Maxillofacial Notes DR - Mahmoud Ramadan

Maxillofacial Prosthodontics
Short Notes
By
Dr. Mahmoud Ramadan

1st Edition
2010
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Table of contents
Page
Subject
Table of Contents.
Objectives of maxillofacial prosthesis.
Types of maxillofacial defects.
Maxillofacial team.
Diagnosis and treatment planning .
Congenital cleft palate.
20
Congenital cleft palate.
31
Maxillofacial Splints.
40
Maxillofacial Stents.
58
Radiation and Radiotherapy prosthesis.
63
Acquired Mandibular Defects.
71
Facial Impression.
73
Nasal Prosthesis.
76
Occular Prosthesis.
79
Cranial Prosthesis.
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Dr. Mahmoud Ramadan
Introduction
Objectives of maxillofacial prosthetics :
1. Improve or restore the esthetics or cosmetic appearance of the patient which is of prime
importance for every body .
2. Improve or restore the functions that include :
a. Speech function in patients with cleft palate .
b. Nutritional function in patients with lost parts of the jaw .
c. Avoid the escape of food to the nasal cavity . In children with cleft palate trying to
overcome the feeding problem and help to maintain the child general health .
3. Protect the tissues :
To protect the adjacent tissues as in the radium protective shield , also to protect wound , stop
bleeding and carry medicaments after surgery . In contact sport mouth guards are used to
protect the teeth against possible injuries .
4- Therapeutic or healing effect :
Placement of appliances such as the radium needle , carrier stents and splints which are used to
aid and promote the healing process .
5- Psychologic therapy :
To raise the morale of the patient which is very important for such type of patient .
Essentials of maxillofacial Prosthesis:

The maxillofacial appliance must meet certain requirements :
1- The appliance must be easily seated in place comfortably and securely as mush as possible .
2- The appliance must be durable and easily cleaned .
3- The material used must be easily adjusted and altered if needed .
To attain these goals each patient must be treated individually .
Types of Maxillofacial defects :

There are three types of maxillofacial defects .
I.
Congenital :- e.g. cleft palate , cleft palate , cleft lip , missing ear , prognathism .
II.
Acquired : Accidents , surgery , pathology .
III.
Developmental : Prognathism , Retrognathism .
Classification of Maxillofacial Restorations :

Maxillofacial restorations can be classified into different groups or phases according to its site
into :
I Intra oral restorations :
a. Obturators :
Used in patients with congenital or acquired cleft palate .
b. Stents :
Used in different forms e.g. Antihoemorrhagic stent , mouth protectors and Radium carriers .
c. Splints :
Used in cases of fractures to hold fragments .
d. Resection Appliance :
Used in cases of mandibular defects to correct its continuity ( closure of the mandible ) .
II. Extra oral restorations :
a. Radium shield : Used in cases of radiation treatment to protect unaffected areas .
b. Restoration of missing eye , missing nose or missing ear .
c. Ear plugs for hearing aids .
III. Combined intra Oral and extra oral restorations :
Used in case where there is lost part of the maxilla or mandible with the facial structures .
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IV. Cranial and facial restorations :

a. Cranial onlays & Inlays : used in cranioplasty to compensate for lost cranial bone due to
skull injury .
b. Intra mandibular implants : used to restore lost part of mandibular bone with acrylic
or metal part .
Maxillofacial team :
Team is a group of people working to achieve certain purpose . The members of the team must
cooperate in every way to fulfill their goal :
The member the team furtria as a unit .
The maxillofacial prosthodontist serves primarily as a member of a team and must cooperate
with the other members in planning rehabilitative treatment for patients with maxillofacial
defects ( The members of the team function as a unit ) . Every member should have some
knowledge in other specialties .
Members of the maxillofacial team :
1- Plastic Surgeon :
Plays the most important part when surgical correction and rehabilitation of the deformity is the
proposed and favorable line of treatment . Correction of hare lip is usually done surgically . Also
correction of congenital palatal defects is done surgically in most cases .
2- Speech therapist :
The speech therapist plays an important role in rehabilitating patients with maxillofacial defects
. He often works closely with the prosthodontist in the design and fabrication of the appliance .
The responsibility of the speech therapist is great and is essential after surgery or prosthetic
restoration . The patient must be trained to articulate the words normally .
3- Radiotherapist :
Treating cancer of the oral regions with radiation or radio agents requires close cooperation
between the radiotherapist and the dentist . Radium source carriers are often required to control
the radiation at the site of the lesion radiation is sometimes combined with surgery .
4- Dental specialists :
A. Prosthodontist :
In inoperable cases , prosthetic appliance may be the only way to help in rehabilitation of facial
injury . When surgery is contraindicated or failed and when surgery is postponed for some time ,
prosthetic management is called for . The prosthodontist should be the most knowledgeable
member of the team charged with management of the patient , not only about the actual
mechanics and construction of the prosthetic device but also about disease under treatment . The
prosthodontist relationship with the oral surgeon must be intimate to be able to offer better
service to the patient . One of the common situations in which the oral surgeon needs the help of
the prosthodontist is in the design and fabrication of immobilization appliances for jaw
fractures.
B. Orthodontist :
Plays an important role and he is almost invariably required in management of malocclusion in
cleft lip and palatal cases . In such situations the child must be checked orthodontically especially
in the period of mixed dentition .
C. Oral surgeon :
An important of the team for treatment and also for planning the steps for rehabilitation . Also
he may be called upon for any extractions in the field of irradiation .
D. Dental technician :
For the construction of various maxillofacial and surgical prosthesis . Dental technician needs
special skill and training .
E. Other dental specialists :
1- Pathologist will be of value in the diagnosis of oral lesion particularly those involving the
odontogenic and salivary gland tissues .
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2- Periodontist help to maintain periodontal health .

3- Pedodontist should be consulted for problem involving children .
5- E.N.T. ( Ear , Nose & Throat ) Specialist :
Important to check hearing acuity and to treat the common symptoms associated with the cleft
palate patients .
6- The psychiatrist :
The patient's rehabilitation cannot be considered complete until he is emotionally conditioned to
accept his deformity , the appliance and prospects of recurrence of disease .
The psychiatrist tries to make him accept the problem with healthy attitude , and gain the
patient cooperation in the course of treatment .
7- Social worker :
The social workers have special skill and training for the management of stress and this is of
importance for such patients .
Contraindications of surgery in maxillofacial defects :

1- Advanced age of the patient :
This is specially true when the surgical treatment requires multioperations.
2- Poor health :
When general health makes surgical procedures dangerous e.g. cardio vascular disease , heart
disease and diabetes and also if the general anaesthesia is contraindicated .
3- Very large deformity :
When anatomic parts of head and neck are not replaceable by living tissues and if is not
practical to attempt a grafting procedure .
4- Poor blood supply :
On postradiated tissues and due to unhealthy vascular condition at the site of deformity .
5- Susceptibility to recurrence of malignant lesion .
6- Expenses of the operation .
Indications of maxillofacial prosthesis :

1- When plastic surgery is contraindicated for one or more of the above mentioned reasons .
2- When recurrence of malignancy is expected , the prosthetic restoration is preferred .
3- When radiotherapy is being instituted , radium appliance and radium protector shield can be
used .
4- When displacement of fractured facial bones occurs .
5- Temporary M.F. Prosthesis can be used when plastic surgery requires various steps .
6- When cleft palate is not repairable by surgery .
7- For esthetics in prognathic or retrognathic mandibles .
Diagnosis and treatment planning :

Patient referred for maxillofacial rehabilitation requires the same thoroughness and attention
afford the regular dental patient seen in the dental office . Their management may be further
complicated by prior surgery and / or radiation therapy .
The diagnosis includes :
1- Dental History .
2- Chief complaint .
3- Physical examination .
4- Aids of diagnosis including laboratory investigations x-ray and study casts .
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Treatment plan :
Treatment should be mainly directed to :
1- To cure or control the disease and to prevent further disability . The prime consideration in
all aspects of rehabilitation procedure is to insure the patient that he remains free of
recurrence .
2- The objective of the total plan should contribute to the patient's well being and acceptance by
his society .
3- Each member of the team should know the overall objectives and the service to be rendered
should be closely coordinated . Arrangement for patient return at appropriate intervals to his
dentist for routine dental care and to his physician for regular health care must be
considered .
4- Maxillofacial prosthetic treatment is established after final evaluation of the physical and
radiographic finding , analysis of study casts full consideration of the patients needs for the
device and psychologic acceptance of it .
5- The patient should understand the limitations of the appliance and the complications that
may arise .
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Congenital Cleft Palate

Definition:
Cleft may be defined as lack of continuity of the roof of the mouth through the whole or part of
its length in the form of a fissure extending anteroposteriorly.
Embryology of primary palate:
During the 5th to 6th week of embryonic development the primary palate is formed. The
primordial structures give rise to:
1) The upper lip.
2) The anterior portion of the maxillary alveolar process.
3) The premaxilla.
Therefore the primary palate represents portion of the embryonic fronto-nasal process and
maxillary processes.
The union of the different processes begins at the meeting point of the premaxilla and the
two maxillary processes in anterior and posterior directions to end with a (Y) shaped suture. The
union progresses anteriorly along the upper limbs of the (Y) to form the upper lip and maxillary
ridge and along the lower limb of the (Y) to form the hard and soft palate.
Etiology:
Congenital cleft palate results from lack of fusion of embryological processes which would
normally unite to form the palate during the 6th and 9th weeks of the embryonic life along the
lines of fusion. The fusion of the right and left palatal shelves and inter-maxillary process is at
about the 10th to 12th weeks.
The exact cause of the clefts is not well known. Some researchers believe that the abnormal
position of the embryo may play a role in inducing the cleft pressure of the amniotic fluid, failure
of the tongue to drop, or persistence of epithelium at the junction of the two palatal alveolar
processes could be the cause of failure of union between the palatal shelves.
Factors that influence the induction of the cleft palate:
1- Hereditary:
The incidence of clefts is greater in the children of parents with deformities.
2- Environmental:
A- Endocrine factors:
Experimentally cleft palate was induced in pregnant mice by injecting cortisone. Also hormonal
disturbance e.g.. pituitary may be an influencing factor.
B- Radiation and x- ray:
Large number of deformities including clefts occur when mothers receive therapeutic radiation
of the pelvis during the early months of pregnancy.
C- Nutritional inadequacies:
High percentage of cleft palate could be induced experimentally by controlled dietary deficiency
as vitamin A and riboflavin. Others suggested that the endocrine disturbance occurring with
dietary deficiency might be responsible for the occurrence of clefts.
D- Infection and disease:
Infectious disease of the mother as German measles was thought to induce clefts in children.
E- Stress and disturbances of fetal circulation:
Some studies indicate that anxiety associated with first trimester of pregnancy might cause cleft
since stresses agent influence cortical activity.
F- Chemical irritation:
Mothers exposed to chemical irritation e.g.. hypoxia and hypervitaminosis A.
It is more logic to consider the hereditary factor as increased by the environmental factors.
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Classification of cleft lip and palate:

Cleft lip and palate were grouped in different categories according to location and / or extent of
the cleft. Different systems of classification have been suggested by different authors.
A) Davis classification (1922).
B) Veau's classification: (1931) still used
Type I: Cleft of the soft palate only.
Type II: Cleft of hard palate and soft palate.
Type III: Cleft of both hard and soft palate plus unilateral
Cleft in the alveolar ridge and upper lip.
Type IV: Cleft of both hard & soft palate and bilateral
Clefts in the upper alveolar ridges and upper lip.
C) Stark's classification (1958) (The most widely used today).
D) Olin's classification:
Group I: Cleft lip only ; unilateral or bilateral with nasal deformity.
Group II: Cleft palate only ; part of the soft palate, or the entire soft & hard palates may be
involved.
Group III: Cleft lip and cleft palate involving the alveolar ridge. Patient may have unilateral or
bilateral clefts.
Group IV: Clefts of the lip and alveolar ridge not involving the palate. This condition is of rare
occurrence.
E) Harkin's classification:
Patients are classified according to the degree of the cleft into:
1- Bifid uvula.
2- Cleft of the soft palate.
3- Cleft of soft and hard palate extending through the palatal bones.
4- Cleft of the soft and hard palate extending to the incisive foremen.
5- Cleft of soft and hard palates extending through the alveolar process and lip on one side.
6- Cleft of soft and hard palates extending through the alveolar process and lip on both sides.
F) Davis classification: (1922) (Not used now) Classification depends on the extent of cleft
Group 1: all clefts of the lip
Group 2: All posterior alveolar clefts.
Group 3: complete cleft of alveolar ridge, palate & lip.
Disabilities (Problems associated with cleft palate):

Disability of the cleft palate patient is due to inability to close well the nasopharynx from the
oropharynx.
1- Speech:
1) The inadequacy of the velopharyngeal closure causes air to escape through the nose during
speech. The result is nasal speech which is unintelligible, calls attention of itself and causes its
bearer to be mal- adjusted.
2) The occurrence of congenital defect presents a more complicated problem than the acquired
defect. In the former condition the normal speech pattern is not formed so even with correction
of the anatomical defect the patient needs speech therapy to break the abnormal pattern first
and to learn normal speech. In cases of acquired cleft palate, the speech returns to normal
immediately after the correction of the defect, because the speech pattern is already formed.
Mechanism of speech & deformities in cleft palate:
For the vowel sounds the air stream escapes continually through the mouth, the shape of
which is altered for various vowels by raising or lowering the tongue and by altering the shape of
the exist through the lips.
The oral consonants are produced by air stream being stopped in its passage through the
mouth by the formation of complete or partial seals or stops. These are produced by the tongue
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pressing against the teeth or palate, or by closing of the lips. These called plosive sounds as
P,B,T,D,K and G are made by sudden breaking of the seal brought about by withdrawal of the
tongue or opening of the lips. For example the lip closure of P and B sounds, the tongue and
anterior hard palate contact in T and D sounds.
When the seal or stop is not complete but a channel through which the air stream must pass
is made extremely narrow called faricative. For example S,Z or C are soft sounds in which the
tongue separates itself from the anterior aspect of the hard palate forming a thin slit like channel
through which the air stream pass. Fricatives (from friction) the air pass out make friction as in
F,V and Ph labiodental Th, J lingudental fricatives.
Tongue and portion of the hard palate posterior to e.g. (J,CH,SH,L,R) contact of tongue
and nasopalate e.g. Hard K,G and Ng. Nasal sounds M,N and NG as in ring are produced with
the soft palate lowered allowing the air stream to escape through the nose.
2- Mastication:
This function is impaired due to escape of food through the nasal cavity. Also missing teeth
and mal occlusion frequently complicate the problem of mastication in cleft palate patients.
3- Swallowing:
If both the hard and soft palates are involved, the natural process of swallowing is
impossible and the first problem facing is nursing a child born with a cleft. Breast feeding is
quite difficult due to lack negative pressure in the oral cavity, regurgitation and escape of fluids
through the nose. The position of the baby during feeding should be changed to sitting position
rather than on the back. Special nipples for feeding bottles with flanges to close the palatal gap
should be used.
4- Appearance:
The presence of cleft lip and palate affects the shape of the face. The most common cause of
facial deformity is improper surgical repair of the hard palate. This is due to trauma to the
centers of bone growth and the contraction of scar tissue leading to reduction in the lateral
dimension and forward growth of the maxilla and hence deformity of the middle third of the
face.
In the absence of a labial cleft, maxillary and facial development will often processed
normally. Clefts involving only the soft palate will of course leave no facial deformity.
5- General Health:
The child's health may be affected due to problems of feeding inadequacy of nutrition and
mouth breathing.
6- Psychological:
Most of the children with such congenital defects have problems with adjustment to society.
They might withdraw completely taking negative attitude towards the outside world, or they
may turn aggressive and react violently to others.
Anatomy and physiology of palatal and pharyngeal muscles:

