each junction. Verify a complete seal and uniform thickness of resins on the walls. x) Using a light-cure source, cure for 4-5 minutes. Then pack resin into the plaster lid to engage the teeth. Fit the lit on the mold and observe that the resign margins in the plaster lid are adapted to the cured hollow obturator section and cure. xi) Remove the cured base from the mold and seal it on obturator section. xii) Unite the base and obturator section by adapting a thin cord of resin around the junction and cure. xiii) Trim and polish the completed obturator before insertion.

Advantages: i. The ease and rapidity of the technique expedites rehabilitation by introducing the hollowing obturator at the earliest opportunity. ii. The technique is versatile because the base and teeth may be cured in conventional poly (methyl methacrylate) and bonded to the light cured obturator when necessary. iii. Easy to repair by using increments of visible light- cured resin iv. Impermeable to oral fluids. v. A light accurately fitting obturator aids in the retention of the prosthesis and resonance of the voice. XI) AN INNOVATIVE INVESTMENT METHOD FOR FABRICATION OF A CLOSED HOLLOW OBTURATOR PROSTHESIS: - This technique is described by Karen Mc Andrew, Sandra Rothenbeger et al (1998) 86 PROCEDURE: Create the master cast design and fabricate the metal framework. Verify the fit of the metal framework clinically. Make a functional impression of the defect area and fabricate an altered cast. Fabricate a wax or autopolymerized acrylic resin record base and wax occlusion rim. Record the maxillomandibular relations. Set the teeth in wax and verify clinically with wax try in finish the waxing and seal it to the cast for investing and carry out dewaxing. Once the wax has been eliminated, open the flask and

166

block out the undercuts along the floor and walls of the defect area with wax to a minimal thickness of 3 mm. Cover the area of the palate with a 3 mm layer of wax. It is important to cover the retentive portion of the framework so that this area will eventually be replaced with processed acrylic resin (to minimize the possibility of leakage along the framework resin interface.) Wax a ledge around the periphery of the defect to leave an opening to the defect area. Verify the fit of the portion of the flask containing teeth. Relieve any areas of wax that prevent full seating of the flask. Place another top flask onto the waxing of the hollow defect. Invest with plaster and boil out the wax. Separate the flask and smooth the plaster index of the hollow section. Pack and process the hollow section and palate with heat-polymerized acrylic resin.

Fig. 57: Metal framework has been fabricated, verified intraorally for accurate fit and seated on master cast.

Fig. 58: Investment of completed waxing after clinical verification of esthetics and accurate registration.

Fig.59. Master cast flask after wax investment and boil out.

167

Fig. 60: Block out of undercuts in defect area on master cast.

Fig. 61: Left: Tooth retained portion of initial upper flask after wax boil out. Right: Plaster impression of hollow portion of defect area after wax boil out. Center: Master cast invested in lower portion of flask.

Fig. 62: Master flask after processing with hollow obturator flask. Plaster has been retained in hollow section. Fabrication of cap to close hollow obturator.

Fig. 63: Master flask with processed and sealed hollow portion of obturator and corresponding flask with teeth ready for processing.

168

Fig. 64. A, Polished palatal surface of completed obturator. Coverage of cap junction surrounded with heatprocessed acrylic resin.

B, Tissue view showing extension of hollow obturatorsection.

Separate the processed flasks, with the plaster remaining in the obturator section. Bevel the outer edges of the acrylic resin section and fabricate a light- polymerized resin cover to fit over this area. Gently remove the plaster from the obturator section with a bur and reduce the thickness of resin within this section. Do not perforate the floor or walls of the section and leave a minimal thickness of 3mm. Lute the cover to the opening with visible light polymerizing or autopolymerizing acrylic resin. Place the initial flask, with the invested teeth, onto the flask containing the processed base. Relieve, any areas that prevent complete seating of the flask. Roughen all areas of the processed base the pack heat-

polymerizing acrylic resin and process teeth onto the obturator followed by deflasking the denture and equilibration of occlusion. Polish and deliver the prosthesis. Advantages: i. This technique provides a lightweight and seamless obturator. ii. It can be used for either complete or partially edentulous cases. iii. It uses one master flask against two separate processing flasks. iv. Clinical and laboratory time are minimized. v. A durable virtually water tight prosthesis is obtained that can be used alone or in conjunction with an extra oral prosthesis.

169

OPEN OBTURATOR This technique was described by Arie Shifman (1983) 126

TECHNIQUE Box the final impression and pour the cast in artificial stone. Leaving the floor of the defect uncovered, two layers of baseplate wax is added to the vertical walls of the defect. Additional wax may be added where future reduction of the obturator is anticipated. Drill two holes into the base portion of the cast, where the defect is present and cement 2 handpiece burs in it. The proximal end of burs should

protrude 2-3 cm into the defect portion. Trial pack a silicon based material without the accelerator to determine the correct amount required to fill the defect portion of the cast to the level of remaining palate. manufacturer instruction and pack it into the defect portion. After the silicone has set, soften and remove the wax liner from the cast and remove the hardened silicone from the inverted burs. The burs are index for the detachable silicones core of the obturator. Proceed with an accepted technique for the laboratory fabrication of an obturator. Cut the silicone core into pieces and remove it from the finished obturator. Advantages of this method: i. Processing is better with improved vision and control of proper extensions of the obturator. ii. Deflasking is easier and the acrylic resin proceed against silicone has a smoother surface than against gypsum material. iii. With this method, retention and stability are not altered, as the lateral and anterior wall heights as well as medial and posterior extensions remain the same. The weight is also favorably reduced. iv. This design produces improved speech, intelligibility, facilitates hygiene and is easier to fabricate. Mix the predetermined amount of silicone with the accelerator according to

170

HOLLOW OBTURATOR WITH REMOVABLE LID Phansokol & Martin (1985) 106 It is an alternative to closed or open hollow obturators and has the benefits of both and allows the patient to clean the inner surface. In this technique an obturator is made with any acceptable technique with the superior border 5 mm thick and at least 5 mm from the superoinferior border. It must not touch soft tissue. A line is drawn on the obturator 4 mm from the superior border, a large fissure bur or disk is used to make a ledge along the outer border. A groove on the lower half of the ledge is made with No. 6 round bur. The edges are rounded and polished. The hollow extension is filled with modeling clay to make flat surface. An impression of the obturator is made in alginate, poured in stone and mouthguard material is used by vacuforming to make the removable lid.

A lot of techniques have been presented for modifications of an existing obturator. Ziada & Donovan (2004) 156 described a procedure for reducing the vertical height of the hollow box obturator in which a cap like piece of 4 mm height from the highest point is cut, and tried in the patient to the desired height. A lid is then fabricated with light cured denture base material.
144

Wang and Hirsch (1997) Technique: -

described a procedure to convert an open

hollow obturator into a closed one. The tissue side of the obturator base is first relined by chairside reline material, which acts as an impression material. The remainder of the acrylic base is lubricated with petroleum jelly. The relined obturator is boxed with 2 3/4th high adhesive paper. The cast is poured with a mixture of fast set stone and plaster.

171

The cast is separated carefully and reline material removed and then visible light cure resin material used to close the open end.

Implant Retained Prosthesis For Maxillary Defects.17,100,101,119,135

Cantilevering forces, which are generated by prosthesis for maxillectomy defects, are disadvantageous gravitationally and can be progressively destructive, even when fulcrumed with multiple rests and minimal undercut engagement. This is particularly evident when a few sound teeth are called upon to support a contralateral prosthetic dentition, even with a gate hinge type of load distribution. Osseointegrated implants can play a pivotal role in the rehabilitation process by augmenting the available retentive base or by replacing critical missing teeth. Implants provide retention; enhance support and stability of the prosthesis. The anteroposterior defects as seen in congenital defects are more amenable to implant restoration because lateral (cross arch) stability can often be attained. Lateral defects, are more difficult restorative problems as cross arch stability is missing and resistance to superior displacement is missing unilaterally. The number of implants and their location is determined by the nature of the defect and the available bony sites. The most ideal location in the edentulous total maxillectomy patients is the residual premaxillary segment because of two reasons. It is directly opposite to the most retentive portion of the defect located along the posterior lateral wall. Generally satisfactory bone is found in the region. The maxillary tuberosity is considered when the premaxilla is not found to be suitable as the bone in the tuberosity region is not very dense. The other sites considered are:Pterygoid plates in which longer and mesially incline implants are placed. Edentulous posterior alveolar process if there is at least 10mm of available bone beneath the maxillary sinus. (The predictability of sinus lift and bone grafting in maxillectomy patients is yet to be determined)

172

The Zygoma has been used for placement of implants. It requires an intraoral access to the zygomatic buttress through a trans-sinus approach. Once a suitable window has been created, piloting and implant placement are carried out with direct visualization of the receptor site from the sinus opening and tissue reflection to the exit area. Healing for integration usually requires 5 6 months before impressions and subsequent prosthetic construction can be initiated. To minimize the complication of diverse angulations, the head of the zygoma implant has been engineered to allow prosthesis attachment at an angle of 45 degrees to the long axis of the implant. This creates the opportunity to keep away the screw access sites relatively parallel throughout the span of the restoration. To avoid potentially damaging off-axis loading to these and the additional standard implants, it is important that a rigid bar or casting assembly be used to join the implants across the arch. Prosthetic retention can be attained through a variety of mechanisms, which may include O-rings, precision or semi-precision attachments, magnets or bar clips.

The use of implants within the defect should be discouraged, as it is very difficult to maintain hygiene around them. Also the use of pre or post operative radiation does not preclude the use of implants it has been found that radiation doses above 5000 centigray, compromise the remodeling of bone around the implant and thus predispose to bone recession and premature implant loss. Clinical procedures: Following implant placement, they are left buried for 6 8 months. During this period the patient uses the surgical or interim obturator. During the second stage surgery it is advisable to thin the mucoperiosteum to create a zone of keratinized, attached mucosa around the implants. This will go a long way in achieving better maintenance of the implants. There are two ways to go about the prosthetic procedures. If there is inadequate interocclusal space then healing abutments can be attached and the retentive bar fabricated using the UCLA abutment technique.

173

When conventional abutments are used, the length should be so selected that they project 1-2 mm above the peri- implant tissues. Healing abutments should be used for 2-3 weeks to allow for healing to get complete

The fabrication of definitive prosthesis: It is usually desirable to fabricate a trial denture before designing the retentive apparatus. Tapered impression copings, which engage either the abutment cylinders or implant fixtures, are selected, inspected and screwed tightly in position. A primary impression is made in irreversible hydrocolloid using a stock tray with adhesive. Care should be taken to record the lateral wall of the defect and desirable undercuts. Following the removal of the impression, impression copings are removed, attached to either abutment analogues or fixture analogues and inserted into the impression. A preliminary cast is pored. A special tray is fabricated with the design to record the position and angulation of these copings as well as the residual normal tissues and the defect. The final impression is made in elastomeric material, the fixture analogs are screwed in the tapered impression copings and the master cast is poured. Record bases are fabricated. If conventional abutments are used, then the gold cylinders are incorporated within the acrylic resin record base. If UCLA technique is used, then record base is fabricated after blocking out the area around the fixtures. Jaw relations are recorded and transferred to an articulator, which can accept bulky maxillary cast. The teeth are

arranged. Neutrocentric concept or lingualized occlusion is used in these cases. After try in and verification of the jaw relations, the trial dentures are repositioned on the articulator and a stone template is fabricated with the maxillary teeth incorporated within it. This stone template is mounted on the lower member of the articulator and used to design and prepare the wax pattern for the retentive apparatus. Retentive bar design: The factors that complicate design in maxillectomy patients are: Fewer implant sites available leading to limited antero-posterior spread of implants. Multiple axis of rotation due to occlusal loads. The use of bar and attachments lead to exposure of implants to unwanted, destructive lateral torquing forces,

174

Davis did a photoelastic study to compare the forces applied and found that a) Anterior loads caused higher and more concentrated stresses around the anterior and middle implants, as compared to posterior loads, since more posterior loads are partially supported by the residual edentulous denture bearing surfaces. b) The addition of occlusal rests on the bars between the implants increased the stability of the prostheses and alleviated the stresses around the posterior implant when a posterior force was applied. c) The O ring resulted in most favourable force distribution but least retention. Beumer and Curtis have given the following suggestions for the design:

With the use of attachments like ERA (which allows vertical compression), the addition of occlusal rests improves load distribution. The concave rest should be milled into the occlusal surface of the bar, in the shape of a half circle, is the only part of the bar that is to be engaged by the prosthesis other than the attachment. The placement of rests at either end of the bar enables the prosthesis to rotate around these rests and reduces the wear on the attachments and directs more of the occlusal forces along the long axis of the implants.

Design outlines: 1. If the entire premaxilla remains the number of implants, distribution and design of retention bar follows conventional prosthodontic principles. 2. If only 2 implants are placed , one each in canine region a Hader bar design is used.

Fig. 65: Two implants placed which are joined by a retentive bar that is perpendicular to midline and parallel to occlusal plane

175

3. If 4 or more implants are used. The support is provided posteriorly by the residual denture bearing surfaces and anteriorly by the implants. The attachments connected to the distal portion of the bar allow for the compression of the distal extension area of the prosthesis into the denture bearing area without applying excess torquing force onto the implants. 4. If 6 or more implants are used and the antero-posterior spread is greater than 2 cm, the overlay obturator prosthesis can be designed so that occlusal forces are primarily supported by the implants.

Fig. 66: Six implants placed anteriorly with sufficient A-P spread allow obturator to be implant supported.

5. Maxillary defects where only one or both maxillary tuberosities remain are particularly difficult to restore. Implants are useful in retaining these restorations, but should not be used to provide support or be the primary means to provide stability. In such cases O-ring attachments are used as they allow rotation of the prosthesis in multiple planes when functional or gravitational forces are applied.