Anatomy of the soft palate:
The soft palate is a curtain of soft tissue attached anteriorly to the posterior border of the
hard palate and laterally to the walls of the pharynx. Its posterior border is free with the uvula
hanging from its center.
The soft palate is composed of paired extrinsic muscles entering from side to be inserted
into the soft palate these muscles are:
Tensor palatine muscle:
It originates from base of the skull descends more vertically. They terminate in tendon
which pass around bony hook like process pterygoid hamulus. In contraction it depress the soft
palate make it more tense and thus assists its contact with the tongue.
Levator palatine muscle:
It originates on the petrous portion of the temporal bone and the cartilaginous portion of
Eustachian tube. They have downward and forward directions. Their contraction draws the soft
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Dr. Mahmoud Ramadan
palate upwards and backwards causes the free margin of the soft palate to touch the posterior
pharyngeal wall as in swallowing or oral breathing.
Palato pharyngeal muscle:
Arising from the posterior borders of the thyroid cartilage pass upward to form posterior pillars
of fauces. They curve inward to enter the palate. Some fibers blend into lateral and posterior
1- it acts with the tensor to depress the palate against the levator palate in swallowing.
2- Raise the back of the tongue.
Pharynx:
The pharynx is a simple, funnel shaped tube wide at the head and narrow at esophageal
end. The pharynx has three muscles superior, middle and inferior constrictors. The constrictor
muscles are so arranged by inter looking fibers that a wave of constricting impulses helps the
food to pass towards the stomach. The upper part of the pharynx is formed by the superior
muscles, this part is concerned with both speech and swallowing. While its lower part is
concerned with swallowing only.
During speech the pharynx is contracted and causes an inward movement of the lateral
walls. In some cases passavant described a horizontal ridge or cushion " Cross roll " around the
lateral and posterior walls of the pharynx at the horizontal level of the hard palate and he called
it passavant's ridge passavant believed that the passavant's ridge is a component of the usual
mechanism of closure during speech that is visible by the presence of a cleft.
Recent studies indicated that the ridge appeared during speech in approximately 10% of
non cleft palate subjects compared with finding of about 50% of unrepaired cleft palate subjects.
Moreover evidence is lacking to suggest that the ridge is a compensatory factor associated with
cleft palate help in reducing the coronal diameter of palatopharyngeal orifice.
Palato Glossus muscle:
They originate from the sides and base of the tongue and curving outward and upwards to
enter the under surface of the soft palate forming the anterior pillars of fauces, and like palato
pharyngeal muscle, unite in the median aponeurosis of the palate to form an inverted (V).
In contraction they have three functions:
1- It acts with the tensor to depress the palate against the levator palate in swallowing.
2- Raise the back of the tongue.
Palatopharyngeal mechanism:
The palatopharyngeal valveolar or sphincter functions through the action of several muscle
groups.
At rest, the soft palate drops downward such that the oro-pharynx and naso-pharynx are
opened to allow for normal breathing through the nasal passages. When palatopharyngeal
closure is required, the middle one third of the soft palate arcs upward and backward to contact
the posterior pharyngeal wall. At the same time the lateral pharyngeal walls move medially to
contact the margins of the soft palate. The posterior pharyngeal wall may move anteriorly to
facilitate contact with the elevated soft palate.
Complete palatopharyngeal closure is required for normal deglutition and production of
some speech sounds, such as plosives. For vowels and nasal consonants the palatopharyngeal
part will be opened in varying degrees.
Function of the Palatopharyngeal mechanism:
1- Speech mechanism:
Speech mechanism is divided into five components: respiration, phonation, resonation,
articulation and neurologic integration, also audition and ability to hear sound can be added.
2- Respiration:
Speech is a process initiated by the energy inherent in the stream of air. During exhalation a
continuous stream of air is passed from the lungs (with sufficient volume and pressure) to be
modified in its course by the maxillofacial structures giving rise to the sound.
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Dr. Mahmoud Ramadan
3- Phonation:
As air leaves the lungs, it passes through the larynx, whose vocal folds modify the stream of air
by creating resistance to it, set up a sequence of laryngeal sound waves with characteristic pitch
and intensity.
4- Resonance:
The sound waves produced at the vocal folds are amplified. Amplification is by pharynx,
oral cavity and nasal cavities.
5- Articulation:
To modify the laryngeal tones and to create new sounds within the oral cavity by tongue,
teeth and lips. The tongue is the most important articulatory structure.
6- Neurologic integration:
The factor for the production of speech are highly coordinated by the central nervous
system. Speech is a learned function as adequate hearing, vision and normal nervous system are
required for its full development.
7- Phonetics:
The voice is principally produced in the larynx, whilst the tongue by constantly changing its
shape and position of contact with the lips, teeth, alveolareoli and hard and soft palates, gives the
sound form and influences its qualities. The oral cavity and the sinuses act as resonant
chambers, and the muscles of the abdomen and thorax control the volume, and rate of flow, of
the air stream passing into the speech mechanism.
The soft palate in conjunction with the pharynx controls the direction of the air stream after
it passes from the larynx. In all the vowel, and most consonant sounds, the air stream is confined
entirely to the oral cavity, but a few nasal sounds do occur, e.g.. M,N and NG, in which the air is
expelled mainly through the nose. The former are produced by raising the soft palate into close
contact with the pharynx, thus sealing off the nose and forcing the air to proceed through the
mouth.
With the nasal sounds the soft palate is pressed downwards and forwards and the dorsum of
the tongue humped up to meet it, thus sealing off the oral cavity and forcing the air stream to
proceed through the nose. The flow, the alteration in size of the mouth and the change in shape,
and size of the lip opening giving the various sounds their characteristic form.
The consonant sounds are produced by the air stream being stopped in its passage through
the mouth by the formation of complete or partial seals or stops. These are produced by the
tongue pressing against the teeth or palate, or by the closing of the lips. The sudden breaking of
the seal brought about by the withdrawal of the tongue, or the opening of the lips, produces the
sound. In many sounds there is a build up of air pressure behind the stop which when the seal is
released produces an explosive effect. Examples of these are: the lip closure of the P and B
sounds ; the tongue and anterior hard palate contact in T and D sounds.
In some cases the seal or stop is not complete, but the channel through which the air stream
must pass is made extremely narrow: an example of this is the production of an s, z,or c soft
sound, in which the tongue separates itself from he anterior aspect of the hard palate by about 1
mm., forming a thin slit- like channel through which the air stream hisses.
Speech, therefore, is largely a matter of the control of the size and shape of the mouth,
which is chiefly governed by the position of the tongue and its contact with teeth, alveolareoli
and palate.
Fortunately for the prosthetist, the tongue possesses remarkable qualities of adaptability,
and rapidly becomes accustomed to change occurring in the mouth.
The factors in denture construction affecting phonation:
The Vowel sounds:
These sounds are produced by a continuous air stream passing through the oral cavity
which is in the form of a single chamber for the (A, O, U sounds and a double chamber for the I
and E sounds), the division occurring through the dorsum of the tongue touching the soft palate
in the post dam region. The tip of the tongue, in all the vowel sounds, lies on the floor of the
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Dr. Mahmoud Ramadan
mouth either in contact with or close to the lingual surfaces of the lower anterior teeth and gums.
The application of this in prosthetic construction is that the lower anterior teeth should be set so
that they do not impede the tongue positioning for these sounds, that is, they should not be set
lingual to the alveolar ridge, since the vowels E and I necessitate contact between the tongue and
soft palate, the upper base must be kept thin, and the posterior border should merge into the soft
tissue in order to avoid irritating the dorsum of the tongue, which might occur if this surface of
the denture was allowed to remain thick and square ended.
The consonant sounds:
For convenience, these sounds may be classified thus:
a) Labials: Formed mainly by the lips (e.g.. B, P, M).
b) Labiodentals: Formed by the lips and teeth (e.g.. F, V, Ph).
c) Linguodental: Formed by the tongue and teeth (e.g.. Th).
d) Linguopalatals: Formed by the tongue and palate.
(i)
Tongue and anterior portion of the hard palate D, T, C (soft), S, z, R).
(ii)
Tongue and portion of the hard palate posterior to that of (i) (e.g.. J CH, SH, I, R).
(iii) Tongue and soft palate (e.g.. C (hard), RG, NG)
e) Nasal (e.g.. M, N, NG also belonging to the other groups).
Unless careful consideration is given to the following aspects of denture construction, speech
defects will occur varying from the almost indiscernible to the unpleasantly obvious.
Objectives of cleft palate prosthesis:

The prosthesis must establish a competent naso oral separation to satisfy the following
objectives:
1- Socially acceptable speech:
The prosthesis must help the patient to acquire normal speech pattern. For reasonable speech
articulation and resonance there must be adequate dental relation together with adequate
oronasal separation.
2- Restoration of masticating apparatus:
a. Help in mastication and increases the efficiency of chewing and confine the food material in
the oral cavity.
b. Help in deglutition and prevent the seepage of fluids to the nasal cavity during the act of
swallowing.
3- Prevent the seepage of nasal secretion into the oral cavity.
4- Facial esthetics and dental harmony.
a. Improve the esthetics of the patient.
b. Restoring the missing, malposed and improve the articulation of the teeth to establish dental
esthetics.
5- Improve psychological condition of the patient.
Indications of maxillofacial prosthesis in unoperated cases (speech aid prosthesis):

Generally speaking, surgical repair of cleft palate is to be preferred to prosthetic correction by
the speech aid prosthesis. However, there are some situations in which a prosthesis should be the
restoration of choice. Some of such situations are:
1- A wide cleft with a deficient soft palate:
When the cleft is wide and lack the required amount of tissue for the closure to function
properly.
2- A wide cleft of the hard palate particularly in bilateral clefts. Surgical repair may produce a
low vaulted palate. In such cases, it may be possible to close the soft palate with local flaps and
restore the hard palate with a prosthesis.
3- When there is partial or complete paralysis of the remnants of the soft palate.
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Dr. Mahmoud Ramadan
4- Neuro muscular deficient of the soft palate and pharynx. In such cases it is difficult to create
and maintain a pharyngeal flap large enough to produce a competent palato pharyngeal
sphincter without closing the airway in the presence of neurogenic deficiency of the critical
muscles. A pharyngeal flap serves best when it is surrounded by a dynamic musculature.
5- When the premaxilla has been removed.
6- Delayed surgery: When surgery is delayed for medical reasons or when the surgeon prefers to
repair the palate at late age, the cleft palate may be temporally closed with a speech aid
prosthesis.
7- Surgically risky patients.
8- Expansion prosthesis:
To creat space for the premaxilla it may also be used to stabilize the parts in normal position in
association with autogenous bone grafts.
9- Combined prosthesis and orthodontic appliance:
An orthodontic appliance may be combined with a prosthesis to move malposed teeth to a more
favorable alignment.
10- When adult patients have missing teeth and the functional closure is not sure.
Indications for A prosthesis in operated cases:

1- Treatment Prosthesis: Sometimes a transitional prosthesis is made to accomplish a certain
function for a limited time. It has been shown that in soft tissue of the pharynx can be
activated, stimulated or conditioned by close approximation of a prosthesis. Some of these
prosthesis are made as a diagnostic aid.
2- When the soft palate is short and adequate palatopharyngeal closure is lacking. Also
incompetent palato pharyngeal mechanism.
3- When perforation are present in the hard or soft palate and cannot be closed surgically.
4- Absen when the soft palate movement is inactive or completely.
5- When scar tissue in the palate interferes with its mobility.
6- Surgical failures ; for example:
a. Short soft palate due to insufficient available tissues.
b. Rigid soft palate due to excessive scelerotic tissue and / or abnormal function of the
involved muscles.
c. Defects in hard and soft palate communicating to the nasal cavity.
d. Mutilated and restricted alveolar ridges are common in certain cases.
e. Surgical intervention sometimes necessitates sacrificing certain teeth in the cleft palate
that should be replaced.
f. The floating pre-maxilla and its management has been a subject of investigation. Special
care is exercised to properly position and align the premaxilla with the lateral segments.
Cleft palate cases in which the premaxilla is removed results in a large defect that must be
treated with a prosthesis.
g. The pharyngeal flap operation is an excellent surgical procedure to cope with palato
pharyngeal incompetence. Due to various reasons, such as the narrow width of the flap,
the position or subsequent shrinkage of the flap failure may result. Speech aid prosthesis
are made to overcome these failures.
Contraindications to maxillofacial prosthesis:

1- Easability of surgical repair:
When surgical closure of the cleft will end with an anatomical and functional palate, this surgical
repair is that method to be recommended.
2- Mental retardation:
A mental retarded patient is not a good candidate for a removable maxillofacial prosthesis. An
appliance needs reasonable personal care and a retarded individual may not be capable of such.
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Dr. Mahmoud Ramadan
3- Uncooperative patient and parents.

4- Uncontrolled dental caries:
If caries is rampant and not controlled, a prosthesis of any sort should not be recommended.
5- Lack of trained prosthodontist:
The prosthodontist engaged in the cleft palate rehabilitation should have received adequate
training in cleft palate center. He should be thoroughly familiar with the anatomy and
physiology of the area involved and the basic rules governing fixed and removable partial
denture prosthesis.
Diagnosis and treatment planning:

Diagnosis and treatment planning are carried out through the maxillofacial team
representing different specialties.
Full consideration should be given to the following:
1- Type and width of the cleft.
2- Position and relation of the maxillary segments to each other.
3- Form of the maxillary arch and its lateral anteroposterior dimensions.
4- Length, thickness and mobility of the soft palate.
5- Perforations remaining in the hard and soft palate and labial sulcus after surgery.
6- Posterior and lateral pharyngeal wall activities and size of nasopharynx.
7- Floating premaxilla.
8- Number of missing teeth in line of cleft, malformed and malposed teeth and partially erupted
teeth.
9- Constricted maxilla.
10- Condition of tonsils and adenoids.
11- Growth and development of the child, mental attitude and general health must also be
considered.
12- Speech articulation of the patient, his voice quality and hearing acuity.
Acceptable speech cannot be accomplished without creating proper palato pharyngeal
sphincteric action.
In most cases with cleft lip and palate, surgery on the lip in done in the first few months.
Some surgeons prefer to have the lip repair done even before the mother sees her baby to avoid
the psychological trauma to the mother. Surgical repair of cleft palate if indicated is usually done
when the child reaches 2 years old, although some surgeon prefer to wait until 2 6 years.
Preparation of the case for prosthetic treatment:

The oral cavity should be prepared before the construction of the speech aid prosthesis as
follows:
1- Decayed teeth are preferably restored with full coverage to prevent recurrence of decay and
to shape the teeth in the desirable form to support and retain the speech aid in position.
2- Every tooth in the cleft palate patient should be, saved to avoid problems of retention.
3- Teeth needing extraction or other surgical treatment should be preferably done before the
construction of the speech aid.
4- Orthodontic treatment to expand the arch or approximate the two segments and correct
malposed teeth is done at this stage if possible.
5- Gingivectomy for partially erupted teeth is recommended to expose the clinical crown to be
used for retention.
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Dr. Mahmoud Ramadan
Prosthetic management of cleft palate:

A. Preoperative devices (for children)
1- Feeding devices:
Most of infants with cleft lip and palate will be unable to nurse from the breast or ordinary
bottle, since repeated pressure of the tongue on the nipple forces it upwards against the edges of
the cleft and tends to increase the width of the cleft and push parts of the palate upwards.
Since normal suckling and swallowing is impossible, a more upright position of the infant,
and a bottle with the nipple opening slightly enlarged are often all that is needed to aid feeding
and control nasal regurgitation. The wide opening of the nipple will compensate for the slow flow
of milk associated with defective suckling. Some infants with cleft palate may have cardiac and
digestive disorders that may cause the failure of the infant to grow up and increase susceptibility
to aspiration of fluids and also laryngospasm. Nasogastric tube is sometimes used for feeding.
Under these difficult conditions feeding devices can be made in early infancy to facilitate food
intake prior to surgical closure of the palate.
The fabrication of a small palatal prosthesis to obdurate the cleft is indicated so that oral
feeding can be encouraged and the irritation and interference with normal sucking and
swallowing movements associated with tube feeding are eliminated. Also it helps to ensure that
adequate nutrition can be maintained.
The feeding appliance consists of an acrylic plate, constructed from a low fusing dental
compound impression. The plate is attached to the neck of feeding bottle to cover the cleft during
feeding. An acrylic plate with a wire handle held by the mother may be used to cover the cleft
during breast feeding.
2- Expansion type prosthesis:

These are used preoperatively for complete unilateral or bilateral collapsed clefts, and to
properly align the lateral segment and prepare it for surgical closure with or without bone
grafting. As a diagnostic aid, a transitional prosthesis sometimes indicated to diagnose the need
and possible progress in speech to be achieved by certain surgical procedures. In the period of
expansion several successive prosthesis may be needed considering the growth and possible
eruption of the teeth. The expansion sprosthesis is composed of the following portions:
a- Palatal portion:
Composed of two separate lateral sections united by expansion device covering the hard
palate. If this is used in the predental eruption period, it must extend over the alveolar ridge to
the mucobuccal fold. At a later age when the teeth are erupted the prosthesis is extended to the
lingual surface of the teeth. Wrought wire clasps could be added to provide retention.
b- Pharyngeal portion:
Sometimes it is advisable to combine expansion devices with a speech aid prosthesis to
achieve improvement in speech and deglutition simultaneously with expansion.
B. Cleft palate prosthesis for adults:

1- Mobile prosthesis:
Delabarre (1820) emphasized the importance of the normal soft palatal movement during
biologic and activities and constructed a prosthesis a soft rubber velar as in the more simple
hinged type obturator. Although these prosthesis were mobile under influence of the cleft soft
palate, the movement was more similar to mechanical movements than to physiologic function.
2- Meatus obturator:
This prosthesis serves a space filling function. A speech pathologist and dentist team
designed the meatus obturator to reduce the resonance of the nasopharynx, particularly in the
lateral regions around the auditory meati. Molding to muscle function was not a feature in its
production.
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Dr. Mahmoud Ramadan
3- Fixed pharyngeal obturator (speech aid):

This prosthesis has a space filling function in that it is designed to be held in the lower
region of the nasopharynx and is formed to compensate for tissue deficiency. It acts as against
which the palatopharyngeal musculature can form a seal.
In the past, the anterior tubercle of the atlas bone was used as reference point to place the
pharyngeal section. But it was found that its position varies between individuals and in the same
individual during movement. Again passavant's ridge or pad was considered a reference area for
the pharyngeal portion but it is present in few cases (passavant's ridge coincide with the anterior
tubercle of the atlas vertebra). Recently it was found that in 90% of the individuals, the palato
pharyngeal closure takes place in or above the level of the palatal bone.
Fixed pharyngeal obturator requirements:
1- The prosthesis must be designed to suit the patient regarding his oral and facial condition,
masticatory function, and speech.
2- The prosthesis must preserve the remaining structures wrong design of the maxillary portion
will result in premature loss of the hard and soft tissues and further complicating prosthetic
habilitation.
3- The prosthesis requires greater retention and support. In adult cases, crowing and splinting
of the abutment teeth increases retention and, support.
4- Closed vertical dimension in more suitable in the cleft palate patients.
5- Minimum weight should be kept. The material used should be easily repaired and altered.
6- Soft tissue pressure in the velar and nasopharyngeal areas by the appliance must be
avoided.
7- The prosthesis must not be displaced by velum, lateral and posterior pharyngeal wall muscle
activities or tongue movement during swallowing and speech production.
8- Pharyngeal section should be properly placed. The superior surface of the pharyngeal section
must be at the level of the palatal plane.
Sections of the speech aid:
The parts of the speech aid are identified with their anatomical structures (Fig. 4-A) to
which they are adapted as follows:
1- The palatomaxillary section:
It covers the cleft of the maxilla (hard palate), contains clasps for retention, and carries
dental replacements when indicated to:
a. Establish functional occlusion.
b. Improve esthetics and facial balance.
c. Increase mastication and deglutition efficiency, and subserve frontal speech needs.
2- The palatovelar section:
This section supplements the palatal cleft and must remain in constant lateral contact with
the soft palatal muscles in repose or activity to increase deglutition efficiency and subserve oral
speech purposes.
3- The pharyngeal section:
It extends posteriorly into the pharyngeal cavity in order to be surrounded by the
sphincteric action of the pharyngeal muscles during deglutition and speech.
The extent and dimensions of these sections depend upon the degree of dental and palatal
deficiencies presented, hence each speech aid is different.
For patients with deciduous, mixed or not fully erupted permanent dentition the three
sections of the speech aid are made of acrylic resin, and wrought wire retainers without occlusal
rests. In patients where the permanent teeth are fully erupted, the anterior section should be
made of cast metal or combination of cast metal and acrylic resin.
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Dr. Mahmoud Ramadan
Clinical steps of construction:

a. Preliminary impression:
In a suitable stock tray the primary impression is made from fast setting irreversible
hydrocolloid. The undercuts in the palatal cleft if present are closed with gauze soaked with
Vaseline.
b. Preparation of the deciduous teeth for retention:
Most of the deciduous teeth do not have sufficient undercut for retention, however the
proper use of small bilateral undercuts would give adequate retention.
If sufficient space is not available for running the wires of the clasps through the teeth we
should prepare room for them or change the design. After proper design of the clasp on the
study casts and restoration of the teeth for retention is completed, the case is ready to make the
final impression.
c. Final impression:
An acrylic special tray was constructed on the study cast with a spacer. The impression is
made from rubber base impression material, the undercuts in the hard palatal cleft (if not
desired) are treated in the same way as in the primary impression.
d. Recording jaw relation:
All the usual steps for recording vertical dimension and centric occlusion are followed for
cleft palate patients who need complete or partial denture prosthesis.
e. Design and construction of the prosthesis: The prosthesis is constructed in three sections:
1- Palatomaxillary section (Anterior portion):
Is similar to that of conventional partial and complete denture. In must cases the number of
retainers is increased. After delivery the patient must worn it for at least one week. The length of
the adjustment period depends on the ability of the patient to adapt to this part. Necessary
adjustments are done before the addition of the other sections.
2- Velar section or tailpiece (Middle portion):
This section varies in operated and non operated clefts:
a. In non operated clefts with the upper prosthesis in position, the extent of the tailpiece over
the margin of the cleft is marked on the posterior part of the appliance. The tailpiece extends
posteriorly to the anterior of the uvula.
b. In operated cases with short soft palate which require a prosthesis, the position of the
tailpiece is marked on the posterior margin of the prosthesis. The tailpiece extends 3 mm
behind the posterior margin of the soft palate.
Construction of velar section:
A piece of base plate of the required width and length, which acts as a tray, is securely
attached to the posterior portion of the upper prosthesis with 2 mm relief and is brought to the
mouth to a check its proper extension. The upper portion of the tray is filled with zinc oxide
impression paste and the appliance is inserted in the mouth. The patients is instructed to hold his
head in a vertical position for one minute, to prevent the escape of material into the naso
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Dr. Mahmoud Ramadan
pharynx. After one minute, the patient is instructed to swallow some water to register soft palate
muscular movement in the impressions. After the material is set, the prosthesis removed from
the mouth and is sent to the laboratory for processing of the tailpiece.
In order to reduce the number of time the appliance has to be heat cured, self curing
acrylic is used for this procedure. I can't seems that limiting the process to two steps is more
feasible to avoid the complication arising from curing the appliance three times, the maxillary
and velar sections could be constructed at the same time a wire loop attached to the end of the
velar section.
The finished tailpiece is inserted into the mouth, and the injection of some water stimulates
the muscle movement along the lateral edge of the velar section. Lateral overextension of the
velar section usually causes undue muscle displacement and eventual tissue soreness. The velar
section should touch the remnants of the soft palate in repose and function.
3- Pharyngeal section (Posterior portion):
Construction of pharyngeal section (speech bulb):
The loop of wire is attached to the end of the velar section and adjusted to the level of
maximum activity of the pharyngeal muscles. The wire should be short 2-4mm from the
posterior wall of the pharynx. In adult patients the level of the pharyngeal activity is superior to
that in children.
Green compound is added around the wire loop to reinforce the wire. Also soft modeling
compound is added on the loop. The prosthesis is inserted with the soft compound in the
patient's mouth. The patient is instructed to move his head up and down and then from side to
side while the compound is still soft. The prosthesis is removed, cleaned, dried, reheated on an
open flame and tempered in warm water, then reinserted in the mouth and the patient is asked
to swallow and to pronounce a strong " Ah ". The patient is instructed to place his chin against
his chest and move his head from side to side. The appliance is checked and stick compound is
used to correct the impression section by the above way.
Impression wax, softened in water at 150 160 F for 4 to 5 minutes, is added over the
green compound and then inserted in the patient's mouth. The same movements are performed.
The advantage of the impression wax is that it can stay soft in the patient mouth for half an hour
to give him chance to perform the functional movements. The prosthesis is reinserted a number
of times with gradual adjustment to the speech bulb until the functional impression is made of
the involved area.
During construction of the speech bulb the speech therapist works closely with the
prosthodontist. Ideally, the size of the bulb is adjusted until the patient demonstrates good oral
air pressure for production, and until unwanted nasal resonance is eliminated. At the same time
the patient must be able to breath clearly through his nose and produce acceptable nasal sounds.
A special large flask is used for heat curing the tailpiece into clear acrylic resin.
If the lateral and posterior walls of the pharynx are sensitive enough to produce a gag
reflex, no attempt is made to obtain a functional impression for the speech bulb. The speech bulb
is constructed under extended in self curing resin at the beginning, and let the patient to use the
prosthesis for two or three weeks. After the patient is accustomed to the undersized bulb, a final
impression of the speech bulb is processed from heat curing.
The speech appliance is inserted in the patient's mouth and checked for the following:
1- Muscle adaptation of the speech bulb during swallowing and phonation.
2- Excessive pressure against the posterior and lateral walls of the pharynx.
3- Stability of the appliance during function.
4- Improvement of voice quality and articulation of speech.
Cleft palate speech aid repair:
If the speech aid bulb need repair without any alteration of the anterior part, the
conditioning material is applied to the bulb portion. The bulb portion is then duplicated into
clear acrylic resin.
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Dr. Mahmoud Ramadan
The tissue conditioning material is far superior in making the pharyngeal impression. The
patient have the opportunity to use the speech aid at home normal conditions. Whereas in the
clinic the patients tend to exaggerate the movement which leads to inaccurate impression.
4- Silicone retentive obturator:

Indications:
a) Congenital clefts.
b) Acquired defects.
c) More retention is required.
Material: Silicone or rubber latex.
Technique of construction.
5- Palatal Lift Prosthesis (Improve speech):
- Soft palate of sufficient length but lack of sufficient mobility due to muscle paralysis.
- Lift the soft palate to contact the palato pharyngeal wall.
- Maintain some opening on the sides of the elevated palate for nasal breathing.
6- Fixed Prosthesis (Stabilize Premaxilla).
7- Snap-on Prosthesis:
Types:
a) with speech pulp.
b) without speech pulp.
8- Unconventional speech aid prosthesis:
Two sections: Nasal portion Denture.
9- Titanium self tapping implants:
Position: Alveolus Ptrygoid plates.
9- Root coping (attachments) Telescopic crown with rest.
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Dr. Mahmoud Ramadan
Acquired Cleft Palate

While congenital clefts are confined to the lines of union of the different embryonic
processes of the palate, the acquired clefts (some times called fenestration can occur any where
in the palate in various sizes. The defect may involve the alveolar process, tuberosity, the hard
and/or the soft palate.
Etiology of acquired clefts:

1- Trauma: From a sharp instrument or pencil, from gun short or in cases of comminuted
fracture of the maxilla.
2- Disease: As in tuberculosis, syphilis, osteomyelitis of the palatal bone, cancer and suction disc.
3- Surgical operation: Surgical removal of tumors (malignant or benign) involving the palatal
structures.
Disabilities:
Nearly the same as in congenital clefts.
1- Speech: Although speech is changed after surgery but ensure the patient that such a defect
will be corrected after insertion of the prosthesis.
2- Appearance: This is the big problem. Diplopia may result in resected maxilla due to lowering
of the eye to removal of the floor of the orbit.
3- Mastication: Food regurgitation through the nose is a problem.
4- Psychologic considerations:
Rehabilitation of acquired cleft palate:

1- Surgical reconstruction:
It is the best line of treatment but it has it's limitations. It is indicated in the following cases:
1) If the defect is the result of trauma.
2) If the size of the defect is small.
3) No susceptibility of recurrence.
2- Prosthetic rehabilitation:
Is indicated in the following cases:
1) Large defects that difficult to be corrected by surgery.
2) When there is likelihood of recurrence.
3) Large soft palatal defects as they are difficult to restore surgically to normal function.
Prosthetic therapy for patients with acquired surgical defects of the maxilla can be divided
into two phases of treatment:
1- Initial phase called surgical obturation entails the placement of a prosthesis at surgery or
immediately there after. This prosthesis must be modified at frequent intervals to
accommodate for the rapid soft tissue changes that occur within the defect during
organization and healing of the wound. It's objective is to restore and maintain oral functions
at reasonable levels during the postoperative period until healing is completed.
2- Second phase of prosthetic therapy. Starts 3 4 months after surgery at which time surgical
site becomes stable dimensionally permitting construction of the definitive prosthesis.
Surgical obturation:
Surgical obturation can be carried out with a variety of materials and restorations e.g.
sponges, gutta-percha and acrylic resin prosthesis. Acrylic resin prosthesis is more superior and
is our concern.
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Dr. Mahmoud Ramadan
Obturation may be accomplished with the placement of an immediate surgical obturator at

surgery or with the placement of a delayed surgical obturation six to ten days post-surgically.
Immediate Surgical Obturation

This type of obturator is well suited for dentulous patients requiring a partial or total
maxillectomy because the remaining teeth can be used to help retain the prosthesis in position.
Advantages of the immediate surgical obturation:

The rationale for using the maxillary immediate surgical obturator prosthesis is threefold:
1- Functional: the prosthesis act as a matrix for the surgical dressing placed in the maxillary
defect. It also permits the patient to speak and swallow more normally upon awakening from
anesthesia. It allows earlier removal of the nasogastric tube.
2- Hygienic: the obturator separates the maxillary surgical site from the contents of the oral
cavity. Reduce the oral contamination of the wound and hence the liability of infection.
3- Psychological: the obturator prosthesis restores the patient's self image by reproducing the
contours of the lost oral structures and allowing the patient to function in a social
environment. It lessen psychologic impact of surgery. It helps to reduce period of
hospitalization.
Preoperative guidelines:
A good working relationship with the surgeon will permit ample time for patient evaluation
and treatment. Patient evaluation includes the following data:
a) Medical history: A history of the patient illness as well as the past medical history will provide
clues to potential problems in future care.
b) Dental history: the dental history can be obtained from the patient directly or in conjunction
with clinical observation. The patient's dental hygiene and previous experience with dental
prosthesis should be noted.
c) Comprehensive clinical and radiographic examination: this examination will confirm or deny
the patient's dental history and provide information useful in planning the patient's prosthetic
rehabilitation.
d) Diagnostic casts: Impressions are made in irreversible hydrocolloid to provide both diagnostic
and working casts. Inter-occlusal records and mounting the casts on a suitable articulator are
required for proper analysis.
e) Photographs: Photographs provide an excellent record of preoperative conditions.
-
Immediate surgical obturator are fabricated on maxillary casts obtained before surgery. The
patient must be seen before surgery for impression making to construct the immediate
surgical obturator. It is in the form of a simple acrylic plate with no teeth and carrying
retaining clasps. Retention of the plate in the mouth is by clasps, ligation to the teeth, wiring
to the teeth or pinned to available bone (in edentulous subjects or when the number and
distribution of the remaining teeth is not suitable for retention).It is inserted immediately
after surgery and while the patient is still in the operating room. It must not be removed
before seven to ten days post-surgically.
The prosthodontist must be informed a reasonable time before operation to give chance for
construction of the surgical obturator the surgeon and the prosthodontist should discuss the
extent of the operation and draw a diagram on the lines of surgical incision (better on the
cast if it available at this time).
Principles relative to the design:

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Dr. Mahmoud Ramadan
1- If it is possible persuade the surgeon to leave the posterior edge of the hard palate and
tuberosity. Otherwise the soft palate will be flabby and often drop inferiorly and will exhibit
little motion during the immediate post operative period.
2- The surgeon is encouraged to make the anterior incision through the socket of an extracted
tooth instead of between adjacent teeth. This will help to preserve the periodontal tissue of
the remaining tooth and minimize the risk of amputating its root. The surgeon should also be
informed if any of the planned incision will involve a fixed restoration. Sectioning the
restoration may be done before surgery on the dental chair to decrease operative time under
general anesthesia, but may contribute to patient apprehension and discomfort prior to
surgery.
3- The obturator should terminate short of the skin graft mucosal junction. When surgical
packing is removed extension into the defect may be accomplished with tissue conditioning
material.
4- Prosthesis should be simple and light in weight.
5- Prosthesis should be perforated at the inter-proximal extensions to help wiring to the teeth at
the time of surgery.
6- Normal palatal contours should be reproduced facilitate speech and deglutition.
7- No posterior occlusion at the defect side.
8- Old dentures if available can be used after their modification. Reduce the flange at the defect
side and remove posterior teeth. The surface should be improved for better retention by the
addition of tissue conditioning material before surgery.
9- Add a couple of wire loops at the fitting surface where the growth is going to be excised (cases
where the growth is big).
Preoperative dental procedures:

While planning the maxillary immediate surgical obturator prosthesis, the design of the
interim and/or definitive prosthesis should be planned. The following factors must be
considered:
1- Tooth analysis and their modification:
Abutment teeth and their contours should be identified. If retentive undercuts do not
appear to be adequate, tooth modification should be considered, which may include recontouring
"dimpling" or placement of restorations. Modification should be accomplished at this instead of
at the insertion of the definitive prosthesis. The occlusion may require modification to
accommodate rests and/or clasp of the definitive obturator. The patient should be informed of
these procedure initially. Tooth modifications are easily accomplished at this time than after
surgery.
2- Mold and shade selection:
Mold and shade selection can be accomplished at the initial visit so that the definitive
obturator can be made more esthetics by having the anterior teeth in place.
Technique of construction:
1- Tray modification: stock trays may be modified to accommodate the size of the tumor. The
tray may be extended posteriorly to record a significant part of the soft palate if affected.
2- The patient should be placed in an upright position, so that the soft palate will assume a
normal and relaxed position. To overcome the problem of gagging associated with impression
making topical anesthetics may be used and it is preferable to use rapid setting hydrocolloid.
3- Upper and lower alginate impressions are made. It is important to make accurate
impressions of the vestibular depth on the unresected side.
4- Casts are poured in stone plaster. The upper cast is duplicated for future reference. It may be
better to make more than one upper impression to give chance for selection. Mount the casts
on an articulator with the aid of a jaw relation record.
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Dr. Mahmoud Ramadan
5- After discussing the surgery, the surgeon and prosthodontist will outline the proposed
surgical margins on the upper cast. The lateral boundary is usually the labial and buccal
reflection, and the median boundary is the midline of the palate. The questionable extensions
are the anterior and posterior margins.
6- The maxillary cast is altered to conform to the proposed surgical resection. Teeth to be
included in the resection are removed from the cast, but the alveolar height maintained. The
residual alveolar ridge is trimmed moderately on the labial and buccal surface to reduce the
stress on the soft tissue closure. Any elevation on the cost denoting the swelling should be
removed to have a normal palatal contour. The cast should be modified so that an adequate
thickness (approximately 2 to 3 mm) of acrylic base will not create occlusal interferences the
cast should be reduced to the level of the palatal cusps. This will allow an adequate thickness
of acrylic resin to mimic the natural palatal contours without impinging laterally or
anteriorly on the surgical flap. The cast in the region of soft palate resection should be
reduced to the level of the hard palate. This will result in the obturator prosthesis being
posterior and superior to the natural drape of the soft palate and minimize impingement on
the tongue during speech and swallowing.
7- Wire retainers (wire clasps) are prepared on the standing teeth.
8- Waxing up of the obturator is carried out. An upper base palate (double thickness of base
plate wax) is adapted to the modified palate and ridges. In patients with excessive vertical
overlap, the obturator extension anteriorly must be thinned to avoid occlusal interference
with mandibular anteriors. Edentulous upper jaws can be retained by wires to the zygomatic
bone.
9- The waxed up obturator is invested, processed in clear acrylic resin finished and polished.
Clear acrylic resin is preferred because it makes it easy to see extensions and pressure areas
during surgery. Holes are drilled in the buccal flanges when it is supposed to be wired to the
zygomatic bone.
10- Wire loops (two) are fixed to the fitting surface of the obturator at the site of surgery with
self curing resin. This wires will help to retain compound in cases of big tumors.
11- Now the obturator is ready for insertion in the surgical room put the obturator in an
antiseptic solution. In most instances the immediate surgical obturator is easily fitted and
secured. Care is taken to adjust the lateral extensions of the obturator short of the skin graft
mucosal junction to avoid pressure to this area. The lateral and anterior aspects of the
prosthesis should be reduced until correct facial contours are obtained without creating
excessive tension during closure.
12- Now, this is the time for molding the compound, or tissue conditioning material to the
surgical wound. Green stick compound is softened in warm water and attached to the wire
loops. The plate is seated in position in the patients mouth after blocking the deep undercuts
with vaselinied gauze. The plate with the compound is removed and reseated in the patients
mouth several times while the compound is still soft to prevent it's anchorage to undercuts of
the surgical wound. Cheek manipulation can help in molding the material while it is still soft.
N.B. A skin graft taken from the inside of the arm may be applied to the surgical wound
(skin grafting) in this case the skin graft is spread on the surface of the compound with it's
raw surface upwards helping to maintain its contact with the walls of the surgical wound.
13- If the surgery is more extensive than planed it is preferable to add a lining material (e.g.
tissue conditioning material) to the prosthesis.
14- In dentulous patients retention can be obtained by clasping or wiring to existing teeth. A no.
8 round bur is used to create openings for every available inter-dental space. Thus, to achieve
stability and retention, many teeth can be ligated to the time of surgery. In edentulous
patients the prosthesis is wired or pinned to the alveolar ridge and/or zygomatic arches.
Ligation wire openings should be placed as high as possible on the buccal and palatal aspects
of the remaining alveolus to assure sufficient bone for placement of the ligation wire through
the alveolus. These openings should be connected by a recess into which the ligature wire will
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Dr. Mahmoud Ramadan
be placed. This recess will run mesiodistally between the inter dental wire for the dentulous
patient or labio (bucco) palatally for the edentulous patient. This will prevent the ligature
wire from irritating the patient's tongue.
15- The prosthesis and packing are removed after seven to ten days post surgically. The
prosthesis is cleaned from blood clots and nasal secretions and any necessary adjustments are
made.
e.g.:
- Adjustment of wire retainers.
- Minor occlusal discrepancies on the intact side.
- Application of tissue conditioning material to improve adaptation seal and comfort.
- Modification of the compound if present.
16- The patient is then recalled weekly for any necessary adjustment, until he has no trouble
(may be one or two months).
Delayed Surgical Obturation