176

GENERAL OUTLINE OF PROSTHODONTIC REHABILITATION OF SOFT PALATE DEFECTS Velopharyngeal dysfunction may be congenital, developmental or acquired, it affects all age groups It may occur as insufficiency or incompetency. Velopharyngeal Insufficiency: denotes speech and resonance

aberrations related to a congenital or acquired anatomic defect of the soft palate that makes the sphincter incomplete such as that occurring in cleft palate or post surgical resection

Velopharyngeal Incompetence: denotes dysfunction of an anatomically intact velopharynx that occurs in patients with the following disorders. The soft palate and pharynx are innervated by a nerve plexus (pharyngeal plexus) including fibers originating from the IX, X, and XI cranial nerves and possibly some fibers from the VII nerve. Any disease or disorder that affects the normal function of any of these cranial nerves or their central origins can have significant effects on the function of the palatopharyngeal complex. 1. Traumatic brain injuries, cerebrovascular accidents or post neurosurgical treatments of brain/ meningeal tumours. 2. Central or peripheral degenerative or metabolic disorders of the nervous system such as multiple sclerosis, Parkinsonism, bulbar poliomyelitis, cerebral palsy, Amyotrophic lateral sclerosis, dystonia and myasthenia gravis. 3. Muscle or connective tissue disease myotonic dystrophy or mixed connective tissue disorder. Other conditions related linked to incompetence of anatomically intact velopharyngeal valve: these are behavioral mislearning, tonsillar upper poles hypertrophy, hypotonic (dyskinetic) velopharynx, overly stressed velopharynx (wind instrument playing).

177

As general rule, palato-pharyngeal insufficiency is treated with a pharyngeal prosthesis or speech bulb prosthesis if the surgical procedures like palatal push back, pharyngeal flap or posterior wall implants cannot be carried out. Palatopharyngeal incompetence is treated with a palatal lift. Prosthetic restorations of post cancerous defects, occurring in the soft palate area vary according to the site and extent of such defects. The most important factor pertaining to the type of prosthetic treatment is the integrity and function of the posterior border of the soft palate; the prime objective of treatment in patients with oronasal communication is a return to the physiologic functions of mastication, deglutition and speech. If these objectives are achieved the other

sequelae of surgical procedure such as seepage of nasal fluid into oral cavity, and escape of food into the nasopharynx will normally be corrected.

Obturator prosthesis fabricated for patients with palatopharyngeal deficits vary with the location and nature of the defect or deficiency. In contrast with the obturator prosthesis constructed for hard palate defects, prosthesis for palato-pharyngeal deficits must function in concert with soft tissues displaying considerable movement.

178

CLASSIFICATION OF SOFT PALATE OBTURATOR PROSTHESIS: This classification has been given by Beumer and Curtis17 and is according to the location and nature of defects of soft palate and palatopharyngeal defects

Structures Involved
TOTAL SOFT PALATE DEFECTS Entire soft palate

Cause(s)
Surgical excision of neoplastic disease, unoperated cleft palate, surgically redivided cleft palate

POSTERIOR BORDER DEFECTS Median defects Posterior half of palate. Surgical excision of neoplasia, post surgical cleft palate with insufficient length Lateral defects Lateral half of soft palate and often lateral pharyngeal wall SPECIAL OBTURATOR PROSTHESIS Palatal lift All structures intact or when posterior border defect (combination) Neurological disease, Postsurgical cleft palate with insufficient length and movement. Meatal Hard and soft palate Unoperated cleft palate Surgical excision of neoplastic disease. Surgical excision of neoplastic disease

179

B. ARAMANY MOHAMMED (1978) classified defects of palate as

i) Total resection of the soft palate retaining a part of the hard palate: In this type of resection, the soft palate is totally removed, including all its muscles. The function of the superior constrictor muscle of the pharynx remains intact. The prosthesis for such defects involves speech aid prosthesis extending posteriorly from the base of the prosthesis into the pharyngeal region separating the oropharynx from the nasopharynx. At rest position, there is a space around the pharyngeal part of the prosthesis to effect nasal breathing.

ii) Median resection of the palate: The resection may involve parts of the hard and the soft palate. However the levators, tensor, uvula, palatoglossus and palatopharyngeous muscles are left functionally intact. The normal physiologic movement of the palate will take place on eliciting the velopharyngeal mechanism whereas; the presence of the defect will make this movement functionally inadequate. The anterior margin of the defect is not mobile, whereas the posterior aspect of the defect will move superiorly and posteriorly, increasing the size of the oronasal communication. The prosthesis extension from the parent prosthesis passes through the soft palate defect to permit the sphincter action of the margin of the defect to produce an oronasal seal. iii) Lateral resection involving approximately half of the soft palate: Lateral resection often jeopardizes the integrity of the remaining halves of the muscles of soft palate. Since the palate is intended to function through a paired mechanism, the loss of half of the mechanism drastically alters the function of the palate during swallowing and speech. It the defect is small, velopharyngeal closure may be effected without the help of prosthesis. If the defect is large or the patient is unable to develop compensatory movement, a retro velar speech aid is constructed. A

180

pharyngeal extension from the base of the prosthesis passes through the defect till the potential space behind the remaining segment of the soft palate. Velvopharyngeal closure is attained by the levator action of the remaining soft palate and the contraction of the pharyngeal muscles against the pharyngeal extension of the prosthesis. OBTURATOR PROSTHESIS FOR SOFT PALATE DEFECTS: 17,135,136 Sharry
125

describes the pharyngeal obturators that are used in

patients with congenital or acquired soft palate defects to separate the nasopharynx and oropharynx during speech and deglutition. The prosthesis consists of a complete or partial denture base and a pharyngeal extension that will not only physically modify the pharyngeal airway but also provide an object against which the surrounding muscles can function to provide a seal between the oropharynx and nasopharynx during function

1. Hinged Obturator: Delabarre and Snell first introduced it in early 1820s. Modifications by Stearn and Kingsley made it the prosthesis of choice in the latter half of the nineteenth century. In this type, the pharyngeal section is attached to the prosthesis by means of a hinge. The objective is to create a movable obturator that functions in a manner similar to the normal soft palate. This obturator relies on the activity of the superior pharyngeal constrictor muscles and residual soft palate muscles to function.

Fig. 67: Hinge type pharyngeal obturator

Its success depends upon the muscle activity of the residual palate and the stability and retention of the denture base, which has to support the

181

additional weight of the hinge and mobile obturator section. Also the shape of the nasopharynx changes at rest and in function, hence, it is very difficult to obtain adequate nasopharyngeal closure 2. Fixed or horizontal Obturator: Introduced by Suerson in 1868 and advocated by Fitzgibbon in 1920s. It is placed in a fixed position within the pharynx at the site of maximal muscle activity or approximately the level of the palatal plane. During physiologic function, the obturator is contacted by the posterior pharyngeal wall and the lateral pharyngeal musculature, thus creating a separation between the oropharynx and nasopharynx. It is the most commonly used type.

Fig. 68: Fixed or horizontal pharyngeal obturator.

3. Meatus Obturator was introduced by Schialit in 1946 and is described in detail later. Beumer and Curtis17 have described obturation of acquired defects of the soft palate in three stages. 1) 2) 3) Immediate surgical obturator Delayed surgical obturator Definitive obturator

182

1) Immediate surgical obturator: The principle advantage of immediate surgical obturator for soft palate defects is support and retention of the surgical packing. Immediate surgical obturators, constructed presurgically are approximations with regard to the level of placement and the contours of the lateral and posterior margins. There are differences between surgical obturator for hard palate defects compared to the ones for defects of the soft palate and the contiguous structures as: The drape of the soft palate precludes the clinician from obtaining the impression of the nasopharynx, where normal velopharyngeal closure occurs and where the surgical obturator should be located. Functional measurements of the velopharyngeal mechanism cannot be recorded prosthodontically either prior to or during surgery. Pharyngeal tissue peripheral to the defect will exhibit little movement during function in the immediate postoperative period. The extent of these tumours is more difficult to visualize; hence it is more difficult to delineate the surgical margins presurgically. An extended impression, of the soft palate is obtained and the cast is altered to correspond to the proposed defect. The plane of the hard palate determines the superior- inferior plane of the obturator and that of the soft palate determines the width. Adjustment at surgery is done to avoid excessive tissue contact. It is kept 7 to 10 days post-surgically

following which, the prosthesis is removed along with the surgical packing, and is altered by adding soft interim reline material for changed tissue contacts. The patient is monitored with sequential appointments until the definitive prosthesis can be constructed.

183

2) Delayed surgical obturator:

Patients with smaller defects of the posterior or lateral borders of the soft palate often are best served with delayed surgical obturation as the small defects are masked by postoperative oedema in the immediate postoperative period. In edentulous patients, consideration should be given to attaching the delayed surgical obturator to the existing maxillary denture. 3) Definitive obturator:

Patient

exhibiting

considerable

movement

of

the

residual

palatopharyngeal complex during function have an excellent prognosis for achieving normal speech with prosthesis. If the patient is edentulous, the prosthesis can be attached to the existing dentures. If the patient is dentulous a removable partial denture framework retains the obturator. It is a fixed platform of acrylic resin that provides surface contact for the remaining musculature of the

palatopharyngeal mechanism during function. However, a space exists between the surrounding tissues structures and the prosthesis during rest. Guidelines for location of the obturator segment of the prosthesis: The obturator for an adult patient should be located in the nasopharynx at the level of normal palatal closure. The inferior margin of the obturator should be placed at the level of greatest muscular activity exhibited by the residual

palatopharyngeal complex. The inferior extension of the obturator will usually be an extension of the palate plane as extended to the posterior pharyngeal wall. The superior margin of the obturator should not extend above the level of muscular activity.

184

Design Considerations: 1. Support: it is provided by the following: Occlusal rests on natural teeth. Major connector. Denture bases. Retentive clasps on the primary abutments. Skin graft host tissue junction creates the retentive undercut. Residual ridges and hard palate in edentulous patients provide retention. Indirect retainers on the secondary abutments away from the fulcrum line prevent rotation of prosthesis away from tissue. Endosseous implants provide direct retention. 3. Stabilty is provided by the major and minor connectors and the denture flanges which prevent lateral motion and distribute stress.

2. Retention: -

I)

Prosthetic outline of total soft palate defects rehabilitation: Impression procedure - (Functional impression technique): First a diagnostic cast is obtained by making an impression in a stock tray with palatal portion extended in wax. The cast obtained will assist diagnostic procedure, tray preparation and establishing design for cast partial denture framework. The partial denture design must have provision for multiple occlusal rests on either side of the fulcrum line and multiple retainers with the retentive arm engaging distal undercuts. A wire loop or tray resin is added to the framework as retentive meshwork to approximate the area of the defect. Next, modeling plastic is placed in the region of tray resin for to purpose of border molding. The patient is instructed to flex

185

the neck fully to achieve contact of the chin to the chest. This movement will establish contact of the posterior aspect of the obturator with the soft tissue covering the anterior tubercle of the atlas. Lateral aspects of the obturator are formed by rotation and flexion of the neck to achieve chin contact with the right and left shoulder respectively. The compound is then warmed and inserted and the patient is asked to speak and swallow, so that the remaining palatopharyngeal musculature is activated and shapes the modeling plastic. Since swallowing precipitates a more forceful closure it is performed at the end to avoid under extension. A completed molding will appear dull, and is confirmed by asking the patients to speak, swallow and to breath through the nostrils to test the effectiveness of formed obturator. Speech should sound normal, with the patient able to articulate plosive sounds such as p and b and yet be able to form the nasal consonants m, n and ng. If the position and contours are satisfactory, all extensions are reduced approximately 1 mm with a sharp scalpel. Next, mouth temperature thermoplastic wax is added to the obturator, flamed, tempered and placed in the mouth. functions activating the palatopharyngeal musculature The are

repeated, to reestablish the contours of the obturator. The use of thermoplastic wax ensures against overextension. Adequate areas of contact demonstrate a dull-stippled appearance, whereas a shiny surface indicates a lack of contact. The obturator prosthesis is left mouth for 5-7 minutes before removing it. After removal from the mouth, the prosthesis is checked for overextension. Any area in which, modeling plastic is visible, the plastic is scrapped and new layer of wax is applied. The wax is flamed and tempered, before reinserting. When speech and swallowing are normal and the contour of the obturator appears adequate the prosthesis is tempered in a water bath and replaced in the mouth for an extended period (1 to 3 hours). The patient is instructed to wear the prosthesis without removal and is

186

encouraged to speak, swallow and perform previously described movements. Size and position of the obturator: The lateral dimensions of the

obturator the determined by lateral and posterior pharyngeal wall movement if the obturator is positioned correctly at the level of greatest internal and posterior pharyngeal wall movement a superior extension of approximately 10 mm into the nasopharynx is sufficient. A further superior extension, may add additional width and extra weight, and will occlude the nasopharynx resulting in difficulty with nasal breathing and hyponasal speech. Conversely, if the obturator is placed too low into the oropharynx, tongue function will be disrupted and gagging may be precipitated.

Processing and delivery of the prosthesis The obturator is processed in a customary manner, with either heat activated or auto - polymerizing methyl methacrylate. Following processing, gross excesses is removed. The oral surface of the obturator should be concave to provide adequate space for the tongue. The superior surface should be convex and well polished to facilitate the deflection of nasal secretions into the oropharynx. Also, the lateral margins of the obturator are lightly polished to improve hygiene and the deflection of secretions.

Speech evaluation following obturator placement Speech is usually within normal limits immediately following placement of prosthesis for acquired soft palate defects. As these patients produced normal speech prior to surgical impairment, the prosthodontist will often require the assistance of a speech pathologist to evaluate articulation errors and inappropriate nasal resonance.

2.

Obturation of soft palate posterior border defects The objective for obturation of these defects is similar to the

obturation of total soft palate defects. However, the prosthetic approach differs since the remaining intact position of the soft

187

palate must be circumvented to place the obturator at proper level in the nasopharynx. There are two basic approaches for construction of obturators for posterior order defects. First method is to record the soft palate at rest and after the residual soft palate is circumvented, the obturator is extended superiorly behind the soft palate to the proper level for obturation. This is basically suitable for short taut palate. Second method is to displace the residual soft palate superiorly with the extension, to place the obturator in the proper position into the nasopharynx. Such prosthesis is termed palatal lift. Patients with long or immobile palates should be considered for palatal lift prosthesis. a. Median Posterior border defects The preliminary impression should include the residual soft palate, plus the defect posterior to the soft palate. The cast obtained will serve diagnostic purpose and for adaptation of the wire loop extension for the obturator. Next functional impression is made as described for total soft palate defects. The level of placement of the obturator is the same as in patients with a total soft palate defect. However, a more lengthy superior extension may be necessary to reach the level of normal closure, since direct visualization of the area of normal palatopharyngeal closure may not be possible. If the posterior border of the resected soft palate is severed, and exhibits little motion, it may be necessary, to extend the obturator across the nasal surface of the soft palate to obtain retention. After processing and prior to insertion, the superior surface of the obturator is trimmed and rounded slightly to form a convex surface and the extension of resin across the soft palate is thinned as much as possible. This extension will be approximately 10 mm wide and 2 to 3 thick, also the nasal extension may require, to be reduced to facilitate insertion.