It is placed seven to ten days after surgery. If the patient is edentulous, and the surgical
defect is to be extensive, this approach may be the treatment of choice.
When the surgical packing is removed from the wound a maxillary impression is obtained
with hydrocolloid. The surgical area will be tender and the patient will be apprehensive, thus
this step must be accomplished with great care. The impression must record as much of the
lateral portion of the defect as is possible.
A soft metal edentulous tray is altered so that 1/4 inch clearance exists in all dimensions. In
the area of the defect it may be necessary to remove of the flange of the tray or to bend it
medially. All flanges are covered with peripheral beading wax and additional wax is added in the
area of the defect to provide support for the impression material. Major medial undercuts are
generally not useful and should be blocked out with vaselinised gauze.
Sensitive areas should also be blocked out. The gauze can also be used to limit the extension
of the impression material into the defect. Impression material should be placed on the lateral
side of the tray corresponding to the defect to record the contour of the lateral cheek surface.
The tray is positioned, seated and the cheeks and lips manipulated especially on the defect
side. The impression will cause pain on removal and it should be released gently. The impression
in then inspected for proper extension and adaptation.
If the patient is dentulous the prosthesis is constructed as described in the immediate
surgical obturator. It is delivered and adjusted using pressure indicator paste and articulating
paper. If it fits well and well retained, it is not necessary to add temporary lining material. As
healing progresses, posterior occlusal ramps can be established with the addition of self curing
resin. Posterior occlusion helps the patient to retain the prosthesis in position. Follow up the case
as in the immediate surgical obturator.
In edentulous patients it is preferable to use the patient's own maxillary denture (if present)
as a delayed surgical obturator. The existing denture should be inspected to ensure that it will
adequately obturate the surgical defect. The buccal and/or labial flanges of the denture are
shortened on the side of the defect. It may be necessary to extend the denture with self curing
resin to cover the margin of resection on the soft palate. After adjustment it is lined with a reline
material.
To summarize we can say that objective of immediate and delayed surgical obturation is to
serve the patient through the immediate postoperative period. In most cases it can be maintained
until the definitive obturator is constructed.
A definitive prosthesis is not indicated until the surgical site is healed, dimensionally stable
and the patient is prepared physically and psychologically for the restorative care that may be
necessary.
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Dr. Mahmoud Ramadan
Definitive Obturation
Constructed three to four months after surgery. The suitable time will vary depending on:
1- Size of the defect.
2- Progress of healing.
3- Prognosis for tumor control.
4- Presence or absence of teeth.
5- Effectiveness of the present obturator.
The defect must be engaged more aggressively for edentulous patients to maximize support,
retention and stability. Thus the recovery period is longer for these patients. Changes associated
with healing and remodeling will continue to occur in the border area of the defect for at least
one year (in edentulous patients) by this time the mental outlook of most patients will be
improved.
Treatment planning:
To suggest the line of treatment we must have information about:
1- Prognosis for tumor control.
2- General health of the patient.
3- Data from mounted diagnostic casts.
4- Radiographs for questionable teeth.
5- Desires of the patient from that treatment and his expectations.
Treatment concepts:
Several concepts will be discussed now regarding the definitive obturator:
1- Movement of the obturator:
The obturator will move during function, if the maxillary alveolar ridge and teeth are
involved in the resection. It will be displayed superiorly with the stress of mastication and will
tend to drop without occlusal contact. The degree of movement and size and configuration of the
defect. The patient must be warned about this problem.
2- Tissue changes:
Dimension change of the defect will continue to occur for at least a year secondary to scar
contracture and further organization of the wound. Also movement of the obturator during
function may contribute to tissue changes. The obturator portion should be acrylic to facilitate
the possibility of rebasing or relining.
3- Covering prosthesis:
Obturator for acquired clefts of the maxilla are basically covering prosthesis serving to
establish the oral nasal partition. The contours of the defects are relatively static during
function.
4- Extension into the defect:
The degree of extension into the defect is dependent on the requirements of retention,
stability and support. If these properties can be obtained from the remaining maxillary
structures, the extension into the defect need not to be extensive. Mostly, the defect must be used
to improve these qualities. Again extension of the prosthesis into the defect will vary according to
the configuration of the defect and the character of its lining tissue. Extension superiorly along
the nasal septum offers little mechanical advantage as the pseudo-stratified columnar epithelium
lining the nasal septum and other nasal structure will tolerate little stress. In contrast, extension
superiorly along the lateral margin of the defect will enhance retention, stability and support.
Stress is well tolerated by the skin graft and oral mucosa lining the cheek surface of the defect.
In edentulous patients the defect must be used more extensively for retention, stability and
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Dr. Mahmoud Ramadan
support. The use of the defect for dentulous patients will vary depending on the size and
configuration of the defect and the number of teeth remaining. If the prosthesis is not properly
designed and constructed, the stress on the remaining hard and soft tissues can be pathological
and can lead to premature loss of abutments and irritation of soft tissues.
5- Teeth:
Presence of teeth enhances the prosthetic prognosis.
6- Weight:
Bulky areas should be hollowed to reduce weight to avoid unnecessary stress to the teeth
and supporting tissues. There is controversy whether the supporting surface can be left open or
should be closed. If the obturator is left open, nasal secretions accumulate leading to bad odor
and added weight. On the other hand open obturator has less weight and is easier to adjust. For
drainage a small diagonal opening is made between the inferiolateral floor through to the cheek
surface for drainage. The cheek will close against the opening so the seal is not compromised.
However, sealing the top of the obturator is of advantage if the patient complains of
accumulation of secretions.
Edentulous Patients with Total Maxillectomy Defect

With any sizable palatal perforation retention in the classical sense of complete dentures is
impossible. Air leakage, poor stability & reduced bearing surface will compromise adhesion,
cohesion and peripheral seal. Therefore, the contours of the defect must be used to maximize the
retention, stability and support. The surgical defect should be well healed before fabrication of
the definitive obturator.
Maxillary obturator prosthesis in edentulous patients will exhibit varying degrees of
movement depending on the amount and contour of the remaining hard palate, the size, contour
and the lining mucosa of the defect and the availability of undercuts. During mastication the
prosthesis moves superiorly into the defect. With the release of occlusal pressure, the prosthesis
drops in the opposite direction.
In edentulous patients with a total maxillectomy defect, the axis of rotation is located along
the medial palatal margin of the defect. The portion of the obturator most distant from this axis
will exhibit the greatest degree of motion. In a posterior maxillary defect, where maxillary
segment is retained the axis of rotation moves posteriorly. With these smaller defects the degree
of movement during function is less as additional maxillary structures remain for support and
stability. With anterior resection of the maxilla, the axis of rotation is located along the posterior
margin of the defect. The anterior lip margin of the prosthesis will exhibit the greatest
movement.
Retention, stability and support:

Retention is the ability of the prosthesis to resist vertical tissue away displacing forces.
Stability is the ability of the prosthesis to withstand the horizontal forces of dislodgment, support
is the resistance to the vertical stress (tissue ward movement) during mastication and
swallowing. In most cases acceptable retention, stability and support can be gained from the
residual palatal structures by engaging the defect appropriately.
Remaining palatal structures:

The arch form, the amount of palatal shelf remaining and the character of the residual
alveolar ridge influence stability and support. The palatal shelf is located perpendicular to the
direction of occlusal stress and it provides considerable support during function. A square or
ovoid arch will exhibit relatively more palatal shelf area following a total maxillectomy. The
reduced area and undesirable angulation of the palatal shelf in tapering arches does not provide
as much support during mastication.
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Dr. Mahmoud Ramadan
The height and contour of the residual alveolar ridge and the depth of the sulci are
important considerations. A healthy well formed ridge with extensive sulci will enhance stability
and support.
The defect:
Acceptable retention can be gained by engaging key areas within the defect. The edentulous
patient should know that the prosthesis will exhibit considerable movement during function.
Engagement of the skin graft and scar band formed at the skin graft mucosal junction will
improve retention. Since, the lateral portion of the obturator exhibits the greatest degree of
movement, retention can be improved by appropriate obturator tissue contact superior
laterally.
Additional retention may be gained by extending the prosthesis along the nasal surface of
the soft palate. Flexible materials are some time used in edentulous patients but they have short
time of service, fungal contamination and poor adjustability. Engagement of key portions of the
defect can improve support and stability. Stability is enhanced by engaging the super lateral
portion of the defect and some times the medial margin (when lined with keratinized
epithelium). Support can be obtained from the oral side of the skin graft mucosal junction
from the oral surface of the soft palate.
Technique of construction:
1- Preliminary impression:
To record the remaining maxillary structures and the useful portion of the defect, an
edentulous soft metal tray is altered. The medial and anterior undercuts are blocked out as
these undercuts are not engaged by the prosthesis. Adhesive is applied to the tray. Hydrocolloid
mix is loaded in the tray, impression material is placed laterally to record the lateral
configuration of the defect. Before seating the tray, impression material is injected into the
posterior and lateral undercuts. Accurate diagnostic cast reproduces the usable undercuts, aids
in evaluating the degree of retention and stability.
2- Special tray:
Undesirable undercuts are blocked out on the diagnostic cast before constructing the
special tray (made of acrylic resin on a spacer). Extensions of the tray are verified in the mouth.
Inaccessible areas are checked with disclosing wax for possible overextension. Border molding of
the tray is carried out using modeling plastic. The palatal margins of the defect area is also
developed by border molding. Border will ensure the stability of the tray which is a key factor in
obtaining an accurate reproduction of the borders of the defect.
3- Final Impression:
Several perforations are made in the tray for escape of excess impression material that may
prevent correct of the tray. Adhesive is painted. Excess secretions are removed. The material is
injected into desirable undercut and the loaded tray is seated into position. The lips and cheeks
are manipulated and the patient is asked to do eccentric movements of the mandible. After
setting the tray is removed with a gentle teasing action.
A alternative impression technique: is suggested by making use of the surgical prosthesis.
First, do any necessary alterations if needed until the prosthesis is acceptable then apply a new
layer of tissues conditioning material.
4- Recording Jaw relation:
On the master cast construct record bases. if the defect is large and stability and support
are difficult to obtain a conventional record base, construct the permanent bas from the master
cast. if stability and support are adequate conventional self curing base is made on the master
cast (after blocking of undercuts with clay to protect the cast).
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Dr. Mahmoud Ramadan
Vertical dimension of occlusion is recorded as usual. If there is trismus the vertical

dimension of occlusion is reduced to allow passage of the bolus of food between the denture
teeth.
Centric relation is then recorded with recording medium. Care must be exercised to ensure
that the record base is not displaced during registration. Even in the relatively stable bases,
pressure on the defect side will cause superior displacement into the defect and compromise the
accuracy of the recording. Soft wax, zinc oxide or plaster are preferred as recording media.
5- Occlusal schemes:
Non anatomic teeth are used and set following contours established by the wax rims and
anatomic landmarks. They are set in centric occlusion and adjusted to eliminate lateral
deflective occlusal contact.
6- Try in.
7- Processing, delivery and follow up:
The waxed up obturator is processed in heat cured acrylic resin. To gain retention use a
soft silicone material for the obturator segment of the prosthesis to engage the undercuts more
aggressively.
Superior surface of the obturator should be slightly convex and well polished. Slap
projections should be rounded and polished. Polishing improves cleansibility and results in less
friction at the prosthesis tissue interface during functional movements. Pressure indicator
paste is used to delineate areas of excessive tissue displacement.
Home care instructions:
Most maxillary obturator require rebasing within the first year of delivery because of
further organization of the defect with dimensional changes.
Edentulous Patients with Partial Maxillectomy Defects

In patients with partial maxillectomy defects, more of the hard palate remains and thus the
prosthesis has more stability and support. Retention may be compromised because access and
use of the defect may be impaired. The defect should be utilized as mush as feasible to enhance
the function. Soft silicone material are useful.
Dentulous Patients with Total Maxillectomy Defects

Better prognosis with the presence of teeth which assist retention, support and stability.
Treatment concepts:
a) Location of the defect:
Surgical resection usually includes the distal portion of the maxilla and rarely does a distal
abutment remains. The extent of the resection anteriorly varies. Thus Kennedy class II partial
denture with extensive lever arm is that required.
b) Movement of the prosthesis:
The degree of movement of class II partial denture is dependent on the quality of the ridge
and palate and the ability to utilize the support from both the edentulous segment and teeth.
With resection of the maxilla mucosal and bony support are compromised. Hence the defect
must be used to minimize the movement trying to reduce the stress on the abutment teeth.
c) Arch form:
Square or ovoid arches posses more bearing surface perpendicular to occlusal stresses
resulting in more stable prosthesis during function. Tapering arch forms provide less palatal
shelf area and thus support is compromised.
d) Teeth:
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Dr. Mahmoud Ramadan
Preservation of the remaining teeth is important for retention. Partial denture design must
anticipate and accommodate to the movements of the prosthesis during function without
exerting pathologic stresses on teeth. Maximum retention, stability and support must be
obtained from the use of the defect.
e) Partial denture design:
Diagnostic casts are surveyed to locate undercuts, guiding planes and select the path of
insertion. Often a compound path of insertion must be employed to use the undercut in the
defect. Major connectors must be rigid, occlusal rests must direct occlusal forces along the long
axis of the teeth, and guide planes must be designed to facilitate stability and bracing.
Retention should be within the physiologic limits of the periodontal ligament and maximum
support must be gained from the residual soft tissues. A tooth closely adjacent to the anterior
margin of the defect must have a rest and a retainer, if adequate retention is to achieved. the
anterior occlusal rest and retainer ensures oriention of the prosthesis.
If this concept is not employed the prosthesis will tend to rotate out of the retentive area is
not employed the prosthesis will tend to rotate out of the retentive area posteriorly. Often the
bony support for the tooth adjacent to the defect is questionable and does not permit its use as
abutment. Other adjacent tooth will have to be used.
The fulcrum line is determined by the position of the occlusal, incisal or cingulum rests.
Since there is no cross arch reciprocation of either buccal or lingual retention, this partial
denture may be viewed as a unilateral partial denture. For this reason both buccal and lingual
retentive arms may be considered to obtain cross tooth retention and reciprocation.
Prosthetic procedures:
1234-
Treatment plane.
Required restorative procedures.
Mouth preparation.
Master impression to construct the partial denture frame work.
Prior to impression making, the medial palatal undercut in the defect is blocked out with
gauze, however, the lateral portion of the defect should be recorded with the impression as these
contours will be necessary to fabricate the tray for the altered cast impression. The master cast is
made and the metal frame work fabricated. The obturator portion should be of acrylic resin to
allow for adjustment and rebasing. Retention for the obturator portion should extend laterally
into the defect and should be located 2mm. Superior to the normal palatal contour. Frame work
is adjusted to the abutment teeth in the patient's mouth using disclosing wax.
When the framework seats properly, the undesirable undercuts within the defect are
blocked out on the cast with wax. Self curing acrylic resin is molded to the frame work and the
defect in preparation for the altered cast impression (to make the form of the tray for the
defective area).
The prosthesis is then placed in the mouth and the tray is examined for extension and
proximity to the tissues. Modeling plastic (green stick compound) is added to the tray material
until desired extensions are achieved. Retention, stability and seal of the prosthesis are checked
and if inadequate, further extension into the undercut area may be indicated. Adhesive is applied
to the obturator part and an elastic impression material is used to complete the altered cast
impression. When the frame work is stead in the mouth, the patient is directed to make
eccentric mandibular movements. After setting, the impression attached to the frame work is
removed and examined for tissue adaptation, proper extension and excessive displacement of
tissues. The master cast is segmented. Then the framework with the altered cast impression are
seated on the tooth segment. The impression is boxed and poured in dental stone.
In the finished obturator, slight pressure against the cheek is desirable to ensure maximum
retention, stability and support.
Record the jaw relation try in, processing in the usual manner then finish and polish.
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Dr. Mahmoud Ramadan
Dentulous Patients with Partial Maxillectomy Defects

The prognosis improves as the margins of the resection moves posteriorly. If the maxillary
cuspid of the defect side remains, the prosthetic prognosis improves. Even the presence of central
or lateral on the defect side will enhance the stability and support.
The fulcrum is dependent on the placement of rests. As more teeth are remaining on the
defect side, the fulcrum line shifts posteriorly. As the fulcrum shifts posteriorly, the distolateral
extension of the obturator should be lengthened as this area offers the greatest mechanical
advantage.
Hollowing the obturator bulb:

To avoid extra weight of the obturator when the bulb is too big, hollowing the bulb is
indicated. This is done as follows: during packing a small cellophane bag filled with sand is
packed within the bulb. After processing a hole is drilled through the bulb and sand drained
away. The opening is then closed with self curing resin.
Methods of Retention of Acquired Obturator:

12345-
Clasping (in dentulous patients).

Retaining buccal flange engaging both tooth and tissue undercuts (in dentulous patient).
Maximal extension (in both dentulous and edentulous patients).
Undercuts in the defect (in both dentulous and edentulous).
Inter-maxillary springs (in edentulous patients) fixed between the lower denture and
obturator.
6- Implants in the intact side.
7- Magnets in the undefective side.
8- Denture adhesives and creams.
9- Swing lock attachments (in dentulous patients).
10- Engagement of lateral scar (from skin graft).
11- Anterior nasal aperture extend beyond the midline.
12- Palatal shelf.
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Dr. Mahmoud Ramadan
Maxillofacial Splints
Definition:
Appliance used for immobilization of the fractured jaw guided by centric occlusion into
their original position until repair occurs.
Uses:
In the treatment of fractured jaws: immobilize fractured segment till healing occurs.
In surgical orthodontics of malposed jaws: ex: mandibular prognathism after segmental
osteotomy to splint bone segments together.
In conjunction with bone graft.
In treatment of periodontally mobile teeth (periodontal splint).
Advantages:
Good fixation of fractured segments for long period of time.

Allow early movement of the mandible so decrease trismus.
Not harmful to teeth and supporting structures as intermaxillary fixation.
Require little post operative attention.
May extend to restore edentulous fragment.
Requirements
Should be rigid and not allow mobility of the fractured segment.