188

If

the

level

of

normal

palatopharyngeal closure

is

considerably above the posterior border of the soft palate, the inferior surface of the obturator may be reduced further. b) Lateral posterior border defect In these situations the post-surgical relationship forces the clinician to engage the opposite lateral pharyngeal wall behind the soft palate to achieve palato pharyngeal closure. Methods of fabrication: A partial or complete prosthesis is constructed before the fabrication of obturator. The retention of the obturator is best provided by a wire loop attached to the conventional prosthesis. In situations where soft palate exhibits little or no motion a cast meshwork may be constructed as a component of the partial denture framework. After the conventional prosthesis is fabricated and adjusted, the retention for the obturator is adjusted. The obturator is fabricated following functional pharyngeal impression techniques. There must be adequate movement of the residual palatopharyngeal mechanism to control nasal airflow. In defects with limited mobility during palatopharyngeal function, continuous contact is maintained between these tissues and the obturator both at rest and during function. Generally, following

delivery the speech is hyponasal; the lateral extensions of the obturator are reduced gradually, until nasal breathing is acceptable. Implant Retained and Supported Obturator prostheses: In edentulous patients with soft palate defects, the posterior palatal seal area is altered making it difficult to obtain and maintain peripheral seal and the long lever action and gravitational force further decreases retention. If the posterior palatal seal area is relatively intact then, two implants in the premaxillary segment will suffice. If the posterior palatal seal area is compromised and residual palatal structures provide inadequate support and stability, then four or more implants are required.

189

These osseointegrated implants enable the design and fabrication of complete overlay dentures with retentive capabilities similar to prosthesis for dentulous patients with fixed partial dentures. Maximizing the antero-posterior spread of the implants improves the load distribution. The design of the prosthesis is based on the status of opposing dentition, number and length of implants, quality of bone, antero-posterior spread and the size of the defect. The use of attachments like the Hader bar anteriorly and the ERA posteriorly allow the prosthesis to rotate around a predictable axis, permitting residual denture base area to aid in the support of occlusal loads.

Fig. 69: The use of Hader Bar anteriorly and ERA attachment posteriorly allows the prosthesis to rotate around a predictable axis, permitting the residual denture bearing surfaces to aid in support of the occlusal loads. a At rest, b- Under load.

4. Special Obturator Prosthesis 10,16,17,72,120,129,140 The palatopharyngeal mechanism or velopharyngeal valving mechanism regulates the resonation and speech utterance and partakes in non-speech oral activities such as swallowing, blowing, sucking and whistling. Velopharyngeal dysfunction implies the presence of hypernasality, inappropriate nasal escape, and decreased air pressure during the production of oral speech sounds. Compensatory articulations in the form of secondary glottal, lingual and labial errors are often present. The following modalities are used to correct these. a) Palatal lift prosthesis It was first advocated by Gibbons and Bloomer (1958).51

190

There are two prosthodontic procedures available in the treatment of patients with palatopharyngeal inadequacies. i) The palatal lift prosthesis. ii) Combination palatal lift/Pharyngeal section prosthesis.

i) The Palatal lift: It used to elevate the soft palate to its maximal position during normal speech and deglutition enabling closure by pharyngeal wall actions.

Fig. 70: In an anatomically normal but paralyzed soft palate, a palatal lift prosthesis is used to get velopharyngeal closure. Pp palatal plane, ta- median tubercle of atlas.

ii) The combined palatal lift: It is preferable, if the soft palate is insufficient to achieve proper palatopharyngeal closure. The prosthesis will elevate the soft palate and also obturate the palatopharyngeal gap, thereby stimulating palatopharyngeal activity and pharyngeal muscle contraction.

191

Fig. 71: in a congenital anatomic insufficiency of velopharynx, a palatal lift plus obturator is used to elevate the soft palate and obturate the velopharyngeal space. Pp palatal plane, ta- median tubercle of atlas.

Evolution of the palatal lift: It has evolved from speech problems associated with insufficient velvopharyngeal closure. These speech difficulties have their origin in

neuromuscular deficiencies, injury to the soft palate, paralysis or inadequate length, inadequate movement of the soft palate following the surgical closure of a congenital cleft palate or poliomyelitis, and the submucous cleft palate. Adequate lateral wall movement is necessary for lift to be effective. Parts of a lift prosthesis: Lamina: The portion of prosthesis, that underlines elevates and supports, neurologically impaired velum. It consists of i] Base - that underlies the anterior one third of the velum and is attached to the basic prosthesis. ii] Midsection iii] Vertex - That underlies a variable portion of the terminal one third of the velum, and contacts with the palatopharyngeal musculature. Objectives of palatal lift and combination prosthesis:

192

To reduce hypernasality (nasal escape of air) by palatal elevation. To reduce the degree of palatal disuse atrophy. To increase palatopharyngeal function by constant and continuous stimulation. To increase neuromuscular response by gentle stimulation and speech exercise.

To assist in the repositioning of the tongue.

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

Disadvantages / Contraindications: When adequate retention is not available for the basic prosthesis, If the palate is not displaceable Uncooperative patient.

Pre-requisites of the palatal lift - pharyngeal section combination prostheses.16 i) The maxillary portion of the prosthesis is designed to achieve optimal retention and stability. ii) The lift portion of the prosthesis should be placed so that palatal elevation occurs in the area where normal palatopharyngeal closure takes place. iii) Elevation of the soft palate should be gradual so that the soft palate becomes less resistant to displacement. iv) The pharyngeal section should be placed in the region where constriction of the posterolateral pharyngeal wall takes place to encourage muscle stimulation and activity.

193

v) The reduction of the pharyngeal section, when indicated should be gradual. vi) Speech therapy, including lip, tongue, and palatal exercise and placement should be instituted in conjunction with the construction and insertion of prosthesis.

Fabrication of palatal lift Prosthesis : Before starting the fabrication, the prosthodontist must determine the potential amount of force that will be required to lift the soft palate to create the desired effect. A mouth mirror or tongue blade should be used to check the tonicity of the soft palate. Care should be taken during this not to touch the dorsum of the posterior part of the tongue and/or the tonsillar pillars to avoid gagging response from the patient. The mirror easily displaces the soft palate of patients with a flaccid paralysis. However, if the soft palate resists displacement because of fibrosis or tonicity of the muscles, a palatal lift may not be successful, as a lot of force will be required to lift the palate leading to a prosthesis that cannot be kept in place or in pressure irritation and ulceration of the mucosa of the soft palate. Also, the movement of the pharyngeal wall should be clinically evaluated by asking the patient to say ahhhh with the mouth wide open. If there is complete lack of soft palate and lateral pharyngeal wall movement, then the prosthesis will be required to occlude the entire velopharyngeal port to eliminate hypernasality, which will lead to elimination of nasal breathing. Since, velopharyngeal incompetency is seen in patients with neurological deficits; it is important to determine whether they have the dexterity to manipulate the prosthesis intraorally. In young patients and patients with needs which may change it is advisable to make the prosthesis entirely in acrylic. Initially the primary impressions are made in irreversible hydrocolloid. Care should be taken in patients with neurologic deficits as protective reflexes may be lacking and airway obstruction is major risk. The impression must cover areas at least 2cm posterior to the fovea palatini. The tray must support the impression material so that the soft palate is displaced by the impression. Some patients with long arches require the use of custom trays.

194

Principles for retention of palatal lift prosthesis Clasps in palatal lift prosthesis not only retain the prosthesis but also support the lift portion in its functional position. The ideal position of the retentive clasps to engage is the disto-buccal undercut on the most posterior tooth on either side of the arch. This places retentive elements as close to the cantilever of the lift portion as possible. If wrought wire clasps are used, they should engage 0.04 to 0.05 inch of undercut. This is required in molars especially as the length of the clasp arms makes them flexible. If orthodontic brackets are used for retention, the clasps must approach from the distal aspect and continue anteriorly for at least two additional teeth to allow the patient to grasp the clasp and reflect it laterally to disengage the lift. An 18-gauge wire should be used. If sufficient retentive undercut is not available on the most posterior teeth, additional retention may also be gained by placing composite resin in the area of the tooth where increased retention is required. It is also very important to have indirect retention as far anteriorly as possible to make the retentive clasps effective. The mesial marginal fossa of the first premolar serves as an effective site as it is sufficiently anterior to the fulcrum line. After mouth preparation, the final impression is made and framework fabricated. The retentive meshwork or wire loop should extend from the base portion approximately 2 cm. This length provides enough support for the lift moulding process and is not long enough so as to interfere with the processing. The loop should be on the same plane as the hard palate but should have slight relief between itself and the cast to allow for the impression material and ultimately the acrylic resin to coat the superior surface. After the framework is physiologically adjusted the lift generation is done. It is extremely important that a speech pathologist is present during this procedure. Various diagnostic aids can be used to assess during the procedure, whether the lift is adequate and sufficient velopharyngeal closure has been achieved.

195

The framework is placed in the mouth and modeling plastic is added to the retentive loop, shaped and flamed to create a smooth surface and then chilled before placing it in the patients mouth. The first layer should cover the loop evenly and extend several millimeters beyond. If softened compound is placed in the mouth, then the soft palate will displace it downward and the lift action will not be achieved. The goal of the procedure is to displace the soft palate superiorly and can be achieved by placing hardened compound. The patient is allowed to wear the palatal lift for a few minutes at this stage to get used to the sensation of the lift. Small additions are then made to the compound posteriorly until the soft palate is brought into light contact with the posterior pharyngeal wall.

At this stage there is gap between the soft palate and the lateral pharyngeal walls. So, the lateral extent of the lift should be increased sufficiently to close the lateral port. Following each addition, the patient is asked to breathe through the nose and attempt speech. Care should be taken not to overextend the compound orally as any contact of the compound with the dorsum of the posterior part of the tongue will elicit the gag reflex. Enlargement of the lift ceases when the speech pathologist is satisfied with the result, or when the retentive limit of the clasps is reached and the soft palate dislodges the prosthesis by the downward force. If the patient cannot breathe nasally, then some compound is removed from the lateral aspects of the lift until breathing is restored. Ideally, the lateral pharyngeal wall movement allows the maintenance of lateral breathing ports that close down, when the patient speaks. The nasoendoscope can be used very effectively to check for lateral wall movement.

Sometimes, entire occlusion of the nasal airway is required to eliminate hypernasality. Finally, the entire surface of the modeling compound is reduced by 1-2mm and impression wax is added and tempered. After placing in

196

the mouth, the patient is asked to speak, swallow water and move the head in all directions to form the wax. The lift is removed after 5 minutes and any pressure spots where compound is exposed are relieved and more wax is added and the previous step repeated. The palatal lift portion is replicated in acrylic resin ensuring that there are no rough or sharp edges present. Palatal Lift prostheses in edentulous patients: 120 Conventional palatal lift prosthesis must be securely retained in the maxillary arch to resist the rebound of the lift. This situation is very difficult to achieve when the patient is edentulous and there are no teeth to utilize for retention. Therefore, in edentulous patients palatal lift prosthesis must include as movable palatopharyngeal section connected to the denture with Ni-TI wires. The elastic wire shows a unique stress-strain curve with a plateau of 2% to 5 % strain and a return to almost 0 % strain as the stress reduces to zero. Technique: Preliminary hydrocolloid. Referring to the cephalogram, soft palate contour is altered in the cast to simulate the contour of the raised soft palate. Custom tray is prepared for the final impression. Final impressions are made in conventional way and casts poured. After jaw relationship records and arrangement of teeth, the palato-pharyngeal section is waxed keeping two openings to reduce the weight. Process the palatomaxillary section (complete denture) and the palatopharyngeal section separately. On the master cast, embed Nickel- Titanium wires in both sections using autopolymerizing resin impressions are made in irreversible

Insertion and Patient Instructions:

197

The effectiveness of the lift is again evaluated at the insertion appointment and a pressure indicating paste is used to detect localized excessive pressure. Only these areas should be reduced slightly. Arbitrary trimming should not be done. The patient should be trained to place and remove the prosthesis and instructed to wear the lift prosthesis only during waking hours.

Patients for whom the nasal airway has been completely blocked to correct hypernasality, should be instructed to use the prosthesis only when they need to speak and remove during eating food. The patient should be seen within 2 3 days after delivery of the lift. Its use should be limited to day time as the mucosa of the palate

must be given enough time to recover from the coverage and pressure. Also the clasped abutment teeth are at risk of supraeruption due to the high force application by the retainers and need relief from these forces. LaVelle and Hardy (1979) lift prostheses: An optimal result occurs when the prosthesis results in palatopharyngeal port closure during speech production except in association with production of nasal consonants; that is, the resulting pattern of closure would be essentially normal. The result is considered successful when there is palatopharyngeal closure throughout speech production. These patients generally end up hyponasal with their prosthesis in place. This is because they are fully closed and are not able to get airflow when saying their nasal sound as m, n and ng. The result is considered only desirable when the palatopharyngeal port area is reduced so that incompetency is a relatively minor speech physiology problem.These patients are still slightly hypernasal because the prosthodontist was unable to apply adequate lifting pressure in the optimal location to completely occlude the palatopharyngeal port.
72

defined three satisfactory outcomes for palatal

b) Meatus-type obturator prosthesis

125,124,136

198

Schialit first described this in 1946. The meatus obturator only provides a static obturation and is not dependent on the surrounding muscle activity to provide a more physiologic separation between the oral and nasal structures. It is not located in a region of muscle activity. Therefore, speech therapy is not effective in refinement of speech as seen with fixed and hinged pharyngeal obturators and it is not as effective as the horizontal obturator in cleft palate patients. The need for improved retention and stability of prosthesis, may suggest its use in some patients.