Made from radiolucent material to show fracture line in the x-ray.
Not affect function or interfere with occlusion with opposing teeth.
Comfortable to the patient and decrease patient injury.
Ease of construction.
Low in cost.
Impression of fractured jaw

Adequate light and suction should be present.
Use:
hydrogen peroxide to dissolve blood and remove food debris.
Sodium bicarbonate to dissolve mucous and control excessive salivation.
Flavored mouth wash.
Control trismus and pain by local anesthesia.
According to the presence or absence of displacement:
If there is no displacement of the jaws at line of fracture: make alginate impression and
poured to produce casts which mounted on simple hinge articulator.
If displacement occurs: use sectional impression to the fractured jaw with shallow stock
tray is made and another impression to the opposing jaw is taken and the impressions are
poured, the cast with fractured jaw is segmented with a saw at line of displacement and
the 2 segments are reassembled into their original position guided by the occlusion of the
opposing arch and the 2 segments attached with plaster base on the articulator.
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Dr. Mahmoud Ramadan
Types of splints
a)
b)
c)
d)
For dentulous patient:

1) Metal cap splint
2) Labio-lingual splint
3) Fenestrated splint
4) Occlusal waver splint
5) Palatal occlusal splint
For edentulous patient:
Gunning splint
For both dentulous and edentulous patient:
Kingsley splint
Other types
1) Wire splints (direct-interdental-eyelet- intraosseous) wiring
2) Arch bars
3) Bite plane occlusal splint
1. Cast metal cap splint:

Indications:
Permanent teeth with fully erupted crown and definite undercuts
Delayed fracture if displacement occurs and fibrous tissue formed at fracture line which
need excessive reduction force that cannot be applied by acrylic splints
Long term immobilization in case of jaw resection and need of resection guiding flange
In TMJ exercise: by extra oral rode extend from upper and lower metal cap splint and
elastic bands in between the rods
In immobilization of bone segment in segmental osteotomy (ex: mandibular prognathism)
Advantage: Rigid and provide effective fixation
Disadvantages: Weight- expensive- long time of construction
Types:
1. One piece cap splint (simple cap splint):
Use: When position of the fractured segments cab be determined by the occlusion of
opposing teeth without displacement of the jaws.
2. Two piece cap splint (cap splint with screw connecting bar):
Use: When displacement occurs and fibrous tissue present between the fractured
segments as it needs high reduction force.
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Dr. Mahmoud Ramadan
Construction:
Impression of both arches with alginate is made with short tray flange as occlusal surface of
the teeth is only needed.
If displacement occurs, cast sectioned at line of fracture, casts are hand articulated,
reassembled and mounted on simple hinge articulator guided by the occlusion of opposing
teeth.
Cast is surveyed, path of insertion is selected, undercuts were blocked out.
Sheet of wax is warmed and adapted on the occlusal surface of the teeth on the cast and the
articulator is closed to carry the imprints of opposing teeth. Wax should be thin and not
interfere with free way space and the periphery of the wax should be square (not knife edge).
Cusps of teeth may perforate the wax and project through the splint to decrease jaw
separation and help in escapement of the cement through the vents.
Tags (underplates) are embedded in the wax pattern which hold wire loop (overplates), it also
help in intermaxillary fixation.
a) Tags (underplates): it is the female element, waxed in the wax pattern or soldered later.
b) Wire loops (overplates): screwed to the tags with screw.
Wax pattern is invested and casted with direct or indirect casting system:
Direct system of casting: done directly over the cast, stone cast under cuts were blocked
out on the surveyor, then the cast is duplicated into refractory cast on which the wax
pattern is made
Indirect system of casting: wax pattern is removed from the cast (to verify that
undercut is blocked to avoid interference during insertion), invested and casted.
Cement the splints on the corresponding teeth, apply careful directed traction force to the
bone segments till assume proper reduction.
Wire loops screwed to the tags, use quick setting plaster to hold the position of the wire loop
in reduced state of fracture, after plaster setting wire loops unscrewed and removed while it
is attached to the plaster and the jaws are allowed to return temporarily to the displaced
position.
Wire loops invested in the laboratory and connected together by soldering metal bar to them.
Reduce the fractured part again, the wire loops with connecting bar screwed to the tags.
Other method used to connect the 2 pieces metal cap splint using metal rode and metal tube:
the anterior portion contain metal rode (male part) and posterior portion have metal tube
(female part) that contain channel for rode and inserted before anterior portion, after
reduction the metal rode inserted into metal tube to immobilize fractured segments.
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Dr. Mahmoud Ramadan
2. Labiolingual (sectioned-hinged) splint:

Indications:
Dentulous patient- partially edentulous patient- mixed dentition (children).
Construction:
Composed of 2 buccal section (right and left) and lingual section, hinged wire connect the
buccal sections with the lingual section behind the last molar.
Primary alginate impression is taken and poured to produce casts, if displacement of fracture
segment occurs, cast sectioned at line of fracture, casts are hand articulated, reassembled and
mounted on simple hinge articulator guided by the occlusion of opposing teeth.
Wax adapted on the labial, buccal and lingual surfaces and not cover occlusal surface of the
teeth (extend to survey line), wire embedded distal to the last molar tooth on each side to hold
buccal and lingual flange together, the wire form a hinge that allow open and close of splint
without fracture, wire hooks attached to the buccal surface of the appliance, blunt button
which have undercuts is made at midline.
Wax is processed into clear acrylic resin, the acrylic button is divided vertically at midline
with a fissure bur or with a saw.
The splint opened and placed on the teeth, reduce the fracture and immobilization made by
tighten wire ligature around the 2 halves of the acrylic button, and buccally placed wire
hooks are used for intermaxillary fixation and attachment to the facial bone.
Advantages:
Not need intermaxillary fixation.
Not interfere with opposing occlusion.
Clear acrylic resin allow observation of tissue undercuts under the splint.
Easily constructed, easily adjusted and easily repaired.
Provide good oral hygiene (removable).
Retention from proximal embrassres and not need fully erupted crown.
Radiolucent: allow monitoring of fracture union by x-ray.
Removed easily to test union of the 2 fractured part.
Can incorporate undercut in soft and hard tissues.
Disadvantages:
Easily fractured as it not resist force of muscles in case of displacement of fractured segments
leading to misalignment of fractured segments.
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Dr. Mahmoud Ramadan
3. Fenestrated splint:
Indications:
Deciduous teeth with no clinical crown badly decayed teeth post radiation carries.
Construction:
Resemble labiolingual splint without button.
retention mechanically by friction into interproximal spaces.
fit the dentition of one arch through the fenestration of the occlusal surfaces, wire tags or
holes may be incorporated to the buccal flange to facilitate immobilization.
4. Occlusal waver splint:

Indications:
Used in intermaxillary fixation in patient whom occlusion is inadequate for providing a
positive index (ex: unilateral open bite).
Construction:
May be made from acrylic or metal, occlusal surfaces of both arches covered with the splint
and immobilization done with elastic bands and arch bar.
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Dr. Mahmoud Ramadan
5. Palatal occlusal splint:

Indications:
Fixation of maxillary segmental osteotomy fracture of maxilla.
Construction
Covers the palate, occlusal surface and incisal third of labial surface of anterior teeth.
Fixation to maxilla by inter-dental wiring and intermaxillary fixation is not necessary.
6. Gunning splint: (for edentulous patient)

Indications:
Edentulous patient to hold segments of fractured maxilla or mandible together in occlusion.
Types:
a) One piece gunning splint:
Upper and lower impression is made, if fractured segment displaced the cast is sectioned on
the fracture line and reassembled by plaster base.
Two shellac record bases and two wax rims are made on the casts.
Casts with record blocks are mounted on the articulator at proper vertical dimension and
horizontal relation.
Space created in the wax rim anteriorly from canine to canine for breathing, feeding and to
decrease postoperative vomiting.
Wax rims are sealed together and processed as one unit into acrylic resin.
After reduction of the fractured segments, the splint is immobilized extraorally with elastic
chin bandage (Barton bandage).
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Dr. Mahmoud Ramadan
b) Two pieces gunning splint:

Allow early mobility of the mandible after removal of intermaxillary fixation as separate
maxillary and mandibular stents are made:
Two shellac record bases and two wax rims are made on the casts.
Casts with record blocks are mounted on the articulator at proper vertical dimension and
horizontal relation.
Space in the wax wade anteriorly at mid line, wire hooks embedded in the buccal flange
and used for intermaxillary fixation.
Holes in the buccal flange are made for wiring the upper splint to the facial bones, root of
zygoma, infra-orbital bone, lateral orbital rim, nasal spine, malar bone and for
circumferential wiring of the lower splint in the area of first molar.
Male projections (buttons) about 3mm are made on the occlusal surface of one wax rim for
anchorage by self cure to the grooves (female) on the other wax rim during fixation (used as
an index to maintain centric position).
c) Modified gunning splint:

It is made by modifying existing complete denture as follows: repair the fractured denture,
remove upper and lower incisors, and fix upper and lower denture together by asking the
patient to bite on a piece of compound which may be left or processed into acrylic resin to
obtain one piece gunning splint.
Wire hooks are made on the buccal flange, holes are drilled on the upper denture flange for
wiring the upper denture to the facial bone to obtain two pieces gunning splint.
If existing denture lost fitness or develop occlusal discrepancies, use soft liner or tissue
conditioner, it also act as a cushion between hard acrylic resin and traumatized tissues.
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Dr. Mahmoud Ramadan
d) Gunning splint with training flange:

It is a 2 piece gunning splint.
Prevent deviation of the mandible to defect side after mandibular resection or after
irradiation due to fibrous tissue formation.
metal plate extend from the upper splint to the lingual surface pf the lower splint, so the
patient can't close except in correct relation.
at first, patient may use hand to guide the mandible to correct position then it becomes
involuntary by training of muscles.
7. kingsley splint: (for both edentulous and non edentulous patients)

Indication
Fixation of fractured maxilla only both in dentulous and edentulous patient.
Construction
Acrylic or cast metal base plate which covers the ridge, palate and the teeth is made.
Metal rod is extended from the anterior part of the base plate, emerged through oral
commissar bilaterally and attached to vertical rod by universal joint.
Extra-oral immobilization of fractured maxilla is made by elastic or plaster head gear.
Modified kingsley splint:
o Used in emergency to prevent fall of maxilla on the dorsum of the tongue to avoid
suffocation.
o The upper tray filled with compound and attached to maxilla, metal rods soldered to
the tray are protruded from the lip to join to the vertical rode by universal joint.
o The vertical rode terminate in flat plate embedded in plaster head gear.
8. Bite plane occlusal splint:

Indication
Bruxism trauma from occlusion tooth wear clicking pain tenderness premature
occlusal contact disc displacement.
Construction
If vertical dimension lost, squash bite wax is used to restore VD at correct centric relation or
centric occlusion, then processed into acrylic resin and retained by Adams wire clasp or
wired to the interproximal embrasures of the teeth.
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Dr. Mahmoud Ramadan
9. Lingual splint:
Used in para-symphyseal fracture of the mandible at midline to prevent collapse of

fractured segment lingually.
It is fixed with wire to the teeth or to buccaly placed arch bar(holes drilled for wire in
the acrylic at lingual embrasures).
Allow early movement of the mandible and prevent TMJ ankylosis as it not need
intermaxillary fixation.
10. Arch bar:

Used for single jaw fixation.
11. Wire splints:
Direct wiring: wiring of upper and lower teeth together.

Interdental wiring: wiring the adjacent teeth together across the line of fracture.
Eyelet wiring: wire eyelet is made interproximally at the line of fracture, each free wire
end rotate around tooth, enters the eyelet and tied.
Intra-osseous wiring: perforations around fracture line is made and the wire used
through it for reduction.
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Dr. Mahmoud Ramadan
Maxillofacial Stents
Def: removable appliance used to perform specific function as:
Control bleeding.
Protect the tissue from radiation, maintain tissue in position, carry radium in the
treatment of malignancy.
Carry medications.
Promote healing and decrease wound infection.
Protect teeth.
Protect skin graft and preserve the depth of vestibule after vestibuloplasty.
Materials:
1. Hard acrylic materials: heat cure, self cure acrylic resin, may be lined with soft liner
or tissue conditioner.
2. Soft materials: silicone vinyl rubber-poly vinyl vaccuform.
Types:
A. Intra-oral stents:
1. Anti-hemorrhagic stent.
2. Medication carrier.
3. Fluoride carrier.
4. Radiation stents (prosthesis for radiotherapy):
a. Radium applicator (carrier).
b. Positioning peri-oral cone (Docking device).
c. Displacement (positional) stent.
d. Intra oral radiation protective stent ( tongue protector).
e. Positioning dosemetric device stent.
f. Stent for recontouring tissue to simplify dosemetery.
g. Positioning radioactive source.
h. Positioning radioactive source after loading.
i. Stent used in direct implantation.
j. Stent used to prevent tongue and check biting.
5. Pedodontic stent.
6. Periodontic stent (labio-lingual stent- cosmetic stent).
7. Paraplegic stent.
8. Drainage stent.
9. Cyst plug.
10. Occlusal stent.
11. Mouth guard.
12. Oral screen.
13. Trismus stents:
a. T.M.J exerciser (dynamic bite opener).
b. Inflatable bite opener.
c. Intra oral prosthesis with inter arch spring.
14. Stent for vestibuloplasty.
15. Palatal stent.
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Dr. Mahmoud Ramadan
16. Stent for epulis fissuratum.

17. Stent for respected maxilla.
18. Stent for lip and check support.
19. Stents for implants:
a. Stent for surgical implant placement.
b. Stent for implant imaging.
20. Speech rehabilitation aid.
B. Extra-oral stents:
1. Extra oral radiation protective stent.
2. Stent for neck scar (burn stent).
3. Stent for nasal defect ( temporary nasal prosthesis).
4. Nasal stent.
5. Auditory stent.
6. Oro-facial plug.
A. Intra-oral stents
2. Anti-haemorrhagic stent:
Function:
Control bleeding in hemophilic patient after extraction if other measures used to control
bleeding (gentile pressure-haemostatic dressing as thrombin) failed.
Construction:
Primary alginate impression is made before extraction and diagnostic casts are mounted at
centric occlusion, increase vertical dimension of occlusion by 1mm.
Tooth to be extracted are removed from the cast, apply layer of wax on the ridge and
buccal and lingual to the ridge and make wax rim over extraction site, close the articulator
to make the opposing teeth touch the rim.
Process the wax in clear acrylic resin (RPD), then lined with soft liner and inserted
immediately after extraction, patient bite on it to control bleeding.
3. Medication carrier:
Function:
Carry medical paste (palliative paste) to contact oral mucosa in case of chemotherapy and
osteoradionecrosis.
Construction:
Acrylic base plate made on the diagnostic caste with relief space in the area of the lesion in
which palliative paste will be applied.
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Dr. Mahmoud Ramadan
4. Fluoride carrier:
Function:
Used in fluoride gel application to the teeth to protect it from carries (ex: osteoradionecrosis
after mouth preparation for RPD)
Construction:
Made of resilient material (vaccum machine) on the occlusal, buccal and lingual surfaces of
the teeth after covering these surfaces with tin foil to allow a space (reservoir) for fluoride
5. Radiation stents: (prosthesis for radiotherapy)

Function:
Protect or displace vital structures.
Locate diseased tissues in repeatable position during treatment.
Carry radio-active material to turner site.
Recontour tissue to simplify dosimetry.
Positioning of beam.
Requirement:
Stability retention in position during treatment.
Allow visualization of tissue (clear acrylic resin).
Has low weight.
Comfortable to the patient by (easy removed and replaced, permitting easy breath, lined e tissue
conditioner)
Easily repaired, cleaned, and adjusted.
Types:
a) Radium applicator (carrier):
Use:
Allow administration of pre-calculated dose to inaccessible area.
direct radiation to exact location in treatment of malignancy
Construction:
Primary alginate impression casts the area involved is out lined by radio therapist
base plate (heat self cure) clear acrylic resin to allow pressure area to be seen.
Types:
a) Wire carry radium capsule: fixed at 2ends e set cure to plate clone, wire adjusted so that
radiation directed to exact location.
b) Radiation material embedded in play-ethylene tubes: at fitting surface of base and covered
with self cure acryl. Rubber gloves impregnated with lead, protective shield must be used
during radium manipulation for self protection.
c) Soft irradiation applicator (lithium fluoride carrier):
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Dr. Mahmoud Ramadan
Advantages:
Simple, economic, efficient in irradiation of persistent superficial carcinoma.
Easy to control dose to various parts of lesion, if large does required, simply remove some
seeds
Construction:
Primary alginate impression cast outline surface to be irradiated with a pencil adapt
layer of base plate wax to outline. A line is drawn 1 cm beyond periphery lesion, strip of
beading wax attached to cast at this line, self lure acrylic resin extend 1cm beyond periphery
lesion in all directions. While the wax is soft hooks attached to it for retention of
prosthesis.
Grooves placed along inner surface of prosthesis in which nylon tubes embedded to average
depth 5 mm from inner surface in depth of each groove, tubes are parallel to each other at
interval of 1cm, extend 3-5mm out of the prosthesis.
Nylon ribbon contains radioactive seeds fit within hollow tube, prosthesis attached by hooks
(3 wire hooks) to modified orthodontic head gear maintained in stable position to
deliver desired amount of radiation.
b) Positioning peri-oral cone (Docking device):

Function
Positioning perioral cone and direct beam of radiation in exact position in repeated exposure
(beam director)
Deviate mandible, salivary glands and tongue from source of radiation (in treatment of the
lesions on anterior mandible - anterior floor of mouth - anterior hard palate).
Construction:
Edentulous: sheet of wax or tin foil applied to cone of radiation unit, cone attached to upper
and lower denture base of one piece gunning splint while mouth is opened, if dorsum of
tongue is elevated above cane wax extension used to deviate tongue.
Dentulous patient: cone attached with self cure to maxillary and mandibular occlusal index.
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Dr. Mahmoud Ramadan
c) Displacement (positional) stent:

Function:
Recontour or reposition tissues (in or out of) radiation field for exposure or protection ex:
tongue.
Deviate tongue toward radiation source (extraoral) and avoid radiation of salivary gland
which causes xerostomia.
Construction:
Dentulous patient:
2 sheets of base plate wax extended in flat plane to 2nd molar area, depress base of tongue to
lingual border of the mandible, prevent tongue from extend above occlusal plane, hole is
made in anterior portion, in which tongue tip rest reproducible position.
Edentulous patient:
Impression jaw relation: interim record (conventional steps of complete denture until JR
record) casts mounted on articulator, 2sheets of base plate wax attached to mandibular
record base to from stent that will depress tongue.
Also acrylic duplicate of old denture may be used and lined with tissue conditioner.
Direct tech:
Sheet of softened base plate wax formed in patient mouth to desired position over existing
dentition invested, processed in acrylic resin.
d) Intra oral radiation protective stent:

Function: Remove structures from radiation field.
Types:
A. Stent used to protect the maxilla, parotid gland (to avoid Xerostomia): by maximum
opening of the mandible (large one piece stent), if it is difficult to insert especially with
trismus use 2 piece stent.
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Dr. Mahmoud Ramadan
B. Stent used to protect the tongue (tongue protector): in treatment of buccal mucosa,
posterolateral border of tongue, alveolar ridge protect tongue and opposite side of
mandible.
Construction:
Patient is asked to bite on soft compound ball push check, tongue aside (made during
impression of mandible).
Mandibular and maxillary cast mounted on articulator at centric occlusion with incisal pin
opened 2-3mm 3-4 sheets of wax softened, placed between teeth form occlusal index.
Wax strip fit into lingual surface (concavity) created by compound lingual wax extension
is covered to create 1cm concavity then packed into acrylic resin.
Low fusing metal (lead-cerrobend) is melted and poured in cavity of acrylic resin
prosthesis, covered by acrylic resin or wax to decrease scattered radiation (2-3min
thickness lead if low voltage radiation, 5mm thickness lead if high voltage radiation used).
If patient is edentulous it is made on duplicate upper, lower denture.
Needle invested in acrylic resin of affected side to irradiate ridge growth.
e) Positioning dosemetric device stent:

Function
Measure exact amount of radiation (of lithium fluoride capsule).
Construction
Capsule wrapped by tin foil for separation. Self cure acryl wrapped around it (carrier).
Stent is stabilized by maxillary and mandibular record bases or interocclusal wax waver.
Hole placed in one end of stent, orthodontic wire used to push capsule out of resin.
Acrylic resin carrier attached to stent in appropriate position (made with compound to
detect good position).
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Dr. Mahmoud Ramadan
f) Stent for recontouring tissue to simplify dosemetery:
This stent used in radiation of skin of upper and lower lip, as in this site radiation at
corner of mouth is less than mid line of lip due to curvature of lip stent
is used to
flatten lip, corner of mouth entire lip at the same plane.
Made from modeling plastic, processed to acrylic resin.
g) Positioning radioactive source:

Carry source of radiation near lesion in treatment of lesions of (palate- buccal mucosa small superficial lesion at any area of mouth).
Source incorporated in denture base ex: maxillary denture base in treatment of recurrent
carcinoma of posterior wall of maxillary sinus.
h) Positioning radioactive source by after loading:

As positioning radioactive source except radioactive source placed in stent after stent
secured into position, placed in poly ethylene lube.
Used in: accessible superficial area to avoid exposure of the technician to radiation After treatment source removed, placed, in container.
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Dr. Mahmoud Ramadan
i) Stent used in direct implantation:

Some lesions as (tongue - anterior floor mouth) treated with direct implantation of
radioactive source in the tumor.
Prosthesis with tissue conditioner is used to secure position of radioactive source during
treatment and to achieve patient comfort.
j) Stent used to prevent tongue and check biting:
Irradiation of tongue and check lesions leads to edema, mucostis, check biting stent used
to displace tongue, checks, placed over teeth as mouth guard or fluoride carrier.
6. Pedodontic stent:
Function:
Used when unerupted tooth surgically uncovered to stimulate eruption to prevent closure of
uncovered tissue over the tooth.
Construction:
Make impression of the surgical site, poured, wax adapted over the cast and extend to the
surgical site to prevent its closure.
Disadvantages:
Sudden fall or accident which may lead to sub-luxation or damage to the tooth.
7. Periodontic stent (labiolingual cosmetic stent):

Function:
Hold periodontal dressing in place after periodontal surgery.
Used as cosmetic stent or protective prosthesis to cover exposed root surface especially in
anterior teeth.
Construction:
Diagnostic cast is waxed up (in the area of surgery- around exposed roots and in the
embrasures), wax is processed into acrylic resin, retention of the stent by friction with
interdental undercut or by wrought wire clasp if needed.
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Dr. Mahmoud Ramadan
8. Paraplegic stent:
Function:
Used as a mouth controlled device for handicapped patient in: feeding holding things dial
telephone tying painting pushing buttons).
Construction:
Upper and lower primary impression alginate is taken and the upper cast mounted with
face bow transfer and the lower cast mounted with centric inter occlusal record at proper
vertical dimension of occlusion (VDO).
Wax protrusive record is build up between opposing teeth to increase VDO by 2mm and
poly ethylene tube (10-12 inch) is waxed in a hole between 2 central incisors and the wax is
processed into acrylic resin, tested intra-orally and adjusted to harmonize condylar
guidance of the patient.
Entire thickness of intraoral prosthesis should not exceed 3mm to avoid interference of free
way space.
Arch shape metal frame may be embedded in the resin of the oral part to hold extra oral
aluminum tube. Active friction grip connector that accepts various attachments may be
attached to the stent. These attachments held in various devises which patient needs thus
the patient can change these devices himself.
To decrease lever forces on the stent: the stent should have maximum teeth coverage
(extend 2mm into the labial surface) to maximize distribution of forces over large number
of teeth.
9. Drainage stent:
Function:
Drain fluid and blood from periapical infection in endodontic therapy.
Construction:
Primary impression used to produce stone casts, fistula enlarged to form a hole on the cast.
15mm gauge poly ethylene tube is inserted in the hole, and labial surface of the cast is
covered with base plate wax around the tube, the wax is processed into acrylic resin as
apart of RPD.
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Dr. Mahmoud Ramadan
10. Cyst plug:

Function:
In large marsuplized cyst to prevent closure of its opening.
Construction:
Acrylic buccal flange extend into cyst cavity but not reach full depth to not interfere with
cyst wall as cyst decreases in size. Buccal flange extend to buccal sulcus to prevent falling of
the plug deep into cyst cavity. Buccal flange also help the patient to remove the plug.
Gradually reduce the depth of acrylic plug as cyst decrease in size until complete filling of
the cyst cavity.
If the patient has a denture, the plug will attached to it.
11. Occlusal stent:

Function:
Diagnosis and treatment of occlusal prematurities or cuspal interferences.
Increase or decrease vertical dimension of occlusion.
In treatment of TMJ dysfunction (relief of acute pain, symptoms by repositioning of
condylar head into glenoid fossa).
Construction:
Acrylic resin adapted to maxillary and mandibular teeth with opposing occlusal surfaces
free of prematurities.
12. Mouth guard:

Function:
Protect teeth and jaws from injury in boxing contact sports.
Protect fixed restoration when surgery will be made under general anesthesia.
Construction:
Upper and lower primary alginate impression is made and the casts mounted on the
articulator.
3-4 mm thickness of resilient material as (plastic sheets of vacuum machine- silicone
polyvinyl rubber) adapted to the upper cast (to be stable, retentive and not interfere with
tongue) and cover labial and occlusal surface, border trimmed, finished and smoothed.
13. Oral screen:

Function:
Stimulate nasal breathing.
Prevent thumb sucking-prevent lip biting.
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Dr. Mahmoud Ramadan
Construction:
Alginate impression including the reflection of the buccal sulcus of both jaws are made,
casts are mounted on the articulator at correct centric occlusion or centric relation.
2 layers of wax are adapted to the labial surface upper and lower teeth and extended to the
depth of the sulcus , processed into clear acrylic resin, it should not interfere with labial
frenum or muscle attachment and all pressure areas on attached gingival and movable
tissues are relieved.
14. Trismus stents:

Causes of trismus:
a) Acute trismus: trauma, inflammation and infection from perichoronitis, impaction, pain
from inferior alveolar nerve block.
b) Chronic trismus: TMJ dysfunction disc displacement joint disease (rheumatoid
arthritis osteoma of condyle TMJ ankylosis) radiotherapy in resected maxilla or
mandible muscle atrophy from intermaxillary fixation.
Management:
a) Medical treatment: antibiotics- anti-inflammatory- muscle relaxant.
b) Physical treatment:
Exercise: opening of mouth as possible 20 times/3-4 times on day down ward pressure
on the mandible (8-10 times for 10 second).
Mechanical devices:
a. Tapered threaded acrylic screw:
base plate wax is twisted to form a screw with desired taper, then processed into acrylic
resin.
it is turned between teeth, it exert opening force on the mandible and wedge teeth apart.
b. Tongue depressor:
Painted with petroleum jelly and placed between the 2 arches to exert a unilateral force by
the patient.
c. Inflatable bite opener:
Pediatric blood pressure bag inserted and inflated between maxillary and mandibular stents
to force stents apart.
Pressure maintained for 10 seconds followed by 1 minute rest and the procedure repeated
for 10 minutes / 3 times per day.
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Dr. Mahmoud Ramadan
d. Intra-oral prosthesis with inter arch spring:

Spring clips attached to mandibular acrylic stent and its free end locked into a latch in the
maxillary stent. This will apply bilaterally constant force which can be controlled by
adjusting the spring.
It is used for both dentulous and edentulous patient.
e. T.M.J. exerciser (dynamic bite opener):
Function:
Apply bilateral force to remove fibrosis of the trismus.
Construction:
Upper and lower alginate impression is taken in shallow stock tray (as trismus present) after
coating the tray with adhesive and the casts are mounted on the articulator.
2 horse shoe shape stainless steel perforated metal plates adapted between occlusal surface
of upper and lower teeth to receive acrylic resin maxillary and mandibular occlusal stents (3
mm thickness). The acrylic occlusal stents have mechanical retention from the perforation
of the plates. Teeth are lubricated and mix of self cure acrylic resin is applied over the upper
and lower plates and the patient bite in centric occlusion to form upper and lower occlusal
stents.
2 metal rods are welded to the buccal flange of upper and lower metal plates and extending
backward from the commisure of the mouth extra-orally.
Maxillary rod extend back ward in the temporal region where it bend down ward to form a
U-shaped crimps in the area of premolars, mandibular rod bent upward to form a U-shaped
crimps in reverse direction to the maxillary crimps.
Mandibular rod is parallel to the occlusal plane and maxillary rod is place 10-15 mm buccal
to mandibular rod. Elastic bands stretched between upper and lower crimps which exert
bilateral positive seating forces on the upper and lower occlusal stents and opening force on
the mandible.
If the patient was edentulous, the metal rods attached to the buccal surface of the denture
base but detection of the fulcrum exerted by the rods is very important to decrease tipping
of the denture base.
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Dr. Mahmoud Ramadan
15. Stent for vestibuloplasty and skin graft:

Function:
Reposition the muscle attachment and prevent its reattachment at higher level near the crest of
the ridge during healing period after sulcus deepening.
Protect and immobilize the graft, prevent hematoma formation, decrease ischemia of the graft,
help the graft to takes, carry medications, make the patient more comfortable.
Construction:
Modification of the ridge and sulcus depth is made on the cast after consultation with the
surgeon, modified cast is waxed, flasked and processed into clear acrylic resin (to permit seeing
of the pressure area in the mucosa) which is overextended to the new sulcus depth.
If the graft is used it is placed on the stent with its raw surface facing upward.
The stent may be lined with the soft liner, immediately fitted after surgery, may be wired to the
ridge if required ( circumferential wiring) and kept in mouth for few weeks till complete
healing.
Old denture may be modified by extending its border with self cure acrylic resin on the
modified cast and used as a stent for vestibuloplasty.
16. Palatal stent:

Function:
Cover the palate after palatal surgery as (palatal mucosal graftremoval of papillary hyperplasia - torus platinus) to protect the
healing surface and apply medications.
Construction:
Primary maxillary alginate impressions used to make diagnostic cast
before surgery, remove torus platinus or palatal hyperplasia from the
cast.
Acrylic plate is made on the modified cast to cover the palate and wrought wire clasps are made
on the teeth for retention.
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Dr. Mahmoud Ramadan
After surgery, the stent is lined with tissue conditioner and placed on the palate , left in mouth
for 24 hours till healing occurs.
If upper complete denture is present it is used as a palatal stent.
17. Stent for Epulis fissuratum:

Function:
Maintain sulcus depth and prevent obliteration of the sulcus due to fibrous tissue formation after
removal of epulis fissuratum.
Construction:
Primary maxillary alginate impression used to make diagnostic cast before surgery, remove
the epulis fissuratum from the cast and acrylic plate is made on the modified cast to the proper
sulcus depth.
After surgery, tissue conditioner applied to the stent till healing occurs.
If the old denture present it may be used as a stent after modification of its border.
18. Stent for respected maxilla: (Immediate surgical obturator)

Function:
Carry medications and dressing to the surgical site to improve healing and decrease wound
contamination (act as a matrix).
Carry skin graft to the surgical site to improve support, stability and retention of the obturator
(compound used on the stent to support the skin graft).
Restore normal palatal contour and allow the patient to speak and swallow normally after
awaking from anesthesia.
Allow early removal of nasogastric tube.
Improve patient psychology: restore patient self image and allow the patient to function
normal with society.
Construction:
Look in immediate surgical obturator.
19. Stent for lip and check support:

Function:
Support lip and check in facial nerve paralysis (Bells pulsy)- mid facial defects (resected
anterior maxilla and upper lip and nose): these diseases affect speech by decrease valve seal
mechanism of articulation of orbicularis oris muscle and buccinator muscles which lead to
sagging of muscles of check, lip and corner of the mouth on the affected side and abnormal pull
of muscles toward intact side and difficulty to control saliva (saliva dribbling).
Construction:
Open looped half rounded wire (hook) attached to the buccal surface of maxillary RPD at
premolar area and covered with acrylic resin to support upper lip and the corner of the mouth.
After frame work of RPD casted, the wire loop covered with wax to produce the desired lip
support, then the wax replaced with acrylic resin.
Retentive mesh work instead of wire loop may be used in the area of premolars, modeling
compound used to produce desired lip support then replaced with acrylic resin (advantages:
improve facial sagging, more esthetic, improve labiodental sound more than wire loop).
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Dr. Mahmoud Ramadan
20. Stents for implants:

a. Stent for surgical implant placement:
Function:
Determine site of implant placement and implant angulations especially in the anterior
maxillary region.
Construction:
RPD: A) clear acrylic resin stent perforated at implant site.
B) Vacuum formed stent with holes prepared at implant site and it should have positive
tissue stops to be firm, stable during surgery.
CD: old denture may be used as surgical stent with holes prepared at proposed implant sites.
b. Stent for implant imaging: (radiographic stent)

Function:
Detect bone quantity and bone quality at site of implant placement.
Construction:
(a) Poly vinyl stent: modified by filling the teeth at implant site with radio-opaque material
as barium sulfate ball bearing metal cylinders (tubes).
(b) Processed clear acrylic resin: holes drilled in teeth and filled with gutta-percha.
(c) Acrylic stent contain radio-opaque teeth.
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Dr. Mahmoud Ramadan
B. Extra-oral Stents:
1. Extra oral radiation protective stent:
Function
Protect extra-oral organs from effect of radiation ex; basal cell
carcinoma of eye lid- seqamous cell carcinoma of lip.
Construction:
Lead mask cover most of the face, fenestrated for passage of
radiation beam. At least 3-4mm thickness lead covered with
acrylic to prevent scattered radiation which is harm full to
adjacent tissue.
2. Stent for neck scar: (burn stent)

Function:
Neck burn cause extensive scar formation after healing leading to disfigurement so surgery
needed to release scar band and place split thickness skin graft that should be closely
attached to the tissues by custom made stent in order to takes and decrease formation of
hypertrophic scar again.
Construction:
Primary alginate impression is taken to the burned neck which should extend beyond the
margin of the graft, if the burn extended to the nares oral tube is used to maintain air way.
Impression is casted and 2 layer wax spacer are applied on the cast to provide a space for
the soft liner to be applied inside the stent. Wire hooks are made and self cure acryl is
applied on the wax spacer to produce the stent.
Holes drilled in the stent to make mechanical retention of the soft liner which support the
skin graft.
Stent secured in place with loop tape attached to the wire hooks, worn 24 hours/day and
removed only to exchange the soft liner till complete healing occurs.
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Dr. Mahmoud Ramadan
3. Stent for nasal defect: (temporary nasal prosthesis)

Function:
Worn 3-4 weeks after surgery to improve patient appearance till complete healing of the
surgical defect then definitive nasal prosthesis made.
Construction:
It is made of heat cure acrylic resin and lined with tissue conditioner and its retention with
medical grade skin adhesive.
Impression to the defect is made with thin alginate (by adding water) with patient in
upright position to avoid distortion of the tissue bed, block nasal cavity with gauze to
prevent entrance of impression material, impression poured to produce the cast.
Wax pattern is made and processed into heat cure acrylic resin of suitable color with
smooth transition between stent margin and adjacent tissues, the inner surface should be
hollowed to decrease the weight.
4. Nasal stent:
Function:
Support nasal cartilage transplant during healing of normal nasal deformity in cleft lip.
Decrease scar contraction following skin graft to the nostril.
Widen nostril in burned patient prior to graft procedure.
Restore nasal air way passage if obstruction occurs.
Construction:
Impression with green stick compound is taken to the nostril and poured to produce a cast,
wax pattern is made then processed into clear acrylic resin.
The acrylic resin stent is hollowed to maintain air way and tinted with intrinsic stain as skin
color to be less noted by eye.
In case of enlarging nasal air way use series of stents of increasing size or use expandable
nasal stent (have orthodontic expansion screw in the lumen of sectioned stent).
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Dr. Mahmoud Ramadan
5. Auditory stent:
Indications:
In surgical reconstruction of external auditory meatus.
mastoid surgery in patients wearing hearing aids.
protect swimmer from chronic ear infections.
Allow anasethiologist to prolong monitor the patient during extensive surgery.
Construction:
It is made from acrylic resin, polyvinyl-silicone.
Cotton wrapped around dental floss and inserted in external auditory meatus leaving 3mm of
floss exposed.
Free flowing alginate impression is loaded into a syringe and injected into the meatus and ear
pinna. The impression is poured, floss removed.
Mold splitted into 2 halves, lubricated with petroleum jelly and filled with acryl or silicone,
extend beyond ear pinna to facilitate orientation and tinted with the color of skin.
6. Oro-facial plug:
Indication:
To plug skin fistula resulted from infection or done dehiscence which lead to opening on the
outer akin and dribbling of saliva.
Construction:
Impression alginate is taken to the opening, cast is scrapped at the site of the fistula, wax
applied to the defect and flanges made for retention, wax processed into silicone rubber, tinted,
flushed with adjacent tissues for esthetics until corrective surgery is made.
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Radiation and Radiotherapy Prosthodontics
Types of Radiation:
Factors affecting rate of damage:
General tissue effects of radiation:
[ I ] Immediate effects:
[ II ] Delayed effects:
Radiotherapy Prosthesis:
Def.:
Objectives:
Requirements:
Types:
1- Carrier applicator.
2- Director appliance.
3- Maintaining the structure of the tissues to be treated.
4- Tongue protector (shielding).
5- Prevention of tongue and cheek biting.
6- Positioning of the radioactive source (Dosimentric device).
7- Recontouring tissues to simplify dosimetry.
Dental management of irradiated patient:
- Treatment procedures will be divided to:
a) Pre-irradiation treatment.
b) Post-irradiation treatment.
c) Prosthodontic treatment.
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Dr. Mahmoud Ramadan
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Dr. Mahmoud Ramadan
Radiation and Radiotherapy Prosthodontics