Fig. 72 : Meatus type Obturator

Obturator of choice for edentulous patients with acquired defects of the soft palate when retention is a problem as the hinged and fixed obturators create a long lever arm that encourages dislodgement of the denture base. These patients with acquired defects retain normal speech articulation patterns but lack the ability to obstruct the passage of air into the nose. The change in voice quality is less objectionable in patients with acquired defects than in patients with congenital defects that have not developed the oral and pharyngeal function necessary for good speech articulation. May be used for patients with extensive defects of the soft palate exhibiting active gag reflex. It establishes closure with nasal structures, at a level posterior and superior to the posterior terminus of the hard palate. The closure is established against the turbinates, residual vomer and the roof of nasal cavity. The posterior nasal choanae determine the shape of the meatus obturator. These openings are bounded laterally by the medial surface of the medial pterygoid plate of the sphenoid bone, inferiorly by the horizontal

199

plate of the palatine bone, medially by the vomer bone, and superiorly by the vomer and sphenoid bones immediately inferior to the sphenoid sinus. These structures are covered by the respiratory epithelium. The pharyngeal canal that carries the pharyngeal nerve and artery exits through the sphenoid bone at the most superior extent of the choanae. There are no muscles or muscle attachments at the level of the posterior choanae. In the patient with edentulous maxillae where retention of the prosthesis is at best difficult, the meatus obturator is above the denture base rather than posterior to it, as seen with other types of obturators. This relationship lessens the lever action of the obturator on the denture base. The posterior choanae of the nares also tend to be narrow in comparison with the nasopharyngeal size, and the meatus obturator can be made smaller than a horizontal obturator. The associated reduction in weight and the decreased lever action of the meatus obturator creates a more stable prosthesis. In addition, the floor of the nose or scar band of the resected soft palate can often be engaged from above to enhance retention. The meatus obturator can only be used in patients with an absence of mobile soft palate in the midline, as the vertical component of the obturator will interfere with the soft palate function in patients with remaining soft palate movement. The meatus obturator is contraindicated for use in patients whose soft palate defect is narrower than the nasopharynx in the region of the posterior choanae. A narrow palatal defect limits the width of the impression and subsequently the width of the obturator. The meatus obturator is also contraindicated when the path of insertion of the complete denture is different from the vertical path of insertion necessary for the meatus obturator. A prominent anterior residual ridge with labial undercut will prevent seating. Alveoplasty should be considered but weighed against the subsequent reduction in retention. Fabrication of Meatal obturator prosthesis: The fabrication can be achieved in several ways. One of the more reliable methods entails a corrective cast impression technique at the final wax try in stage for the complete denture. If the patients existing denture is adequate, the obturator portion may be attached as an additive procedure. A technique for addition of a meatus obturator to an existing or new denture base is described.

200

An 18-gauge wire loop is added to the posterior border of the denture with autopolymerizing acrylic resin. The loop should be extended horizontally to pass posterior to the remnant of the soft palate. The loop is then extended vertically into the area of the posterior nasal orifices. The loop should not contact mucosa at any point and should be narrow enough at the isthmus to avoid contact with the functioning residual muscles. A primary modeling compound impression is made by adapting the softened compound to the supporting loop in sufficient quantity to obturate the loop in all areas. The denture with softened compound is completely seated. On cooling, the denture is removed and the compound impression is reduced in size to ensure absence of tissue contact. The primary compound impression is then border molded using additional compound of a lower working range. Border seal will be evident when the posterior choanae are obturated, as noted by positive tissue contact and the patients inability to inhale or exhale through the nose. Head, speech and swallowing movements are unnecessary as there are no movable tissues in this area. Certain anatomical landmarks can be identified in the impression. Two lobes denoting the right and left nasal cavities project anteriorly divided by a groove caused by the posterior margin of the vomer bone. Lateral depressions are caused by the inferior turbinates. Posterior to the depression of the turbinates outlines of the orifices of the eustachian tubes may be evident. The impression should be reduced to avoid blocking the tube orifices. When maximum extension has been achieved, the compound impression is reduced uniformly to provide space for the final impression material. To assure positive tissue contact, a functional impression material such as mouth temperature wax is used. The final impression material should remain in place for 5-7 minutes. On removal, it should be evaluated for uniform thickness and positive tissue contact. A cast is poured around the completed impression. The wax and compound are removed, the cast painted with a separating medium, and autopolymerizing/ light cure resin processed to the retentive loop. On removal from the cast, the processed obturator is reduced from the posterior aspect to minimize bulk, and the obturator is lightly polished. The prosthesis is inserted in the mouth to verify complete obstruction of the nasal airway. Vent holes are then placed through the

201

obturator in the area lateral to the contact with the vomer. The vent openings are placed in the superior third of the anterior surface and angled downward at an angle of 45 degrees to the posterior surface. This downward angulation of the vents minimizes the chances of regurgitation of food and liquid into the nose during swallowing. The vents are enlarged gradually until breathing through the nose becomes comfortable. If the quality of speech has deteriorated significantly with the enlargement of the vents, autopolymerizing acrylic resin may be added to reduce the vent openings until an acceptable level of speech versus nasal airway has been attained. On insertion of the completed prosthesis, instructions should be given for its use. The possibility of leakage of food and liquids into the nasal cavity should be emphasized, and the need to remove the prosthesis frequently for hygiene should be stressed. An erect head position while eating and drinking may minimize leakage. Mucous build up on the anterior side of the obturator may necessitate more frequent cleansing. Removal of the prosthesis at night should be encouraged. The need for regular maintenance care to assess the adaptation of the prosthesis and evaluate the health of the oral and nasal structures should be emphasized. On placing the prosthesis, the nasality should improve, only the articulative defects remains, and these are not as unpleasant because of normal nasal quality.

Advantages: Meatal extension is not lengthy and is quite thin in anterior posterior dimension. Light in weight Downward displacement force from the obturator extension is closer to the supporting tissues of the parent prosthesis. Disadvantages: Nasal air emission is not controlled. Hyponasal speech and impaired nasal respiration. Distortion in nasal resonance because oral cavity and oropharynx are increased proportionately. in sizes and nasal cavity is reduced

202

The meatus obturator interferes with the normal physiologic flow of mucous posteriorly from the nose into the oral cavity. It may cause constant irritation to the sensitive respiratory mucosa. Although the meatus obturator has not gained widespread acceptance for use in cleft palate habilitation as originally intended by Schialit and Sharry, it may still be useful in the treatment of edentulous and partially edentulous patients with acquired soft palate defects where retention and stability of the prosthesis are difficult to achieve. The meatus obturator can result in a more stable maxillary prosthesis and permit acceptable speech for these patients.

203

The cleft lip and palate deformity is a congenital defect of the middle third of the face, consisting of tissues of the upper lip or palate. The aetiology has been discussed in the discussion about the development of the palato-maxillary region. Treatment for cleft lip and palate is unique in that it includes various health disciplines, which are interdependent and interrelated. Hence a team approach based on total patient care will enhance the level of rehabilitation.

Classification of cleft lip and palate

Numerous methods of classification have been proposed for these, congenital anomalies of the middle third of the face. The method proposed by Stark is the most widely used today, with that proposed by the Cleft palate association being next common in usage.

Classification by Olinger95

Class I - Fissure in the azygos uvulae Class II Fissure in the uvula

204

Class III Fissure in the soft palate Class IV Fissure in the soft and hard palates Class V Unilateral cleft fissure in the soft and hard palates through the alveolar ridge at the junction of the maxilla and premaxilla, accompanied by a cleft of the lip.

Class VI Bilateral cleft, fissure in the soft and hard palates through the alveolar ridge, involving both sides of the premaxilla, freeing the premaxillary bone with a double cleft lip.

Fitz Gibbons Classification 50 Type I Type II Cleft of the soft palate only Cleft of the soft and hard palate

Type III Cleft of the soft palate, hard palate and unilateral extension on one side of the pre- maxilla involving the lip as unilateral hare lip, sometimes, extending upto the nostril for varying distances. Type IV Cleft of the soft palate, hard palate and bilateral extension through both sides of the premaxilla leaving an island attached to the base of the septum and bilateral hare-lip extending upto both sides of the nostril. These are further described as congenital, acquired, post operative and dentulous or edentulous.

205

Cleft Palate Association

STARK

VEAU

Primary palate Pre Palate Pre Palate Pre Palate Pre Palate Subtotal unilateral Subtotal bilateral Total unilateral Total bi-lateral

Secondary palate Palate Palate Palate(Submucous) Subtotal Total Class I Class II

Primary & Secondary Pre palate Total unilateral Class III

and palate Pre palate Total Bilateral Class IV

and palate

DIAGNOSIS AND TREATMENT PLANNING INCLUDES Case history: includes general and dental case history. Impressions for study cast, Intraoral wax occlusal registration. Radiographs -Intraoral full mouth, bitewings, occlusal x-rays. Cineradiography - to record on film the function of the mandible, tongue, velum and surrounding tissue during phonation blowing and swallowing. Laminography - For the study of cranial facial growth and velopharynx orifice size during a sustained sound. Pantomography : Used for clinical diagnosis of the oral facial region and growth appraisal.

206

Clinical examination of patients: includes both hard and soft tissue examination. Photographs: Intraoral and facial color photographs for diagnosis, teaching and illustration of before and after treatment. Speech recordings: which includes disc, wire or tape recording by a speech therapist. & sound spectrographic recording.

Other investigations: measurement of nasal and oral pressure and flow, otologic and hearing examinations. Psychologic and social considerations

Analysis of all factors pertinent to the patient psychosocial status, at this particular stage in the entire structure of therapy, must be integrated with the diagnostic data accumulated. Social services should be available to enable the patient to make full use of medical dental and speech care both preventive and the therapeutic, so that he can achieve the fullest possible, physical emotional, and social adjustment. General outline of prosthetic management of cleft lip and palate: Indications for Prosthesis: 1. In Unoperated patients Wide cleft with deficient soft palate Wide cleft of Hard palate Neuromuscular deficiency of soft palate and pharynx When patients are high anesthetic risk cases. When delayed surgery approach (Zurich Approach) is followed. In cases where combined prosthetic and orthodontic appliances like expansion prosthesis are to be used to improve spatial relations prior to surgery. 2. Indications of prosthesis in operated palates: Patients with hypernasality and inadequate speech following push back and pharyngeal flap procedures.

Contraindications for prosthesis: a. When surgical repair is feasible and when surgical closure of the cleft will produce anatomic and functional repair.

207

b. A mentally retarded patient who is not capable of controlling and taking care of his appliances. c. Uncooperative patient d. Rampant caries and periodontal breakdown situations e. When experienced prosthodontic help is unavailable f. The edentulous condition is not a contraindication for speech aid prosthesis. Goals and objective of prosthetic treatment It should aid in restoring the basic function of mastication, respiration, phonation and deglutition. It must be worn by the patient without discomfort or damage to the supporting and surrounding structures. It should be shaped so that it will give the remaining anatomic structures an functions. It should be of simple, sturdy construction with special attention to retention, occlusion and cosmetics. opportunity to regulate efficiency the functions of

speech, breathing and swallowing without any impediment to these

PROSTHESIS FOR CLEFT LIP AND PALATE

1) For Infants 2) For Young Children and Adolescents 3) For Adults General Considerations For Impression In Cleft Palate Cases a) Impressions for infants Maxillary and mandibular impression trays for infants can be constructed by adapting a piece of baseplate wax against the ridge. This wax patterns is then processed in acrylic resin. This can be repeated in other cases to collect additional trays, for future use. Also, pre-made trays can be used to make a primary impression.

208

TECHNIQUE : An irreversible hydrocolloid material is used for impression. The amount of water used for this is 5/6th of that recommended by the manufacturer, and water is used at 100F in order to speed up the setting of the material. The maxillary impression is made with the infants head tilted at a downward angle of 15 degrees. This position make's it possible to maintain a direct view of the oral cavity at all times and it directs the flow of material towards the oropharyngeal space. At least 4 assistants should be available to i) Hold the infants head. ii) Depress the tongue and hold the suction. iii) Hold the infants body and face iv) Mix the impression material. Proper instruments should be available, to gain access to material should it be dislodged and enter the nasal or oral pharynx. The tray should not be over packed, nor should too much force be applied in placing the tray in position. The part of the tray that will be directly over an undercut should contain less of the impression material. b) Impressions in older children and adults The following suggestions should be kept in mind. i) If the patient is a child, he should be given the opportunity to see and examine the tray. He should be told that his utmost co-operation is needed; otherwise it will be necessary to make several impressions. ii) The patient should be empty stomach. iii) A topical anesthetic is applied to a child who has a severe gagging reflex. iv) The tray should not be over loaded. Excess material in nasopharynx will increase difficulty to removing the impressions without a fracture. v) All oral perforations, which are small, should be packed with gauze that has been saturated with petroleum jelly.

209

TECHNIQUE: Patient should be placed in either an erect or a supine position. It is suggested, that supine position be used for

preliminary impression and final impression in order that the dependent tissues do not become displaced. Depending upon the extent of defect and psychological state of the patient, it may be necessary to place an airway in the nostrils and pack the throat with gauze. It may also be necessary in the same instance, to place several strings in the cavity to aid in removal of the impression. The lips of the patient should be lubricated with petrolatum, so that the impression material does not stick to the lips, and also prevents the lips from cracking during the procedure. When a stock impression tray used, the edges of the tray should be covered by beading wax, and the portion of the tray which will come into proximity with defect should be build up with beading or boxing wax to direct the impression material into the defect. Individual acrylic resin trays are made on the stone cast obtained from the preliminary. A final impression is made with one of the materials such as rubber base or irreversible hydrocolloid. 1) Prosthetic Appliances For The Infants: At birth the following variables exert a profound influence on the rehabilitation of cleft patients. Configuration and the extent of cleft Growth potential of the patient Parental co-operation Appliance design

Whether the patient requires maxillary orthopedics, orthopedics followed by bone grafting or neither depends on a lot of factors and is decided jointly by the surgeon, orthodontist and the prosthodontist. The factors, which need to be considered, are the length and position of the minor segment, position of the anterior portion of the greater segment or the premaxilla, the degree and location of the apparent tissue deficiency and the area of coverage or extension of the appliance.

210

TYPES OF APPLIANCE i) Active or expansion type ii) Passive or holding type The type of appliance to be placed will be determined by the configuration of the defect.

i) Active/Expansion Type it is used if any degree of collapse is present. If the collapse appears primarily in the anterior region a fan type of appliance is used. If the collapse of the arch is throughout its length a straight jackscrew appliance is used ii) Passive/Holding type: Indicated if the cleft configuration is wide or the segments appears in an ideal relationship All appliances, whether active or passive are fabricated and inserted prior to lip closure. The primary purpose of the appliance prior to lip closure is not to proliferate tissue or initiate growth but to guide the maxillary segments into proper spatial position with each other and with the mandibular arch. Salient feature regarding infant appliances: o Active or holding appliances can achieve and maintain ideal arch configuration in patients with complete clefts of the lip and palate. o Once the lip has been surgically closed, the greatest tendency for additional collapse is seen in those who presented initially with some degree of arch collapse. o A high degree/percentage of success is achieved in patients whose initial arch configuration is wide. o Lip closure can increase deformation or arch collapse unless controlled by appliances. o Parental, co-operation is essential for successful treatment. The moulding pressure of the surgically closed cleft lip along with the appliance helps to create an ideal arch form based on the Wolfs law that the functional stresses shape bone.

211

Nasoalveolar Molding in Early Management of Cleft Lip and Palate 69,135,145 The basic goal of any approach to cleft lip, alveolus, and palate repair whether for the unilateral or the bilateral anomaly, is to restore normal anatomy. Ideally, deficient tissues should be expanded and malpositioned structures should be repositioned prior to surgical correction. foundation for a less invasive surgical repair. This provides the Historically, the use of

presurgical infant orthopedic (PSIO) appliances, or molding plate therapy, has aided significantly in reducing the size of clefts of the alveolus and hard palate prior to surgery. Since its introduction by McNeil in 1950, various techniques for molding the intraoral alveolar segments closer together in unilateral and bilateral cleft situations have been described (Mylin, 1968; Latham, 1980). PSIO appliances are generally consist of three components- A bulb prosthesis made of acrylic resin which fits on the protruding or laterally displaced premaxilla held in place by elastic straps attached to the bonnet for extra oral anchorage. Although controversy surrounds the use of PSIO devices in conjunction with various surgical protocols when employed to move only the alveolar segments closer together, this text describes a new approach of presurgical nasoalveolar molding (PNAM) therapy developed at the Institute of Reconstructive Plastic Surgery at New York University Medical Center. PNAM includes not only the reduction of the size of the intraoral alveolar cleft through the molding of the bony segments, but also the active molding and positioning of the surrounding soft tissues affected by the cleft, including the deformed soft tissue and cartilage in the cleft nose. This is accomplished through the use of a nasal stent that is based on the labial flange of a conventional oral molding plate and enters the nasal aperture. The stent provides support and gives shape to the nasal dome and alar cartilages. Presurgical nasoalveolar molding may be successfully

employed in the early management of the both the unilateral and bilateral cleft anomalies in newborns. In the bilateral cleft condition presurgical nasoalveolar molding may be combined with columellar elongation to create a neocolumella through

212

a non-surgical approach. When there is a close coordination between the presurgical phase of treatment and the surgical method employed, these new techniques greatly improve upon the results usually produced through traditional PSIO. The result is an overall improvement in the esthetics of the nasolabial complex in both the unilateral and bilateral cleft conditions while minimizing the extent of surgery and the overall number of surgical procedures. Clinical Method for Correction of the Unilateral Oronasal Cleft Deformity 1. Diagnostic Evaluation: As soon after birth as possible, all members of the interdisciplinary cleft palate team evaluate the infant. The cleft defect is examined for the presence of natal teeth, a Simonart band, unusual undercuts, or other tissue abnormalities. If a tooth is present near the cleft, it is often removed, as its presence will complicate healing during the surgical phase of treatment. 2. Impression procedure: An impression of the intraoral cleft defect is

made using high consistency polyvinyl siloxane in an acrylic tray. Light body material is not used for relining, as the registration of minute tissue detail is not necessary. The impression is obtained with the infant fully awake and without any anesthesia. The infant is held face down to prevent the possible aspiration of regurgitated stomach contents. One person cradles the infant securely around the chest and torso, supporting the head and neck, while another obtains the impression. High-volume evacuation is also ready at all times also in case of regurgitation of the stomach contents. Care is taken to ensure that the material has registered the border regions of the maxilla and premaxilla as well as the cleft region. It is not necessary, however, to impress deeply into the nasal cavity in the cleft, reducing the risk of traumatizing the nasal tissues. The infant should be able to cry during the impression-making procedure. If no crying is heard, the airway is blocked. A finger motion should be used to clear any impression material posterior to the tray and to prevent the infant form closing down on the tray, which also will compromise the air way. All impressions of clefts in infants should be made in the hospital setting with a surgeon present as part of the impression team. The

213

hospital setting also allows a rapid response by an airway team should there be an airway emergency. A nasal impression may be obtained using clear polyvinylsiloxane (Memosil CD, Heracus Kulzer) expressed directly onto the cleft nose from the radix to the lip. Cotton plugs attached to dental floss are used to prevent material from lodging deep in the nostrils. Great care must be used in obtaining a nasal impression of the cleft infant. The nasal impression is not used in making the nasal stent portion of the nasoalveolar-molding device. 3. Preparation of the plate: When the material has fully set (approximately 2 minute intra orally), the impression is removed and inspected to ensure all desired landmarks have been captured. Poured in modified dental stone and the cast recovered. The modification cast is then lubricated with a thin layer of petroleum jelly. A soft, resilient, slowly polymerizing acrylic (Myerson permasoft, Austenal,) may be applied to the undercut region on the cast. The remainder of the oral molding plate is fabricated from clear methyl methacrylate orthodontic resin using one of many acceptable techniques acrylic oral molding plate with a uniform thickness in a relatively short period of time 4. Delivery of the plate: At the delivery appointment, the oral molding appliance is carefully fitted in the infants oral cavity. The appliance must not fit too tightly, however, as it is primarily retained through extra-oral facial tapes and elastics. Additionally, no acrylic material should project into the cleft areas, as this material will ultimately block the intended movement of the alveolar segments into their desired final presurgical positions. After initially inserting the oral molding appliance, the baby must be observed for several minutes while the clinician stabilizes the appliance against the palate with a gloved index finger. The infant must be able to easily suckle without gagging or struggling. The thickness of the palatal portion of the appliance should be checked and reduced if necessary. Also at the initial insertion appointment for the unilateral cleft patient, an extra oral retentive button is developed with clear resin at the site of the cleft in the lip. This retentive button serves to facilitate both the positive seating of the appliance to the palatal tissues and to secure the retentive lip tapes and elastic bands. The retentive button should be

214

positioned facing downward on the labial flange at a 45-degree angle relative to the occlusal plane, allowing for clearance of the upper and lower lips Proper retentive taping between appointments is crucial if the appliance is to be maximally effective. A broader base tape of Suture-Strip (0.5 X 1.5 inch) (Genetic Laboratories Wound Care, St. Paus, MN ) is first applied to the infants cheeks lateral and superior to the commissures. These base tapes will serve to anchor the thinner (0.25 X 4 inch) suturestrips that are used to hold the appliance against the palate. Small red orthodontic elastics (01875 pr 0.25. inch diameter) are incorporated into the loops of thinner Suture Strips that are folded over on them. The elastic band is placed over the retentive button, and the Suture-Strips are pulled and secured to the base tapes on the babys cheeks. Enough retentive force has been exerted when the elastics have been pulled to twice their original length. The correct force vector on the retentive tapes and elastics should be directed posteriorly and superiorly. The Suture Strips and elastic bands are changed as needed to allow continuous retention of the appliance. The base tapes should remain in place for a longer period of time, while the thin tapes may require replacement several times each day. The base tapes prevent excessive skin irritation of the cheeks that might result from the constant removal of the adhesive tape. Once the Suture Strips and elastic bands have been applied, an additional broader tape is applied over the ends of the thin tape to anchor them to the base tapes. The lip taping force in conjunction with a molding plate yields a controlled movement of the alveolar segments and also serves to improve the alignment of the nasal base region by bringing the columella toward the midsagittal plane and improving the symmetry of the nostril apertures. The parents are provided with detailed instructions on the proper method of lip taping to ensure the maximum effectiveness of the appliance. A supply of taping materials, adhesive, and releasing agent is also provided to the parents. This ensures continuous taping will be maintained between appointments. 5. Modification of plate for moulding: The tissue surface of the appliance is also modified at the initial insertion appointment to begin the molding of

215

the greater and lesser alveolar segments on either side of the cleft. This is achieved through the selective removal of acrylic from the region into which one desires the alveolar bone to move. At the same time, Permasoft is added to line the appliance to a thickness of approximately 1 to 1.5 mm in the region from which one desires the bone to be reduced or removed. The usual movement is to direct the greater

segment inward toward the cleft by adding Permasoft to the inner surface of the labial aspect of the alveolus portion of the appliance while reducing the acrylic form the palatal aspect of the appliance. applied to the greater segment. The usual desired movement is to direct the lesser segment outward from the cleft. To achieve this, the acrylic is selectively removed from the inner labial aspect of the lesser segment of the alveolus (approximately 1 to 1.5mm ) while adding an equal amount of resilient soft liner on the palatal aspect of the alveolus in the lesser segment. These minor adjustments are made weekly. The degree and location of the modification will require a careful consideration of each individual cleft situation. The ultimate goal of this sequential addition and selective grinding away of material is to reduce the size of the cleft gap and to have the two segments of alveolus contact with the configuration of a proper maxillary alveolar arch form. The alteration of the lesser segment of the alveolus is the converse of that

6. Weekly monitoring is done The Nasal Stent When the cleft gap has been reduced to approximately 6 mm or less, a nasal stent may be added to the appliance and the phase of active nasal cartilage molding may begin. The nasal stent is a projection of acrylic that is formed by the careful addition of small amounts of cold-cure acrylic resin until the stent is positioned inside the nasal dome on the cleft side of the nose. The hard acrylic is covered with a thin veneer of soft liner

(Permasoft). As nasal stenting progresses each week, the nasal tip and dome on the cleft side should begin to appear more symmetric when compared with the noncleft side when the stent is in place. The nasal stent also exerts a reciprocal intraoral molding force against the alveolar segments. As the

216

nasal tissues pouch against the nasal stent, this force is transmitted down along the nasal stent and provides additional force that aids in reducing the dimension of the intraoral cleft width.

Fig. 73: Unilateral cleft patient with PNAM appliance with nasal stent.

The parents are again instructed to keep the appliance in place at all times expect for cleaning. The goal of the intraoral molding therapy should be to have the gingival tissues contact on either side of the ridge although a successful surgical result may be obtained even when a small cleft 1 to 2 mm remains between the alveolar ridges. The goal of nasal orthopedics during the later appointments is to ensure that when the lip segments are drawn together with taping, the columella has been repositioned to midline location or even overcorrected prior to surgery. The shape of the nostril and alar rim is also carefully molded to resemble the configuration of the unaffected side. This may be achieved by careful molding with Permasoft on the outside of the nasal rim to support the underside of the expanding soft tissue. simple ovoid or elliptical shape. The nasal molding phase must follow alveolar molding so as to avoid undue stretching of the alar rim circumference on the cleft side. This is more likely to occur if the nasal molding is pursued while a very large cleft alveolar gap remains. It is for this reason that nasal molding should not begin until the intraoral cleft size has been reduced to 6 mm or less. The proper sequence of molding (alveolar followed by nasal) is followed to avoid the production of a mega-nostril. This supporting material helps to produce a symmetric teardrop nostril form rather than a

217

At the conclusion of intraoral molding therapy and nasal stenting, the alveolar segments should be aligned, and the nasal cartilages, columella, and philtrum should be properly repositioned to facilitate the first surgical procedure. This is a one-stage primary lip-nose repair in combination with a Gingivoperiosteoplasty (GPP) to close the alveolar defect (Millard and Latham, 1990). This first surgery is usually performed between 12 and 16 weeks of age. This allows one surgical procedure to address the defects of the entire nasolabial complex in coordination with the oronasal presurgical orthopedics. The lip nose alveolus repair may be performed at a later age if it is determined by the members of the team that the infant would benefit from additional weeks of nasoalveolar molding prior to surgery. Following surgical repair of the lip, the lip is taped for several weeks and no intraoral appliance is used. supporting device is employed. The palate repair, if indicated, in one stage is done once the infant shows evidence of phoneme speech development. This usually occurs at approximately 11 to 13 months of age. Clinical Method for Correction of the Bilateral Oronasal Cleft Deformity In the bilateral cleft deformity, presurgical nasoalveolar molding consists of three distinct treatment phases. 1. First Intraoral Phase: The goal of the first or intraoral phase of presurgical nasoalveolar molding is to align the posterior lateral alveolar segments while retraction and derotating the premaxilla. 2. Second Phase: When the premaxilla has been has been returned to the keystone position within the maxillary arch; the goal of the second phase is to mold the nasal cartilages by repositioning the apices of the alar cartilages toward the nasal tip. 3. Third Phase: The last phase of molding in the bilateral cleft infant focuses on elongation of the columella. Likewise, no nasal stent or

218

Fig. 74: bilateral cleft patient with PNAM appliance.

Finally, a one-stage surgical repair is undertaken to remove the fibrofat tissue between the domes of the lateral nasal cartilages as they are sutured together. This is performed along with a bilateral GPP to close the intraoral alveolar clefts. One of the most significant benefits of the bilateral application of nasoalveolar molding is the nonsurgical lengthening of the absent columella. Using this technique, the columella may be non-surgically lengthened between 4.0 and 7.0 mm (Grayson et al, 1999). Intentional over correction of the columella is encouraged to minimize post-surgical relapse. In the infant with a bilateral cleft, it is not unusual that nasoalveolar molding and columellar elongation will require up to 5 or 6 months of active treatment before the surgical repair. As in the case of the unilateral molding appliance, the device is worn continuously and removed only for cleaning. The infant wears the prosthesis into the operating room. No intraoral appliance or nasal stent is employed post surgically. The lip however, is taped for several weeks while the baby heals. Complications Associated with Presurgical Nasoalveolar Molding and

Columellar Elongation: 1. The Locked-out Segment. 2. Nostril Overexpansion. 3. Tissue Ulceration 4. Failure to Retain Appliance During Oronasal Molding.

219

5. Failure to Tape Lip Segments. Advantages Elongation: of Presurgical Nasoalveolar Molding and Columellar

Presurgical nasoalveolar molding allows for the controlled, predictable repositioning of the alveolar segments without the need for lip adhesion surgery or for the surgical insertion of a pin-retained dynamic molding plate. The reduction in the size of the cleft gap facilitates the repair of the entire lip nose alveolus complex in one surgical procedure. It also allows the surgeon to perform a GPP with out the need for the extensive tissue dissection required when the alveolar segments are far apart. As a result studies have shown no midfacial growth restriction in children who have under gone a GPP following presurgical molding with reduction in the size of the cleft gap when compared with children who had GPPs without presurgical cleft gap reduction. PNAM used in conjunction with GPP also reduces the need for additional surgery to bone graft the alveolus later. The nasal component of molding facilitates the final phases of intraoral molding. In the bilateral cleft patient, PNAM combined with columellar elongation eliminates the need for columellar lengthening surgery

Both the unilateral and bilateral prostheses improve the infants ability to feed. In their most basic form, the devices serve as obturators that provide an intact palatal surface upon which the infant will now be able to generate a suckling force.

Limitations of Presurgical Nasoalveolar Molding and Columellar Elongation. Despite the numerous advantages of these new techniques there are several drawbacks associated with PNAM and columellar elongation. For optimal effectiveness, the molding process should begin as soon as possible after the baby is born. PNAM and columellar elongation require cooperative parents who must be well informed of the importance of their integral role in the successful outcome of the treatment.