Types of Radiation:
1- Waves:
a) Short waves deep penetration more damage.
b) Long waves less penetration less damage.
2- Beams.
3- X-rays.
4- Implants (Radiation Implant seeds).
Factors affecting rate of damage:
1- Dose: Increase the dose Increase the damage.
2- Mode of delivery of radiation:
a) External source ( Increase damage to adjacent structure ).
b) Interstitial radiation therapy ( e.g. needles tubes wires small seeds ).
3- Sensitivity to radiation: the embryonic cells are more sensitive than differentiated cells.
4- Mass of irradiated tissue: increase the mass exposed to radiation increase damage of
tissue.
5- Radical neck dissection: decrease the blood supply increase the risk of damage.
6- Type of radiation:
a) Gamma rays.
b) X-rays.
c) Electron beam.
7- Obesity: increase the obesity increase the damage.
8- Age of the patient: increase the age increase the damage.
General tissue effects of radiation:
[ I ] Immediate effects:
1- Epithelium:
a) Histological picture: epithelium is pale, thin, low keratin, decreased vascularity and
increase fibrous fibers.
b) Prosthetic problems: long time ulcers intolerable prosthesis.
2- Buccal mucosa:
a) Vasodilatation of blood vessels.
b) Inflammation of submucosa.
3- Lip, cheek and tongue:
a) Sloughing of the mucosa.
b) Overgrowth of candida.
c) Increase sensitivity to spicy, hot and cold food.
4- Salivary glands: decrease saliva Xerostomia.
5- Skin: redness, swelling and erosions.
6- Corner of the mouth angular chelitis.
7- Eyes:
a) Conjunctivitis.
b) Depilated lashes and brows.
8- Weight loss and dyspnea.
- The treatment is supportive and symptomatic saline rinses, systemic analgesics,
Nystatin and local anesthesia.
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[ II ] Delayed effects:
1- Salivary glands:
a) Decreased amount of saliva.
b) Increased viscosity of saliva.
c) Decreased the PH of saliva.
d) Difficulty in swallowing.
- Prosthetic effects: the patient can't tolerate his prosthesis due to more friction during
function as saliva acts as an effective lubricant. Retention is compromised, as the
peripheral seal may be difficult to obtain.
2- Eyes: Damage to eye lenses Cataract.
3- Teeth and Periodontal ligaments:
a) Decalcification.
b) Sensitivity.
c) Destruction of tooth bud.
d) Arrest teeth growth.
4- Tongue and mucosa: partial and complete loss of taste.
5- Diet: loss of appetite, nausea and pain.
6- Skin: Erythema, ulceration and pigmentation.
7- Bone: maxillary bone effects is more than the mandibular due to more radiation
absorption osteoradionecrosis.
8- Trismus: when the T.M.J and muscles of mastications are in field 3-6 months after
therapy fibrosis of muscle fibers, impaired mastication and limited mandibular
movements 10 to 15 mm. Treatment: includes exercising and the use of dynamic bite
opener.
9- Edema.
Radiotherapy Prosthesis:
Def.: Stents used to help the radiotherapist in the treatment of oral malignances by radiation.
Objectives:
1- Reduce the side effects of treatment.
2- Protects the tissue not important for exposure.
3- Enable lowering the field of radiation (protect the parotid gland).
4- Safer for radiotherapist in treatment.
5- Increase the accuracy of radiation source (ensure that area of exposure is the same each
time).
6- Decrease patient discomfort and injuries (increase patient cooperation).
Requirements:
1- Comfortable to the patient.
2- Minimal weight more tolerated by patient.
3- High retention and stability this prevent displacement of radiation source during
therapy.
4- High accuracy.
5- High strength to resist breakage (acrylic resin).
6- Easy to clean and repair (smooth) soft brush, soap and water are sufficient to clean the
prosthesis.
7- Allow the patient to breath easily perforation performed through the prosthesis.
8- Allow visualization of tissues clear acrylic resin allow for tissue observation during
procedures.
9- Easy to be inserted and removed by patient.
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Types:
1- Carrier applicator.
2- Director appliance.
3- Maintaining the structure of the tissues to be treated.
4- Tongue protector (shielding).
5- Prevention of tongue and cheek biting.
6- Positioning of the radioactive source (Dosimentric device).
7- Recontouring tissues to simplify dosimetry.
Dental management of irradiated patient:
- Treatment procedures will be divided to:
a) Pre-irradiation treatment.
b) Post-irradiation treatment.
c) Prosthodontic treatment.
a) Pre-irradiation treatment:
- The following must be removed:
1- Teeth in the field of radiation must be extracted prior to therapy to avoid
osteoradionecrosis.
2- Periodontal involved, badly decayed or questionable teeth should be removed before
therapy.
3- Sharp bony specules.
- The following must not be removed:
Teeth within tumor to avoid dissemination of tumor cells.
- The following could be left:
Teeth of unaffected side if radiotherapist allow that.
b)
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Post-irradiation treatment:
Conservative, strict oral hygiene rinses with H2O2 or warm saline.
Antibiotics and analgesics in case of infection or pain.
Any surgical intervention is contraindicated massive tissue loss.
Prophylaxis against tooth decay ( treatment by 10% stannous fluoride application ).
c) Prosthodontic treatment:
- Placement of Dentures (Timing):
Denture construction for irradiated patients should made if 12 14 months had
elapsed for mucosal healing. Some patient may wait 2 3 years before mucosa has recovered
sufficiently to tolerated denture.
- Two groups to consider:
1Patients edentulous prior to radiation therapy and having denture
experience new denture can be made after mucositis has resolved.
Denture bearing area should be checked with PIP before insertion.
2Patients undergoing pre-radiation or post-radiation extraction with denture
after completion of radiation denture bearing should be examined
contour, irregularity and scar before denture fabrication.
- Success of prosthodontic treatment depends on:
1- Pre-operative data.
2- Through oral examination.
3- Prosthodontic treatment (Non traumatic and non irritating denture).
4- Effective follow up system.
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[ I ] Preoperative data:
1- Type and size of tumor.
2- Mode of therapy.
3- Total dose.
4- Data of treatment.
5- Radiation fields.
6- Tumor response.
7- Prognosis of tumor.
[ II ] Oral examination:
1- Routine examination for denture:
- The entire oral cavity should be examined visually and palpated for any soreness.
- Appearance of oral mucosa.
- Scarring and fibrosis at tumor site.
- Degree of trismus.
- Salivary function.
- Tori.
- High tissue attachments.
- Enlarged maxillary tuberosity.
- Flabby tissue.
- Abnormal jaw relation.
2- Undercuts are undesirable to engaged, if they are present in field of radiation.
3- Surgery is contraindicated.
4- Post-irradiation symptoms. e.g. pain, Xerostomia and trismus.
5- Patient warned of possibility of osteoradionecrosis.
[ III ] Prosthodontic procedures:
1- Impression:
- 1ry impression: should be made with alginate and not compound.
- Xerostomia: should be treated by using petroleum jelly.
- Border molding: Done by using low fusing wax or heavy rubber base. The lingual flange
shouldn't used to gain more retention and only for stability.
- 2ry impression: should be made with rubber base.
2- Jaw relation:
- Low vertical dimension of occlusion offers low forces and less trismus.
- Centric relation record should be achieved with no trauma.
3- Try-in:
- Modified anatomical or flat teeth should be used to decrease the horizontal forces.
- Denture base should cut away to minimize irritation.
4- Insertion:
- Any roughness or sharp angles should be removed.
- Silicone soft liners may be used to minimize mucosal trauma.
[ IV ] Follow-up:
- The patient follow-up performed daily for about 2 weeks.
- Then patient follow-up performed once every 3 months.
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Prosthetic Management of Mandibular Defects
Etiology:
1- Neoplasm
2- Trauma
3- Congenital defect.
4- Osteoradionecrosis.
Classification of mandibular defects:
a) Marginal Resection ( Continuity defects)
1- Anterior marginal resection.
2- Lateral marginal resection.
b) Segmental resection ( Discontinuity defects)
- Complications.
- Treatment.
- Prosthetic rehabilitation:
o Intermaxillary fixation.
o Resection guidance restoration. (Types Technique of fabrication)
o Speech aid appliances. (Types Technique of fabrication)
Prosthetic rehabilitation of dentulous patient:
1- with lateral discontinuity defects:
a) Partial denture design.
b) Altered cast impression.
c) Clinical procedures.
2- with mandibular continuity defects:
a) Anterior defects.
b) Lateral defects.
Prosthetic rehabilitation of edentulous patient:
- Factors compromise use of complete denture.
- Factors determining prognosis of complete denture.
- Procedures:
a) Impression.
b) Centric relation.
c) Determining vertical dimension of occlusion (V.D.O.)
d) Determining centric occluding relation (C.O.R.)
e) Occlusion.
f) Processing, delivery and follow up.
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Prosthetic Management of Mandibular Defects

a) Marginal Resection ( Continuity defects):
Superior resection of the alveolar bone leaving the inferior border intact.
1- Anterior marginal resection:
- May include part of the tongue and floor of the mouth if the arch isn't restored in a
short time remaining teeth will be no longer in the neutral zone and the buccal
musculature will cause severe lingual tilt of remaining teeth so, selective extraction and
use of labial bar major connector design will improve the condition.
- After resection an interim prosthesis must be fabricated and inserted during healing
period to prevent collapse of mandibular segment.
- R.P.D. design will be typical to class IV design.
2- Lateral marginal resection:
- Definitive prosthesis is constructed after sufficient healing period has passed.
- The most important considerations:
a) Firm and non movable tissues.
b) With normal buccal and lingual vestibular depth is favourable.
- R.P.D. framework design will be typical to class II design.
b) Segmental Resection ( Discontinuity defects):
Complete resection of a segment of the mandible from the alveolar crest to the inferior
border of the mandible.
Resection often in the region of 2nd premolar and 1st molar.
Resection should be through the alveolus of an extracted tooth rather than interdental
bone to:
1- Preserve supporting bone distal to the last tooth.
2- Used as 1ry R.P.D. abutments.
- Increase the size of the resected mandible increase degree of severity.
-
Complications:
1- Deviation of the mandible towards the resected side:
- Determinants of normal mandibular movements are:
a) T.M.J.
b) Neuromascular complex.
c) Dentition.
- So, when continuity of the mandible disrupts causes: mandibular imbalance and discontinuity
deviation due to scar contraction and muscle adhesion.
2- Traumatic occlusion.
3- Pain and discomfort.
4- Tension to T.M.J., ligaments and muscles.
5- Improper speech.
6- Improper mastication and swallowing.
Treatment:
a) Surgical reconstruction: Alloplastic implant with or without bone graft.
b) Prosthetic rehabilitation:
1- Intermaxillary fixation.
2- Resection guidance restoration.
3- Speech aid appliances.
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1- Intermaxillary fixation:
- Immediate fixation in order to:
a- Preventing or minimizing deviation post-surgically.
b- It helps the patient to preserve the proprioceptive sense of occlusion.
- Technique:
1- Maxillary & mandibular cast from post-surgical impression are essential for
intermaxillary fixation.
2- Arch bars or labiolingual splints Dentulous patient.
3- Gunning splint Edentulous patient.
2- Resection guidance appliances:
- About 2 weeks post-surgically, the patient should practice an exercise program:
a) Maximum opening.
b) Moving the mandible to the unaffected side.
- These movements tends to:
a) Loosen scar contraction.
b) Reduce trismus.
c) Improve maxillo-mandibular relationship.
- Increase severity of resection as in classical radial neck dissection or in radiation therapy
or increase time after surgical procedure increase the difficulty of guidance procedure
and increase occlusal problems.
- If the teeth aren't present guidance isn't effective.
- If only mandibular teeth are present guidance is possible.
- If mandibular and maxillary teeth are present guidance is effective.
- Guidance prosthesis is used as interim prosthesis until acceptable occlusal relationships
and proper proprioception are reestablished it will discarded or reinforce the
proprioceptive mechanism.
Types of resection appliances:
a) Mandibular resection appliance (Mandibular guiding flange):
- It's R.P.D. framework with a metal flange extend 7-10 mm lateral and superior on the
buccal aspect of the bicuspids and molars on non-defect side.
- This flange engages the maxillary teeth during mandibular closure direct the mandible
to proper intercuspal position.
- R.P.D. framework must be suitably stable and retained to counteract lateral forces
generated during closure.
- It may be constructed from:1) Cast Chrome-Cobalt metal: Mandible can position comfortably to acceptable position.
2) Acrylic resin: Some resistance is encountered in positioning of the mandible.
- Fabrication:
1) Construction of suitable mandibular and maxillary casts.
2) Wax interocclusal record to mount diagnostic casts.
3) Surveying of the diagnostic cast of the mandible.
4) Design of R.P.D. framework is outlined framework design should positively engage
most of the remaining dentition to prevent teeth movement.
5) The guidance ramp is usually designed to extend from a continuous clasp along the buccal
surfaces of the bicuspids and molars.
6) If autopolymerized resin is to be used to form the guidance ramp a retentive
meshwork is extended from the continuous buccal clasp of non-defect side.
7) The R.P.D. framework is formed as conventional R.P.D.
8) The waxed up framework should be viewed by clinician before casting.
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Dr. Mahmoud Ramadan
9) If the complete guidance ramp is to be formed in acrylic resin it shouldn't touch or

interfere with the maxillary teeth during a guided closure. (7-10 mm)
10) The prosthesis is applied to patient mouth to verify the guidance.
11) Some patients will have difficulty in engaging the ramp with buccal surface of maxillary
teeth manual manipulation of the mandible is necessary.
- Acrylic Ramp Vs Metal Ramps: Acrylic ramps are advantageous because:
1) Periodic revisions and adjustments of the ramp are possible.
2) The final desired position doesn't have to be achieved with the 1st application of acrylic
resin.
b) Maxillary guidance ramp:
- Preferred for patients with severe mandibular deviation.
- Constructed of acrylic resin or cast or wrought wire retainers.
- It serves as interim prosthesis until acceptable occlusion is established.
- Technique:
1st Visit:
1) Full palatal coverage prosthesis is constructed following conventional prosthetic
guidelines and then fitted and adjusted in the mouth.
2) Mandible is guided until proper occlusion occlusal contact with palatal prosthesis is
noted.
3) Prosthesis is removed and a mix of autopolymerized acrylic resin is prepared and added
to the palatal prosthesis along lateral and anterior borders of non defect side.
4) The prosthesis replaced in the mouth and mandible is moved to desired position forming
a palatal index lingual to maxillary teeth.
5) The prosthesis is then removed to allow for completion of polymerization.
6) Smoothing, finishing and polishing patient instructed to wear the prosthesis
continually.
7) The index shouldn't extend below level of maxillary teeth, because:
a) Interfere with speech.
b) Interfere with deglutition.
c) Interfere with other oral functions requiring tongue manipulation.
2nd Visit:
1) The mandible will usually exhibit more movement laterally toward non surgical side.
2) Adjustment of palatal ramp is done to enable the mandible to assume proper maxillomandibular relationship.
3) When intercuspal position is achieved Mandibular guidance prosthesis is required.
Success of mandibular guidance therapy varies and depends on:
1) Nature of surgical defect.
2) Early initiation of guidance therapy.
3) Patient cooperation.
4) Radiation therapy.
5) Amount of soft tissue dissection.
3- Speech aid appliances:
- Factors that predispose to misarticulation of speech sounds:
1) Following mandibular resection oral cavity decrease in size and portion of the tongue
is excised or used for wound closure.
2) The sensory and motor innervations of the tongue may be compromised.
3) The sensory and motor innervations of the lips and cheeks are compromised by 1ry
mandibular resection and radial neck dissection.
4) Varying amounts of mandible and number of teeth are removed.
5) Mandibular movements are altered.
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Dr. Mahmoud Ramadan
6) Radiation therapy Xerostomia.

Types of speech aid appliances:
I Palatal speech aid:
- Constant sounds as "g & k" required valving by posterior surface of the tongue with
posterior part of hard palate and anterior surface of soft palate very difficult for
mandiblectomy patient.
- If the palatal vault was lowered prosthetically into the space to accommodate for
restricted tongue movements speech improvements might be noted.
- Restriction of tongue movement is divided to:
a) Extreme restriction: inability to contact either palate or maxillary teeth with tongue.
b) Moderate restriction: partial tongue contact with palate or maxillary teeth during
speech.
- The palate is lowered by means of retainer for dentulous patient and palatal acrylic resin
extension onto the upper complete denture for edentulous patient.
- Functional impression of the dorsal surface of the tongue is done with hollow palatal
speech prosthesis.
- After 2 weeks a test should be done with 10 words contains "k & g".
II Tongue prosthesis:
- Articulation is compromised in patients requiring total glossectomy.
- Silicone rubber tongue prosthesis placed following surgery improving quality of
speech and help deglutition.
a) Lateral discontinuity defects:
[ I ] Partial denture design:
- Major connector rigid.
- Occlusal rest direct the occlusal forces along the long axis of the tooth.
- Guiding planes enhance retention and stability.
- Retention within the limits of physiologic tolerance of PDL.
- Support maximum support should be gained from adjacent soft tissue.
- Retainer, minor connector & proximal plates don't express excessive lateral forces on
the remaining teeth during function.
- Cleansability good oral hygiene and prevent plaque accumulation.
- Rotation of mandible causes the resected side to drop down out of occlusion as the
force of contraction of unresected side is increased.
- Location of fulcrum line isn't so easy determined.
- The forces of occlusion are unilateral and the fulcrum line of the partial denture deviate
from normal.
[ II ] Altered cast impression:
- After fabrication of partial denture framework altered cast impression for edentulous
areas.
- We made lingual extension on the unresected area provide added retention and
stability for the prosthesis.
- Maximum soft tissue coverage is always done.
[ III ] Clinical procedures:
1- Altered cast impression is obtained.
2- Impression is boxed with segmented master cast and poured.
3- Centric occluding relation record is obtained wax is soften and the mandible is guided
to the determined position.
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Dr. Mahmoud Ramadan
4- Selection of denture teeth is dependent on configuration of the opposing teeth.