220

These techniques are very labor intensive and require a committed dental team (surgeon, orthodontist and a prosthodontist)

2. Prosthetic Speech Appliances For Children Three types of speech aids are constructed for children. 1. An obturator with a palatal-velar-pharyngeal portion. 2. A baseplate type, which functions to obturate the palate and helps speech 3. An anterior prosthesis, which contours the upper lip and improves the anterior occlusion. i) An obturator with a palatal velar-pharyngeal portion It is used for training, diagnosis and as a temporary appliance. A training appliance is used, to promote increased muscular activity so that the coordinated movement of the soft palate and the posterior pharyngeal wall will achieve velvopharyngeal closure during speech. The diagnostic appliance may be used, for eliminating certain tongue habits. The appliance is to be used only as a diagnostic tool, and aid in increasing muscle activity. For children 3-9 years of age stainless steel crowns are luted or bands are adapted on the deciduous second molars and deciduous cuspids. To these are soldered labial and buccal lugs or protuberances (buccal tubes), which are used to retain the wrought wire clasps on the speech aid appliance. The speech bulb is not as accurately defined and does not achieve complete efficiency during velvopharyngeal closure. It is used to provide velopharyngeal closure during speech and yet present an open port for nasal breathing. The bulb section should be started from a small size (pea size). With each addition of compound the child is asked to bend his/her head down as far as possible. This brings the spine forward causing the posterior pharyngeal wall (tubercle of atlas) to indent the posterior surface of the impression. The operator now has the means to orient the placement of more impression of the material and the location of the bulb. The child is then made to bend his/her head from side to side which causes the palatopharyngeus muscle to trim the anterolateral portion of the bulb. The compound is scraped by about 1mm and thermoplastic wax is added and the movements are repeated.

221

The temporary appliance is used, till a more definitive prosthesis can be constructed. ii) Hard palate obturator This type is used when a perforation exists in the hard palate and the surgeon desires more growth of the childs jaws before surgical closure is done. In this type of case, since the soft palate has been surgically repaired and is functioning well, a speech bulb is not indicated. Retentive crowns or bands are placed on the deciduous second molars and the cuspids while the plate has wrought wire clasps. iii) Anterior prosthesis: This type of prosthesis may be constructed when there is midfacial deformity due to normal growth of mandible and the concomitant arrested growth of maxilla. Mandibular prognathism is seen at ages 9 through 14 as a result of sudden growth of the mandible without comparable growth of the maxilla. Surgical correction is generally not done. Lip plumper also needs to be used if it is felt that the scar contracture is inhibiting growth. This prosthesis restores function to the mandibular dentition and improves profile. Therefore, the patient benefits from a psychological standpoint. normal articulation and mastication. The appliance will also rebuild the arch form besides tooth replacements for

4. Prosthesis For Adults: a) Fixed Prosthesis b) Removable Prosthesis a) Fixed Prosthesis i) It is the treatment of choice when the ridge defect is small ii) A fixed appliance is preferable in cases where stability, longevity, comfort and appropriate hygiene can be accomplished. iii) Fixed prosthesis provides the much needed facial esthetics. iv) Fixed prosthesis may/can be used in conjunction with removable obturator prosthesis.

222

Several factor to be considered for cleft palate crown and bridge prosthodontics are i) Most commonly the lateral incisor is missing in cleft palate patients. Patients with surgically corrected clefts are very likely to have very high smile line, making the residual soft tissue defect in the cleft visible and less amenable to conventional fixed prosthodontic restoration because of the volume of missing tissue. Hence, a combination of fixed-removable treatment should be considered. ii) When the cleft of the alveolus is not reconstructed with a bone graft, the two segments of the maxilla tend to move independent of each other. Placing conventional fixed prosthodontic restorations across the defect puts the integrity of the cement retaining the prosthesis at great risk of failure due to cement line failure, washout and caries. Even double abutting the prosthesis on both sides of the cleft is no guarantee that cement failure will not occur. Hence, alveolar bone grafting to close the bony defect should be considered prior to fixed rehabilitation of the cleft palate patient regardless of the patients age, as it will greatly improve the long-term prognosis. iii) Full crown coverage is preferable for bridge abutments Full esthetics crowns can compensate for hypoplastic enamel formation and errors in morphologic development. In addition, they provide maximum retention of the bridge. iv) In younger patients, preparations must be modified relative to the size of the pulp chamber. Retention pins and grooves should be used with care and should employ techniques that utilitize a minimal of tooth reduction and shoulder preparation. Slight infraocclusion in the cleft area can actually aid in construction of fixed prosthesis. Other fixed options are the use of endosseous implants, bonding/ porcelain veneer restorations, Maryland bridges when the pulp chambers are large and the root configurations of the abutment teeth are not ideal. An implant-supported restoration to replace the missing lateral incisor offers the following advantages17:

223

The 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.

b) Removable prosthesis: A removable prosthesis is preferred when there is a large anterior ridge defect and/or the middle third of the face is depressed. A cleft of the alveolus is generally associated with missing lateral incisor, crowded and poorly positioned teeth, which are sometimes hypoplastic. Furthermore, surgical scarring, the lack of orthodontic guidance, poor oral hygiene and dental disease impact the adult cleft lip and palate patient. Many of these patients have also lost (or never attained) adequate vertical dimension of occlusion. The fabrication of an interim diagnostic overlay removable partial denture at a substantially increased vertical dimension of occlusion may be surprisingly well tolerated. The non surgical technique to treat such patients involves the use of a maxillary overdenture or partial overdenture that establishes correct vertical dimension, replaces missing teeth, provides an esthetic result with appropriate lip support and may support a pharyngeal obturator. Chalian29 has described removable cleft palate prosthesis in ways I) - Snap-on type - Non snap-on type II) - Prosthesis incorporating a bulb - Prosthesis without bulb. Removable partial dentures: these are similar to those for non-cleft patients. The exception is for patients with velopharyngeal deficiencies, when the conventional prosthesis must support a palatal lift and/or obturator prosthesis. Adequate indirect retention is a must in Kennedys Class I and II situation especially due to the long lever arm of the pharyngeal extension, which becomes very difficult when only anterior teeth, remain. Also, in cleft palate patients it should be kept in mind, that when the primary palate has not been bone grafted, tortuous fistula like openings might remain, which are not overtly visible. These should be looked out for and plugged with petroleum jelly laden gauze before

224

impressions are made. Larger defects can be utilized for retention. Also surgically repaired clefts, show various degrees of scarring which may be unyielding. During fabrication of the partial dentures, the components should follow these ridges rather than crossing them and the cast should be beaded only minimally.

Since cleft palate deficiencies are interrelated, for example, when maxillary constriction occurs it is always associated with discrepancies in vertical dimensions. Missing and malformed teeth are related to the extent of the alveolar cleft, and consequently this defective condition is associated with both maxillary constriction and the discrepancy in vertical dimension. I) Maxillary Constriction: The degree of constriction is related to the severity of the forces imposed by the restricting cleft lip, and possible tissue deficiencies in the cleft area. A bilateral cleft will result in a cross bite relationship of the entire arch, except the molar areas. essentially to the immediate cleft area or cleft segment. II) Vertical Dimension: The lateral and anterior segments may not develop in the customary downward and forward direction, leading to decreased vertical dimension and associated over closure. There is thus an excessive inter-arch distance. When the patient is edentulous, this increases the disparity even further as the denture teeth must be positioned at a considerable distance both laterally and inferiorly from the maxillary foundation area and a Class III relationship is not uncommon. TYPE OF REMOVABLE PROSTHESIS: i) Overlay dentures: The position of maxillary cuspids and the anterior portion of each lateral segment determine the need for an overlay denture. A removable overlay is necessary if the cuspids are in an extreme linguoversion and do not occlude normally, or do not provide adequate support to the corners of the mouth. The constricted maxilla is overlayed in the horizontal plane by the flange labial and buccal to the patients own teeth or ridge. Such an extension establishes improved Whilst, unilateral cleft will result in constriction only on the cleft side and confined

225

tooth, labial and facial contour by positioning the artificial teeth to confirm with the lip and opposing mandibular teeth. Thus establishing an improved occlusion. The overlay flange should extend distally up to mesial aspect of the first molar as to enhance esthetics.

ii)

Complete maxillary dentures: An edentulous condition with associated maxillary constriction will increase the prosthetic management problem. Esthetic and lip support will require the denture teeth be positioned buccal/Labial to the edentulous ridge. A full maxillary denture must often support an obturator. With tissue changes and subsequent settling of the denture, the distal extension may function as a lever arm, which can contribute to denture stability. Yet, there is no alternative to complete prosthetic care. The best results are usually achieved by compromise only as the lack of a bony palate, poor alveolar ridge development, shallow depth of the palate, coupled with scarring in the posterior seal area and lip closure area further complicates the situation. The final impression should be made in light body elastomeric impression material in a custom tray after border moulding in low fusing impression compound. Due considerations should be give during border moulding procedure. Care should be taken in the labial reflex region to prevent overextension, especially in relation to the scar bands caused due to lip closure. The posterior palatal seal should not be established across heavily scarred tissue but should follow the creases or folds in the region. As the scar tissue can lead to rebound, only slight beading feathered anteriorly should be done instead of the butterfly pattern. Modification of the anterior tooth position and lip support accompanied with slight reduction of the vertical dimension is indicated. Occlusion without any lateral interferences and reduction of the weight of the restorations are mandatory for a successful prosthesis.

226

The palatal, lingual or pharyngeal tissues should not displace the obturator section. The patient should be instructed about frequent adjustments and relining procedure.

iii) Full coverage overdenture Patients remaining teeth should be protected with full crowns. By covering the crowned teeth with the prosthesis an improved vertical dimension of occlusion may be established. An occlusal splint or prosthesis should first be made to verify the new vertical relationship. tissue borne. Several methods for retaining full coverage overdenture are a) b) c) d) The use of denture acrylic in frictional resistance to the crown. Gold thimbles embedded within the denture base in conjunction with telescopic crowns. Cervical undercuts associated with full crown may also be utilized. Internal attachments. Chalian 29 has also described an unconventional speech aid prosthesis, which is made in two sections so that the patient can insert the nasal portion above the palatal shelves, using the undercut created by the right and left palatal bones. The posterior portion of this part is muscle trimmed like any other speech bulb till proper airflow and resonance balance are obtained. The denture portion is then inserted. The two portions interlock by means of the gold button placed in the denture. The gold button inserts into a soft acrylic area, which is elastic enough to allow the patient to insert and disengage at will. Magnets can also be used to retain the two portions. This type of prosthesis is both tooth and

227

Rehabilitation of patients with maxillofacial defects is not merely a post treatment eventuality. It is a complex interaction of the patient with a variety of health professionals, the main objective being restoration of bodily and psychic function to optimum potential and to prevent additional dysfunction and inconvenience. Rehabilitation involves concern for the patient as a person, as well as for the patients social well being. It implies, extending to the patient and the family and friends all available resources. The maxillofacial prosthodontist normally provides appliances and devices to restore esthetics and functions, to the patient who cannot be restored to normal appearance or function by means of plastic reconstruction. The prosthodontist may also be called upon to treat patients who are at poor surgical risks for extensive plastic surgical procedures. Rehabilitation of these patients is a challenging task and should stress upon the psycho-dynamic interactions of health professionals with the patient and significant persons in the patients life Problems associated with the patients needs and special consideration for prosthesis, potential changes in inter-personal relationships, identification problems, mutilations, employment, special work considerations, stress and strain of physical impairment, social relationships, the face of death, the potential loss of sight, speech and other important functions; all augur against assuming that the patient can take, the trauma all-alone. The most commonly occurring maxillofacial defects are the clefts of the hard and soft palate. The prosthetic means of correcting these defects comprises essentially of two forms of appliances i.e. the obturator and the artificial velum. The literature suggests various types of designs, methods of fabrication and materials in the fabrication of these prostheses. This discussion hereby makes an attempt to throw light on prosthetic philosophies and procedures in rehabilitating these patients. Prosthodontic principles form the basis of all procedures albeit with a few modifications to suit the needs of the situation. The partially dentulous patient with a palatal defect is treated with a definitive prosthesis, which is basically a removable partial denture with an obturator extension. The design philosophy for the partially dentate patient is based on the works of Aramany
7,8

and Desjardins

40

. The tripodal design is

228

favoured over the linear design, with multiple support regions to transfer the stresses. The presence of a large defect with little support gives rise to a greater lateral torquing force. Desjardins suggested the use of a retainer as close to the defect and as far from it as possible. Taylor 135 has modified this slightly and has advocated that one retainer should be located as close to the defect but the second retainer should be as far apart from the first retainer as possible. Aramany has advocated the use of bilateral retention but Taylor has suggested using large guide planes to compensate for the lack of cross arch stabilization. The use of bonded metal or composite contours or crowns can be fabricated and used effectively if the contours of the natural dentition are not ideally suited for these guide planes. In implant supported obturator prosthesis the following outlines as suggested by Beumer & Curtis17 should be considered. If the entire premaxilla remains the number of implants, distribution and design of retention bar follows conventional prosthodontic principles.If only 2 implants are placed , one each in canine region a Hader bar design is used. If 4 or more implants are used. The support is provided posteriorly by the residual denture bearing surfaces and anteriorly by the implants. The attachments connected to the distal portion of the bar allow for the compression of the distal extension area of the prosthesis into the denture bearing area without applying excess torquing force onto the implants. If 6 or more implants are used and the antero-posterior spread is greater than 2 cm, the overlay obturator prosthesis can be designed so that occlusal forces are primarily supported by the implants. Retention of the prosthesis is vital. Ambroise Pare to obtain mechanical retention. Pierre Fauchard
28 28

is considered

to be the first to design an obturator. He used a sponge and a turnbuckle also used winged turnbuckles. In the dentate patient interdental wiring retains the surgical obturator while circumalveolar or circumzygomatic wiring, bone screws and sutures are used in the edentulous condition. In the definitive prosthesis in partially dentate patient casted retainers need to be used while wrought wire clasps can be used for the interim prosthesis. Chalian 29, Roberts also mention the use of intermaxillary or George Washington springs and swivels. Swing lock design with multiple retentive bar clasps can be used as described by Javid & Dadmanesh63 or in combination with conventional

229

retainers as described by Marunick80. Innovative means like utilizing the anatomical undercuts by inflatable balloons has been advocated by Payne & Welton105 and Coffey33. Brown
23

has advocated the buttressing the

lateral border of the obturator against the skin graft and placing it as high and as far away as possible from the rotational path and utilizing the undercut created at the junction of the split skin graft and the mucosa junction. In a young cleft palate patient where an interim obturator or speech-aid prosthesis is required, retention can be gained by soldering a buccal tube (lugs) or an orthodontic bracket to a band or stainless steel crown under which an extended arm wrought wire clasp is given. This is required, as deciduous teeth do not offer enough undercuts and clinical height to use conventional clasps. Magnets (samarium cobalt) can be effectively used to provide retention for an obturator segment to the main denture in a sectional prosthesis as described by Boucher21 and Matsumura et al 83. Use of an overlay (telescopic) crown or a thimble can also be used for overdentures. Also a Baker/Anderson bar with a clip attachment is used for a snap-on prosthesis29. Use of precision and semi-precision attachments provide an aesthetic means of retention and no reciprocal arm is required. Resilient ERA attachment have been favoured especially in implant retained prosthesis but care should be taken for controlling the axis of rotation.17 The weight of the prosthesis is crucial and hence bulky areas should be hollowed out to reduce weight so that teeth and supporting tissues are not stressed unnecessarily especially when the obturator prosthesis is suspended without bony or posterior tooth support on the defect side. Wu and Schaaf153 have found that hollowing the obturator prosthesis reduces weight by 7-33% depending on the size of the defect. The superior surface can either be left open or closed. Clinicians who prefer closed top state that if the obturators are left open, nasal secretions accumulate leading to bad odour and added weight29. Advantages of leaving the top open are that the weight of the obturator is further reduced as there is no lid, it is easier to adjust and speech is better. The effect of length of extension into the defect and top configuration (open/closed) was studied by Aramany and Drane (1972) and Oral96; and they found that the speech quality using the limited

230

extension prosthesis was better than with the maximally extended obturator prosthesis. The lengthy superior extension along the lateral and disto lateral aspect of the defect is essential for stability, support and retention. If a lid is added to the hollow obturator, the obturator bulb occupies significant portions of the nasal and maxillary sinus cavities. Hence, if a closed bulb is used, it may change the configuration, resonance balance and airflow characteristics of the nasal cavity. The voice quality achieved with a closed hollow obturator is inferior to the open obturator96. The open obturator design may be less obtrusive in the nasal cavity and permits more normal airflow, nasal resonance and speech. Beumer and Curtis17 advocate the open top obturator. A drainage channel for the collected secretions may be made. It is a diagonal opening in the inferolateral floor of the open obturator through the cheek surface for drainage154. Removable lids can also be placed on the hollow section to prevent this accumulation106 Often, patients need an extraoral prosthesis, in addition to an intraoral prosthesis. The closed hollow obturator benefits these patients by allowing the attachment of intraoral and extraoral prosthesis to each other, thus providing additional retention and stability. Many methods have been used to fabricate a lightweight, closed hollow obturator. A lot of materials have been used to fill the space in the flask to act as a support to pack the base of the hollow bulb. These include paper clip attached stone (Nififfer & Shipman92), modeling compound (Roberts
29

), sugar (Matalon & Lafeunte82), ice (Schneider122), silicone

putty (Jhanji64) and plaster-pumice combination (Blair20). Chalian & Barnet30 described the fabrication of a one-piece closed hollow obturator by using an acrylic resin shim, while Ohyama et al93 used an acrylic resin case as a scaffold for a silicone closed hollow obturator. Fabrication of closed hollow obturator by using sections of interchangeable flasks was described by Bown24, ElMahdy45 and modified by McAndrew et al86. Beder11 used pour type fluid resin technique to fabricate emergency obturator and Browning26 described the fabrication of a hollow obturator using fluid resin to allow precise control over the thickness of the resin for minimal weight but sufficient thickness so as to allow adjustment if necessary.

231

The use of silicone as an obturator bulb has been described by a lot of authors. It offers the advantages or flexibility, which allows more engagement of undercut and is less damaging to the frail tissues in the defect region. However, it is subject to fungal infiltration and needs to be changed frequently. Boucher21 used silastic bulb attached to the main prosthesis by magnets while Hahn54 used an acrylic insert in the denture to attach the silicone bulb. Wood & Carl151 used flexible impression trays and fabricated silicone obturator. Taicher et al133 used polydimethyl siloxane obturators in patients with severe trismus and unyielding tissue. Vacuforming machines can be used to fabricate immediate surgical obturators.43,70 The use of visible light cured resin has been described. It is definitely the material for the future as it is very easy to use, it reduces the laboratory steps, it is dimensionally accurate, even more than heat-cured resin due to the absence of the monomer content. Soft Palate obturation has been done in three different ways. The fixed horizontal obturator has been found to be the most effective while the meatus obturator is best for edentulous patients with total soft palate defects. The hinge type pharyngeal obturators do not find much favour due to the difficult fabrication, greater weight and reduced efficiency. Gibbons and Bloomer first described palatal Lift prosthesis. Its use still remains controversial. The literature has sufficient number of protagonists to indicate that the palatal lift prosthesis is capable of offering benefits. In fact, its use has also been associated with the stimulation of muscle activity leading to reducing the incompetency leading to a situation, where it is not required. With the increased availability of the advanced diagnostic aids, the procedure even though complicated can be carried out for the benefit of the patient. The treatment of Cleft lip and palate patients has reached a stage where the team approach of all specialties has been universally acknowledged. The use of presurgical orthopedics since its introduction by McNeil in 1950 is gaining favour due to highly esthetic results and ease of surgical technique. The advances in surgical technique with vascularized bone containing flaps, the acceptability of implants on radiated sites, use of accessory sites like zygoma for implants have revolutionized the reconstruction and

232

rehabilitation. Its widespread use will provide the quality of life for the patients that we as maxillofacial prosthodontics strive to achieve.

Rehabilitation of patients with maxillofacial defects has always remained an enigma for the prosthodontist due to the unpredictable nature of the defects and uncertainty of recurrence.

233

An attempt has been made to review to prosthetic aspects of the rehabilitation of the patients with palato- maxillary defects with a strong emphasis on the understanding of the anatomical and physiological considerations and the psychosocial well being of the patient. The rehabilitation is not merely by closing a defect with prosthesis but goes much beyond that. To reach these goals a multidisciplinary approach needs to be adopted Although, the advances in materials have been remarkable, the subspecialty has not reached its full potential. There is thus, a need of for prosthodontists to take interest and involve them in this endeavour to rehabilitate these patients to feel and function normally and integrate back in society with confidence.

Bibliography 1. Ackerman A.J. Prosthetic management of oral and facial defects following cancer surgery. J Prosthet Dent: 1955; 5:413-432 2. Adisman KI. Removable partial dentures for jaw defects of maxilla and mandible. DCNA 1962:849-870 3. Adisman KI, Laney WR; Minimum acceptable laboratory procedures for maxillofacial prosthesis. J Prosthet Dent: 1972; 27:91-93 4. Ampil JP, Ellinger CW, Rahn AO. A temporary prosthesis for an edentulous patient following maxillary resection. J Prosthet Dent: 1967; 17:88-91

234

5. ApplemanRM; Prosthetic repair of defects of maxilla resulting from surgery. J Prosthet Dent: 1951; 1:424-438 6. Aram A, SubtelnyJD; Velopharyngeal function and cleft palate prosthesis. J Prosthet Dent: 1959; 9:149 7. Aramany MA; Basic principles of obturator design for partially edentulous patients. Part I: Classification. J Prosthet Dent: 1978; 40:554-557 8. Aramany MA; Basic principles of obturator design for partially edentulous patients. Part II:Design principles. J Prosthet Dent: 1978; 40:656-662 9. Bailey LW, Edwards D; Psychological considerations in maxillofacial prosthetics. J Prosthet Dent1975; 34:533-538 10. Bardach J, Morris HL; Multidisciplinary management of Cleft lip and palate. 1990- WB Saunders. 366-377 11. Beder OE; Emergency temporary obturators. J Prosthet Dent 1968; 20: 172-175 12. Beery QC, Aramany MA, Katzenberg B; Oral endoscopy in the prosthodontic management of the soft palate defect. J Prosthet Dent: 1985; 54:241-244 13. Bell WT, Chalian VA, Moore K; Polydimethyl silicone materials in maxillofacial prosthetics: Evaluation and comparison of physical properties. J Prosthet Dent: 1985; 54:404-410 14. Benington IC, Clifford T; an injection impression technique for palatal defects. J Prosthet Dent: 1982; 47:414-418; Light Cured obturators. J Prosthet Dent:1989;62:322-5 15. Berkowitz S. Cleft Lip and Palate: Perspectives in management. With an introduction to other craniofacial anomalies. Volume I; 189-194 16. Berkowitz S. Cleft Lip and Palate: Perspectives in management. With an introduction to other craniofacial anomalies. Volume II 17. Beumer J III, Curtis TA, Marunick MT; Maxillofacial Rehabilitation: Prosthodontic and surgical considerations; Ishiyaku-America Publishers; 2nd Edition; 1-22,225-370,387-399 18. Birnbach S, Barnhard B; Direct conversion of a solid obturator to a hollow prosthesis. J Prosthet Dent: 1989; 62:58-60 19. Black WB: surgical obturation using a gated prosthesis. J Prosthet Dent: 1992; 68:339-342 20. Blair FM,Hunter NR; The hollow box maxillary obturator. BDJ 1998, Vol 184,No 10,484-487

235

21. Boucher LJ. Prosthetic restoration of maxilla and associated structures. J Prosthet Dent: 1966; 16: 154-168 22. Brosky ME,Lee C,Bartlett S, Los; Fabrication of a radiation bolus prosthesis for the maxillectomy patient. J Prosthet Dent: 2000:83:119-121 23. Brown KE. Peripheral considerations in improving obturator retention. J Prosthet Dent: 1968; 20: 176-181 24. Brown KE. Fabrication of hollow bulb obturator. J Prosthet Dent: 1969; 21: 97-103 25. Brown KE. Clinical considerations for improving obturator treatment. J Prosthet Dent: 1970; 24: 461-466 26. Browning JD, Kinderknecht J; Fabrication of hollow obturator with fluid resin. J Prosthet Dent: 1984; 52: 891-895 27. Buckner H. construction of denture with hollow obturator, lid and soft acrylic lining. J Prosthet Dent: 1974; 31: 95-99 28. Bulbulian AH; Maxillofacial Prosthetics: Evolution and practical application in patient rehabilitation. J Prosthet Dent 1965; 15:554-569 29. ChalianVA, 158,358-424 30. Chalian VA, Barnett BO. A new technique for constructing a one piece hollow obturator after partial maxillectomy. J Prosthet Dent: 1972; 28: 448453 31. Chambers MS,Lemon JC, Martin JW; Obturation of the partial soft palate defect. J Prosthet Dent: 2004; 91:75-79 32. Chierici G, Lawson L; Clinical speech considerations in prosthodontics: perspectives of the prosthodontist and speech pathologist. J Prosthet Dent: 1973; 29-39 33. Coffey KW; Obturation of congenital or acquired intraoral anatomic defects. J Prosthet Dent: 1984; 52:559-560 34. Cotert HS,Cura C; Modified flasking technique for processing a maxillary resection obturator with continuous pressure injection. J Prosthet Dent: 2001; 86:438-440 35. Curtis Ta, Taylor RC, Rositano SA; Physical problems in obtaining records of the maxillofacial patient. J Prosthet Dent: 1975; 34:539-554 36. DaBreo El,Ghalichebaf M; Provisional restoration for a patient with cleft lip and palate: A clinical report. J Prosthet Dent: 1990; 63:119-121 Drane JB, Standish SM; Maxillofacial ProstheticsMultidisciplinary Practice; Williams & Wilkins1971; 1-13,89-121; 133-

236

37. DaBreo EL; light cured interim obturator prosthesis. A clinical report. J Prosthet Dent: 1990; 63:371-373 38. DaBreo EL; Dimensional change in maxillary prosthetic obturators. J Prosthet Dent: 1991; 66:669-673 39. Dalston RM; Prosthodontic management of cleft palate patient: a speech pathologists view. J Prosthet Dent: 1977; 37:190-195 40. Desjardins RP; Obturator prosthesis design for acquired maxillary defects. J Prosthet Dent: 1978; 39: 424-435 41. DexterWS, Jacob RF; Prosthetic rehabilitation after maxillectomy and temporalis flap reconstruction. A clinical report 42. Didier M, Laccoureye O,VignonM; New surgical obturator prosthesis for hemimaxillectomy patients. J Prosthet Dent: 1993; 69:520-523 43. Disantis WS; Quick technique for construction of surgical obturator. J Prosthet Dent: 1985; 53:128-1129 44. Donald ET; Speech considerations in cleft palate patients. J Prosthet Dent: 1951; 1:629-637 45. El Mahdy AS. 22:682-686 46. Esposito SJ, Mitsumoto H, Shanks M; Use of palatal lift and palatal augmentation prosthesis to improve dysarthria in patients with Amyotrophic lateral sclerosis: A case series. J Prosthet Dent: 2000; 83:90-98 47. Gardner LK, Parr GR, Rahn AO; Combination nasal support breathing flange with hollow obturator prosthesis: A clinical report. J Prosthet Dent: 1990; 63:497-501 48. Gardner LK, Parr GR, Rahn AO; Simplified technique for the fabrication of a hollow prosthesis using vinyl polysiloxane. J Prosthet Dent: 1991; 66:6062 49. Gay WD, King GE; Applying basic prosthodontics principles in dentulous maxillectomy patients. J Prosthet Dent: 1980; 43:433-435 50. Gaylord J;Cleft palate restoration: An interpretation of the Fitz Gibbon technique. J Prosthet Dent: 1951; 1:268-286 51. GibbonsP, Bloomer HH; A supportive type prosthetic speech aid. J Prosthet Dent: 1958; 8: 363-369 52. Groetsema WR; an overview of the maxillofacial prosthesis as a speech rehabilitation aid. J Prosthet Dent: 1987; 57:204-208 53. Habib BH,Driscoll CF;Fabrication of a closed hollow obturator. J Prosthet Dent: 2004; 91:383-385 Processing a hollow obturator. J Prosthet Dent: 1969;

237

54. Hahn GW. A comfortable silicone bulb obturator with or without dentures. J Prosthet Dent: 1972; 28: 313-317 55. Hammond; Dental care of edentulous patients after resection of maxilla. BDJ 1966; 120:591 56. Huryn JM, Piro JD; The maxillary immediate surgical obturator prosthesis. J Prosthet Dent: 1989; 61:343-347 57. Immekus JE, Aramany MA; A fixed- removable partial denture for cleft palate patients. J Prosthet Dent: 1975; 34:286-291 58. Ismail JY, Zaki HS; Osseointegration in Maxillofacial prosthetics. DCNA April 1990,Vol34, No.2, 327-341 59. Jacob RF, Martin JW, King GE; Modification of surgical obturators to interim prostheses. J Prosthet Dent: 1985; 54:93-95 60. Jacob RF, King G; Indirect retainers in soft palate obturator design. J Prosthet Dent: 1990; 63:311-5 61. Jacob RF,Yen TW; Processed record bases for the edentulous maxillofacial patient. J Prosthet Dent: 1991; 65:680-685 62. Jacob RF; Duplication of interim speech aid for definitive impression tray fabrication. J Prosthet Dent: 1992; 68:561-562 63. JavidNS, Dadmanesh J; Obturator design for hemi maxillectomy patients. J Prosthet Dent: 1976; 36:77-81 64. Jhanji A,Stevens ST; Fabrication of one piece hollow obturators. J Prosthet Dent:1991;66:136-138 65. Kaplan P; Palatal contour guide for positioning retentive framework for obturation for a hemi maxillectomy patient. J Prosthet Dent: 1992; 62:715716 66. Karnell MP, Rosenstein H, Fine L; Nasal videoendoscopy in prosthetic management of palatopharyngeal dysfunction J Prosthet Dent: 1987; 58:479-484 67. King GE, Martin JW; Cast circumferential and wire clasps for obturator retention. J Prosthet Dent: 1983; 49:799-802 68. Khan Z;Soft palate obturator prosthesis made in visible light cure resin. J Prosthet Dent::1989;62:671-673 69. Kloeffler GD; A report on maxillary orthopedics in cleft palate treatment. J Prosthet Dent:: 1970;23:227-231 70. Kouyoumdjian JH,Chalian VA; An interim obturator prosthesis with duplicated teeth and palate. J Prosthet Dent: 1984; 52:560-562 71. Lang; Modification of palatal lift speech aid. J Prosthet Dent: 1967; 17: 216

238

72. Lavelle

WE,

Hardy

JC;

Palatal

lift

prosthesis

for

treatment

of

palatopharyngeal incompetence. J Prosthet Dent: 1979; 42:308-315 73. Lazzari JB; A prosthetic closure of a traumatic palatal perforation. J Prosthet Dent: 1952; 2:831-833 74. LeonardRJ; Computerized design of speech prosthesis. J Prosthet Dent: 1991; 66:224-230 75. Light J; Functional assessment testing for maxillofacial prosthetics. J Prosthet Dent: 1997; 77:388-93 76. Lontz JF; State of the art materials used for maxillofacial prosthetic reconstruction. DCNA April 1990;vol 34,no.2, 307-325 77. Mac Carthy D, Murphy N; Replacement of an obturator section of an existing two-piece implant retained edentulous obturator. J Prosthet Dent: 2000; 83:652-655 78. Mahanna GK,Berkellman DF, Marshal JA,Sullivan M; Obturator prosthesis after cancer surgery. An approach to speech outcome analysis. J Prosthet Dent: 1998; 79:310-316 79. Marshall RC,Jones ; effects of palatal lift prosthesis upon speech intelligibility of a dysarthric patient. J Prosthet Dent: 1971; 25:327-333 80. Marunick M; Hybrid gate design frameworks for the rehabilitation of the maxillectomy patient. J Prosthet Dent: 2004; 91:315-318 81. Masumi S, Miyake S, Kido, Toyoda; Use of a sectional prosthesis following partial maxillary resection. A clinical report. J Prosthet Dent: 1990; 64:401403 82. Matalon V, La Feunte H; A simplified method for making a hollow obturator. J Prosthet Dent: 1976; 36: 580-582 83. Matsumura H,Kawasaki K; Magnetically connected removable sectional denture for a maxillary defect with severe undercut: A clinical report. J Prosthet Dent: 2000; 84:22-26 84. Mauk EH; Cleft palate prosthesis: American textbook on prosthodontics. Pg-863-912 85. Mazaheri M, Mazaheri EH; Prosthodontic aspect of palatal elevation and palatopharyngeal stimulation. J Prosthet Dent: 1976; 35: 319 86. McAndrew KS, Rothenberger S, Minsely GE; An innovative investment method for the fabrication of closed hollow obturator prosthesis. J Prosthet Dent: 1998; 80:129-132 87. Miglani DC, DraneJ; Maxillofacial prosthesis and its role as a healing act. J Prosthet Dent: 1959; 9:159-168

239

88. Minsely GE, Nelson DR, Rothenberger; an alternative method for fabrication of a closed hollow obturator. J Prosthet Dent: 1986; 55:485-490 89. Minsely GE,Warren DW, Hairfeild WM; The effect of cleft palate speech aid prosthesis on nasopharyngeal airway and breathing. J Prosthet Dent: 1991; 65: 122-126 90. Morton BC, Trabae JC; Congenital cleft of the palate. J Prosthet Dent::1952;2:557-561 91. Moore DJ,Pishney JR, welsh TB; Comparison of rigid and flexible obturation for the surgical cleft of the soft palate. J Prosthet Dent: 1985; 54:548-552 92. NififferTJ, Shipron TH; hollow bulb obturator for acquired palatal opening. J Prosthet Dent: 1957; 7:126-134 93. Ohyama T, Gold HO, Pruzansky S; Maxillary obturator with silicone lined hollow extension. J Prosthet Dent: 1975; 34:336-341 94. Okay DJ, Genden E, Buchbinder D; Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent: 2001; 86:352-363 95. Olinger NA; Cleft palate prosthesis rehabilitation. J Prosthet Dent: 1952; 2:117-135 96. Oral K; Construction of a buccal flange obturator. J Prosthet Dent: 1979; 41: 193-197 97. Palmer JM; Analysis of speech in prosthodontic practice. J Prosthet Dent: 1974; 31: 605-614 98. Palmer B, Coffey KW; Fabrication of the hollow bulb obturator. J Prosthet Dent: 1985; 53:595-596 99. Parel SM, Drane JB; Prosthetic support of the visual apparatus following maxillectomy and orbital floor resection. J Prosthet Dent: 1975; 34:329-333 100. Parel SM, Branemark PI, JanssonT ; Osseointegration in maxillofacial prosthetics. Part I: Intraoral applications. J Prosthet Dent: 1986; 55:490-494 101. Parel SM,Branemark PI, Ohrnell Lo,Svensson B; Remote implant anchorage for the rehabilitation of maxillary defects. J Prosthet Dent: 2001; 86:377-381 102. Parr GR; A combination obturator. J Prosthet Dent: 1979; 41: 329 103. Parr GR, Tharp G, Rahn AO; Prosthodontic principles in the framework design of maxillary obturator prostheses. J Prosthet Dent: 1989; 62:205-212

240

104. Parr GR, GardnerLK; The evolution of the obturator framework design. J Prosthet Dent: 2003; 89:608-610 105. Payne AGL, Welton WG. An inflatable obturator for use following maxillectomy. J Prosthet Dent: 1965; 15:759-763 106. Phansokol P, Martin JW; Hollow obturator with removable lid. J Prosthet Dent: 1985; 54: 98-100 107. Philip C; orthodontic management of congenital cleft palate patient. DCNA April 1990,Vol34, No.2, 343-359 108. Pigno MA, Funk BS; Augmentation of obturator retention by extension into the nasal aperture. J Prosthet Dent: 2001;85:349-351 109. Pigno 86:578-581 110. Polyzois GL; Light cured combination obturator prosthesis. J Prosthet Dent: 1992; 68:345-347 111. Pomerantz JM, Zimmerman DE; The use of non-parallel canine abutments for a tissue bar overdenture obturator. J Prosthet Dent: 1982; 47:194-197 112. Rahn AO, Boucher LJ; Maxillofacial Prosthodontics: Principles & Concepts; WB Saunders1970; 1-17,83-112,188-227 113. Rahn AO,Goldman BM,Parr GR; Prosthodontic principles in surgical planning for maxillary and mandibular resection patients. J Prosthet Dent: 1979; 42:429-433 114. Ramsey WO; Terminology applicable to palatal lift prosthesis. J Prosthet Dent: 1983; 49:680-684 115. Reisberg DJ, Smith BE; Aerodynamic assessment of prosthetic speech aids. J Prosthet Dent: 1985; 54:686-690 116. Riley C; Treatment obturator for the edentulous patients. J Prosthet Dent: 1970; 24:312-319 117. RiloB, Martinez-InsuaA, Santana; titanium and visible light polymerized resin obturator. J Prosthet Dent: 2002; 87:407-409 118. Robinson JE. Prosthetic treatment after surgical removal of maxilla and floor of orbit. J Prosthet Dent: 1963; 13:178-184 119. Roumanous ED, Nishimura RD, Davis, Beumer J III; Clinical evaluation of implants retaining edentulous maxillary obturator prostheses. J Prosthet Dent: 1997; 77:184-190 120. Sato Y, Sato M,Yoshida; Palatal cleft prosthesis for edentulous patients. J Prosthet Dent: 1987; 58: 206-210 MA;Conventional prosthetic rehabilitation after free flap reconstruction of a maxillectomy defect: A clinical report. J Prosthet Dent: 2001;

241

121. Schmaman J,Carr L; A foam impression technique for maxillary defects. J Prosthet Dent: 1992; 68:342-344 122. Schneider A ; Method of fabricating a hollow obturator. J Prosthet Dent: 1978; 40 : 351 123. SchwartzmanB,Caputo A, Beumer J; Occlusal force transfer by removable partial denture designs for a radical maxillectomy. J Prosthet Dent: 1985; 54:397-403 124. Sharry JJ; Meatus obturator in particular and pharyngeal impressions in general. J Prosthet Dent: 1958; 8:893 125. Sharry JJ; Complete Denture Prosthodontics; McGraw Hill Book Company;343-356 126. Shifman A; A technique for the fabrication of an open obturator. J Prosthet Dent 1983; 50:384-385 127. Shifman A; Clinical applications of visible light cured resin in maxillofacial prosthetics. Part I Denture base and reline material. J Prosthet Dent: 1990; 64:578-582 128. Shifman A; Clinical applications of visible light cured resin in maxillofacial prosthetics. Part II Tray material. J Prosthet Dent: 1990; 64:695-699 129. Shifman A,Finkelstein Y,Nachmani, Ophir; Speech aid prosthesis for neurogenic velopharyngeal incompetence. J Prosthet Dent: 2000; 83:99-106 130. Shimodaira K, Yoshida H, Funakabo T; Obturator prosthesis conforming to the movement of the soft palate: A clinical report. J Prosthet Dent: 1994; 71:547-551 131. Sigurgeissdoiter E,Minsely GE, Rothenberger SL; Incorporation of an ERA attachment for obturator framework. J Prosthet Dent: 2002; 87:477-480 132. Spratley MH, Cheney HJ, Murdoch BE; A different design of palatal lift appliance. Review and case reports. Aust Dent J 1988; 33:491-495 133. Taicher S, Rosen AG, Arbree NS, Bergen SF; A technique for fabrication of polydimethylsiloxane acrylic resin obturator. J Prosthet Dent: 1983; 50: 65-68 134. Tapia G, Casey D, Schaaf NG; Conversion of an interim into a definitive speech aid: a predictable approach. J Prosthet Dent: 2002; 87:106-109 135. Taylor TD; Clinical maxillofacial Prosthodontics; Quintessence 2000; 115,85-155 136. Taylor TD, desjardins RP; Construction of the meatus type obturator: Its advantages and disadvantages. J Prosthet Dent: 1983; 49:80-84

242

137. Tobey EA, Lincks J; Acoustic analyses of speech changes after maxillectomy and prosthodontic management. J Prosthet Dent: 1989; 62:449455 138. Toremalm NG. A disposable obturator for maxillary defects. J Prosthet Dent: 1973; 29: 94 139. Torn DB; Speech and cleft palate: Partial denture prosthesis. J Prosthet Dent: 1952; 2:412-417 140. Turner GE, Williams WN, Fluoroscopy and nasoendoscopy in designing palatal lift prosthesis. J Prosthet Dent: 1991; 66:63-71 141. Vojvodic D, Jerolimov V, CelebicA. Prosthetic rehabilitation of a cleft palate patient: a clinical report. J Prosthet Dent: 1996; 76:230-232 142. Walter JD; Palatopharyngeal activity in cleft palate subjects. J Prosthet Dent: 1990; 63:187-192 143. Wang RR;Sectional prosthesis for total maxillectomy patients: A clinical report. J Prosthet Dent: 1997; 78:241-244 144. Wang RR, Hirsch RF; Refining hollow obturator base using light activated resin. J Prosthet Dent: 1997; 78:327-329 145. Wang RR; Thermoplastic resin used to modify an alveolar orthopedic prosthesis in-patient with cleft lip before cheiloplasty: a clinical report. J Prosthet Dent: 1998; 79:613-6 146. Warren DW; Physiologic approach to cleft palate prosthesis. J Prosthet Dent: 1965; 15: 770-778 147. Watson RM, Gray BJ; assessing effective obturation. J Prosthet Dent: 1985; 54:88-93 148. Williams DR; An impression technique following hard palate repair using tongue grafts. J Prosthet Dent: 1991; 65:424-427 149. Witt PD, Marsh JL, Grames LM,Gay DW; Management of hypo dynamic velopharynx. Cleft Palate- Craniofacial Journal-1995, 32,179-186 150. Wolfaardt JF, Wilson FB, Rochet A,, Mc Phee L: An appliance based approach to the management of palatopharyngeal incompetency: a clinical pilot project. J Prosthet Dent. 1993 Feb; 69: 186-95. 151. Wood RH, Carl W; Hollow silicone obturator for patients after total maxillectomy. J Prosthet Dent: 1977; 38: 643-651 152. Worley Jl, Kniejsky ME; A method of controlling the thickness of hollow obturator prosthesis. J Prosthet Dent 1983,50:227-229 153. Wu Y, Schaaf N; Comparison of weight reduction in different designs of solid and hollow obturator prostheses. J Prosthet Dent: 1989; 62:214-217

243

154. Zaki HS; Modified bypass in the maxillary hollow bulb obturator. J Prosthet Dent: 1980; 43: 320- 321 155. Zarb GA. Maxillary resection and its prosthetic replacement. J Prosthet Dent: 1967; 18: 268 156. Ziada HM, Donovan SO; Procedure for reducing the vertical height of a hollow box interim obturator. J Prosthet Dent: 2000; 83:58

244