5- When occlusal relationship isn't ideal It may be necessary to establish an occlusal
ramp lingual to maxillary teeth on the unresected side.
6- Delivery as conventional dentures but take care from soft tissue extension on the defect
side because, little sensory innervations.
7- Check over extension of borders and dislodgement.
8- Recall visits is important.
b) Mandibular continuity defects:
[ I ] Anterior defects:
There are 2 groups of patients:
1- Patients with anterior inner table resections.
2- Patients with anterior composite resections.
- Both types of patients have posterior teeth and extensive anterior edentulous ridge.
- There is a need for Kennedy class IV partial denture.
The length of the edentulous area depends on:
1- The extent of the surgery.
2- Number and location of posterior teeth.
- In patients with inner table resection the occlusion of posterior teeth is rarely altered
Patient with surgically restored anterior continuity defects may display:
1- Occlusal abnormalities due to graft contraction.
2- Improper positioning of mandibular fragment at the time of surgical reconstruction.
3- Unusual soft tissue configuration.
4- Compromised bony support.
5- Lack of attached mucosa.
6- Obliteration of vestibules.
7- Movement of either lip or tongue prevent the efficient engagement of this bearing
surface by the prosthesis.
8- Tissue band are easily irritated by the prosthesis.
Prostheses for these patients enhance:
1- Esthetics.
2- Support for lower lip and cheek.
3- Improve speech.
4- Enhance control of saliva.
Partial denture design for anterior defects:
1- Long or extended mesial rest on 2nd molar to provide means of indirect retention.
2- Relieve the proximal plates and the distal aspect of the minor connectors for expected
movement of framework during expression of occlusal load.
3- Impression technique:
a) Edentulous areas recorded with altered cast impression technique.
b) Thermoplastic wax is preferred than other elastic impression material more accurate.
4- Try-in procedure: Esthetics, occlusion & speech should be verified.
[ II ] Lateral defects:
Partial denture design for lateral defects:
1- Maximum tissue coverage is must.
2- Continues rest parallel to axis of rotation.
3- Anterior and posterior proximal plates moves freely during function.
4- The buccal and labial retainer placed at maximum height of contour.
5- The lingual retainer engaged an undercut area.
6- Occlusion should be verified in centric.
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Factors compromise the patient ability to function with complete denture:
1- Stability, retention and support compromised.
2- Radiation therapy atrophic, fragile and ulcerated oral mucosa.
3- Decrease saliva (thick ropy saliva) decrease retention.
4- Angular pathway of closure :
a) Increase lateral forces on denture dislodgement.
b) Abnormal jaw relationship.
c) Abnormal profile and position of mandible in relation to maxilla compromise ideal
placement of teeth.
5- Impairment of motor and sensory control of the tongue, lip and cheek.
Factors determining prosthetic prognosis for complete denture:
1- The extent of the bony and soft tissue resection.
2- The location of the bony resection.
3- The status of the remaining tongue. (acts as mean for displacement due to lack of
neuromuscular control of the tongue).
4- The position of the tongue. (resection of base of tongue protrusion no peripheral
seal).
5- Mandibular deviation and characters of mandibular movements.
6- Radiation therapy increase trismus and Xerostomia.
Clinical Procedures:
a) Impression considerations:
1- Maxillary extension and tissue coverage using ( irreversible hydrocolloid ).
2- Disposable syringe is used to inject alginate into different access areas before seating of
tray.
3- Retention:
- Extending the lingual periphery of un affected side to maximum physiological limit.
- Accurate contouring of denture polished surface help the tongue to retain denture.
4- Support from buccal shelf, crest of ridge, retromolar pad and soft tissue bed in
resected side.
5- Stability proper contouring of lingual flange of unresected side.
b) Centric relation:
1- Record is widened in the resected side account for deviation of the mandible.
2- Support for upper lip may be need to decrease due to protrusion and deviation of the
mandible.
c) Determining V.D.O. :
- Due to trismus, deviation, impaired motor & sensory function and muscle imbalance it
is very difficult to do in usual manner.
- Evaluation of swallowing, phonetics and closest speaking space are best for VDR and
VDO.
- Intra-oral and extra-oral tracers can't be used successfully.
- Patient with trismus (low inter-arch space) should have a denture with low VDO to
facilitate eating between teeth.
- Other problems:
1- Instability of the recording bases.
2- Unilateral forces of occlusion.
3- Altered pathway of closure.
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Dr. Mahmoud Ramadan
d) Determining C.O.R. :
- Recorded with wax or plaster.
- The mandible should be manipulated by the operator in most advantageous position.
e)
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Occlusion:
The non-anatomic teeth is preferred due to:
Deviation of the mandible.
Lack of definite closing position.
Loss of proprioception.
Increase lateral stresses.
Setting of anterior mandibular teeth in neutral zone.
Advisable to place maxillary anterior teeth lingual and the mandibular anterior teeth
labial to custom position.
Mandibular posterior teeth on the unresected side buccal to crest of the ridge (
Increase stability ).
Mandibular posterior teeth on the surgical side lingual to crest of the ridge ( Increase
stability ).
Thickening of denture flange below crest of the ridge proper support of lip and angle
of the mouth.
Occlusal palatal ramp should be added in the resected side to give simulations contact
during deviation.
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Dr. Mahmoud Ramadan
Facial Impression
Introduction and selection of materials.
Patient preparation before facial impression:

1- Position of the patient.
2- Preparation of the patient.
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Impression materials and procedures:

Reversible hydrocolloid.
Irreversible hydrocolloid.
Plaster of Paris.
Orthopedic plaster band.
Impression compound.
Silicone.
Introduction:
- The facial impression require much time and energy in preparing the patient and
materials and carrying out this technique.
- Selection of the material according to:
1- Great accuracy is needed, (use reversible hydrocolloid or plaster of Paris).
2- Good details quickly, (irreversible hydrocolloid or silicone).
3- Contour but not very much details, (impression compound or orthopedic plaster bands).
Patient preparation before facial impression:
a) Position of the patient:
- Patient should lying on the table with head slightly elevated. This position is achieved by:
1- Relaxed muscle tone of the face.
2- Easier material application.
3- Gravity helps to stabilize the material.
b) Preparation of the patient:
1- The hair is boxed out by using cloth towels.
2- The face should be free from make up and eye glasses.
3- The facial hair should be isolated by a means of separating medium.
4- Undercuts of defect should be blocked out with gauze.
5- Tie string to block out material, this prevent un expected swallowing, aspiration or other
problem occur during application of material.
6- The face or external borders of defect should be boxed out of wax.
7- If the impression entered to the mouth or nose, care must be taken in order to provide
breathing and prevent the anxiety in patient.
8- The airway is maintained by straws into the nostrils or mouth.
Impression materials and procedures:
a) Reversible hydrocolloid:
1- Thinner reversible hydrocolloid is applied to the face, using 1.5 inch paint brush.
2- Building up uniform layer of impression and embedded L-shaped clips.
3- Whole area is poured with a suitable layer of plaster of Paris which is connected to
improve faster set as one piece with the L-shape clips.
4- Boxed out area is removed in one piece with the impression.
5- Check the impression for any errors.
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Dr. Mahmoud Ramadan
6- Impression is placed under cold water, to prevent cracking of the impression material by
the exothermal setting reaction of dental stone.
7- Impression is then poured to provide the master cast.
b)
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Irreversible hydrocolloid:
The material applied and the L-shaped clips is inserted.
Plaster of Paris is applied till cover the all clips.
When the plaster harden, ask the patient wrinkle his skin. The whole impression is
removed in one piece with straws and the cotton plugs.
c)
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Plaster of Paris:
A mix creamy and thin is poured and brushed carefully onto the face.
Brushing is done to build up the plaster by layers. No paper clips is used.
After initial setting, it should be removed before exothermic changes. (Glycerin is used as
separating medium).
4- After application of the separating medium, the impression is poured with dental stone.
d)
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Orthopedic plaster band material: (Used for fabrication of radiation protection shields)
Cut bands into narrow strips.
Dipped into cold water.
Applied to the face and smoothed to facial contours (no need for boxing).
Additional layers build up.
The material is allowed to harden.
Glycerin or petroleum gel may be used as separating medium.
The impression is then poured with dental stone.
e)
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Impression compound:
Compound is warmed, flattened and applied to the face.
Care should be taken not to distort facial contours.
Reproduction of gross structures should be obtained.
f) Silicone:
1- Material is applied directly from jar with spatula and starts to build up with gauze
reinforcement.
2- Then more silicone is added.
3- 5 min are needed to setting before removal.
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Dr. Mahmoud Ramadan
Nasal Prosthesis
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Ideal requirements for the material used for nasal prosthesis:

Esthetics.
Fabrication.
Physical properties.
Biological and chemical properties.
Restoration of nasal defects:

3- Partial rhinectomy defects.
4- Total rhinectomy defects.
Types of nasal prosthesis:
1- Temporary nasal prosthesis.
2- Definitive nasal prosthesis:
- Impression making.
- Wax pattern carving.
- Processing.
- Delivery.
3- Partial nasal prosthesis.
Ideal requirements of material used for nasal prosthesis:
1- Esthetics:
- Produce fine details.
- The same color, texture, form and translucency.
2- Fabrication:
- Easy manipulation.
- Suitable working time.
3-
Physical properties:
Strong enough.
Sufficient flexibility (used on movable tissue bed).
Dimensional stable.
Light in weight.
Suitable edge strength (permit thinning or fathering margins).
Low thermal conductivity.
4-
Biological and chemical properties:

Resist various chemicals.
Stable with salivary and nasal secretions and adhesives.
Non toxic and non allergic.
Biocompatible.
Durability.
Restoration of nasal defects:

- Nasal defects occur 2ry to: neoplasm trauma.
- Most of partial nasal defects restored with surgery.
- Most of total nasal defects restored prosthetically.
- Presurgical consultation with surgeon is important to defect, if the defect is to be
permanently or temporary restored with a prosthesis.
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Dr. Mahmoud Ramadan
1- Partial Rhinectomy Defects:

The surgeon may restore the defect temporarily with a prosthesis in order to delay the
surgical construction after the observation period is elapsed. Covering the defect with local
flap may delay discovery of the recurrent tumor (basal cell carcinoma) which cause
metastasis and destruction of local adjacent tissues.
2- Total Rhinectomy Defects:
- Prosthetic restoration are preferable than surgical recontouring.
- The surgeon is advised to remove the nasal bones and the rest of the nose to make it
ideally (flat or concave surface) to make the prosthesis that duplicate presurgical nasal
contours.
- Placement of split-thickness skin graft over exposed area is preferable.
- Patient should be informed about benefits and limitation of the prosthesis.
- Photographs of patients with similar defects may be used to educate the patient.
- Conversation with the rihnectomy patient who is wearing nasal prosthesis may be helpful.
- Patient expectations to the prosthesis should be realistic.
- Family members encourage to be present during consultation.
- Psychological consultation and evaluation should be short before resection.
- Before resection, facial impression and photographs should be obtained.
- Before taking impression, the undesirable undercuts should be blocked out with gauze.
Types of nasal prosthesis:
1- Temporary nasal prosthesis:
- The wound is sufficiently healed (3 - 4 weeks) after surgery, this allow for placement of
temporary nasal prosthesis.
- Patient is happy so, he can resume the social interaction and return to work.
- The material of choice is (heat polymerized methyl methacrylate), because:
a) It can be retained with temporary denture liners.
b) Allow for scar contraction and organization of wound (tissue bed changes).
- Retention of the prosthesis is aided by medical grade skin adhesive.
- The wound is sufficiently contracted and organized soft tissue bed is formed (3 4
months) after surgery, this allow for fabrication of definitive prosthesis.
2-
Definitive nasal prosthesis:

Flat defect with intact nasolabial fold is the best to restored.
Retaining the nasal bones compromise the contours of the finished prosthesis.
Defect with surgical margins out of the nasolabial fold may be difficult to restore due to
exposure of the line of junction.
- Margins onto the upper lip may be masked with facial hair.
- Definitive prosthesis with flexible material are:
a) More comfortable to the patient.
b) Retained in position for long period, especially if patient have highly mobile soft tissue
bed.
Procedures:
- Impression making:
1- It is advisable to take impression with patient in upright position. Because, horizontal
position will distort the soft tissue bed.
2- Elastic impression material (irreversible hydrocolloid) Alginate is used and thinned to
increase flow by adding 50 % water more than usual.
3- Opening of the nasal passage should be blocked with gauze to prevent escape of material
to the nasal passage (asphyxia).
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Dr. Mahmoud Ramadan
4- A facial cast is made, then master special tray is fabricated and confined to the defect
area.
5- Using a syringe we inject the flowable material in the undercut areas. But, take into
consideration not to compress the soft tissue bed.
6- Load the special tray with impression material in position. The excess material should be
removed periodically by index finger.
7- When the impression is set it will be removed and poured by dental stone to fabricate the
master cast.
- Wax pattern carving:
1- It is important in carving to produce the same contour, texture and proper placement of
the line of junction.
2- If presurgical cast is not available, the wax is adapted to cast and basic contour is done.
3- Patient should have multiple presurgical photographs for reference.
4- It is preferred to have a family member during carving for better perception of contours
than the patient.
5- Ala of the nose should be in a proper location in relation to nasolabial fold.
6- Care must be taken not to make the nose wide in Alar region (equal to inter-canine
distance).
7- Nares should be symmetrical and resemble the presurgical contours.
8- Junction between Columella and skin should be right angle or acute angle, in order to be
difficult to seen under the tip of the nose.
9- Tip and Dorsum of the nose should be resemble presurgical contour.
10- The bridge area shouldn't be wide and this is verified by wearing of eye glasses.
11- Eye glasses frames may improve appearance, if possible margins of the prosthesis extend
to mask the superior and lateral margins beneath it.
12- If we can't mask the margins for any reason, care should be taken to feather the margin
of the nasal prosthesis. i.e. (smooth transition between the skin and the prosthesis).
12345-
Processing:
Wax pattern is invested in suitable mold material.
Basic shade of the prosthesis should match the lightest color in area.
If the basic shade is darker, it will be impossible to have esthetic match.
Extrinsic coloration done under presence of the patient and under good light.
Evaluation of coloration under varied (different) light sources.
123-
Delivery:
Hollowing the inner surface as much as possible decrease the weight of the prosthesis.
Retention is achieved by using medical grade skin adhesive.
The patient must be followed up periodically.
3-
Partial Nasal Prosthesis:

Fabricated as the same way as total nasal prosthesis.
More line of junction will be exposed than total nasal prosthesis.
For achieving good esthetic results, it should be carefully colored and feathered to mask
the transition between skin and prosthesis.
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Dr. Mahmoud Ramadan
Occular Prosthesis
Materials of construction:
a) Plastic acrylic eye:
b) Glass eye:
Examination of eye socket:
Technique of fabrication of the plastic eye prosthesis:
a) Scleral pattern from stainless steal ball bearing:
b) Registration of socket using alginate impression:
1- Making Impression: preparation of the patient impression procedures.
2- Making stone cast:
3- Selecting the eye:
4- Carving clay pattern:
Materials of construction:
a) Plastic acrylic eye:
Advantages:
1- Not fragile as glass and don't cause etching sensation.
2- It is custom made easy to adjust size, form and contours.
3- Easily adapted to individual esthetic requirements.
4- Actual 3 dimensional effect in Iris construction.
5- Perforated Iris buttons can be socketed.
6- Permits elimination of time consuming steps as multiple mold construction.
7- Method is easy to teach.
b) Glass eye:
Disadvantages:
1- Extremely fragile may explode in eye socket.
2- Glass interact with fluid of the socket.
3- Difficult to fit properly in relation to defect.
4- Giving the wearer the appearance of Exophthalmoses.
Examination of eye socket:
1- Knowledge of the anatomic features of the eye is essential.
2- Existing muscle movements should be studied.
3- Type of operation by the surgeon: enucleation evisceration.
4- If there is implant sphere was embedded at the time of surgery or not and what the type
of its material (gold glass).
5- The amount of orbital adipose tissue present.
6- Extent of muscle atrophy.
7- Contour and tonus of the eye lids.
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Dr. Mahmoud Ramadan
Technique of fabrication of the plastic eye prosthesis:

1- Painting of the Iris disk.
2- The Iris button.
3- The wax form.
4- Molding.
5- The sclera.
6- Veining technique.
7- Conjunctiva.
8- Polishing and fitting.
- 2 methods were stated:
a) The most commonly used make a scleral pattern from stainless steel ball bearing.
b) Using alginate impression to register the contents of enucleated socket.
- It is important for surgeon to place a conformer in the socket after enucleation (except
when unusual amount of hemorrhage) made of acrylic must be large enough to
support eye lids and keep them from collapsing until construction of the artificial eye.
a) Scleral pattern from stainless steal ball bearing:
1- A ball bearing is selected as sphere to make the scleral pattern.

2- Hard base plate wax is softened over the Bunsen flame and compressed over the ball
bearing.
3- It is very important to relief the wax against the (Whitnall's ligament).
4- The wax pattern is trimmed to proper size and shape tried in socket.
5- The center of the Iris marked on the wax.
6- The Iris button is fixed to the hard wax cup using soft green wax.
7- Make any correction to place Iris into proper alignment and position.
8- Special yellow high heat wax is used to buildup smooth and spherical prosthesis.
9- The prosthesis tried in the socket to check for: optimal lid form, mobility and Iris line up.
b) Registration of socket using alginate impression:
1) Making Impression:
Preparation of the patient:
9- The hair is boxed out by using cloth towels.
10- The face should be free from make up and eye glasses.
11- The facial hair should be isolated by a means of separating medium.
12- The eye brow and supra-orbital tissue of the defective eye are retracted.
13- Full width of the face (1 inch above eye brow and to upper lip) is boxed.
14- Patient instructed to close his remaining eye and breath through his mouth.
Impression procedure:
1- Using reversible hydrocolloid (50% water : 50% impression).
2- When material are heated to proper temperature, consistency and ready to be used the
operator tests the material with little finger for proper temperature before applying over
patient skin.
3- The impression material is painted on patient face with camel's hair brush starting
from undercuts and point of the greatest depth then the entire box area building up
at least 3 mm layer of material.
4- Pre bend L-shaped clips is inserted for reinforcement.
5- Wait for 5 minutes for setting of impression and proper reinforcement of clips.
6- Sufficient thickness of Plaster of Paris is poured removed after initial setting by asking
the patient to wrinkle his face and put in cold water to prevent cracking of impression
under exothermal setting of Plaster.
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Dr. Mahmoud Ramadan
7- Check accuracy of impression.

2) Making stone cast:
- Pouring the impression with dental stone with vibrator to prevent air bubbles.
3)
-
Selecting the eye:

This is performed in the 2nd appointment.
It must match remaining eye.
Left or right, size shape, color and blood vessels should be similar.
4) Carving clay pattern:

- Care should be taken in:
1- Restore symmetrically the wrinkles and opening of the eye lids.
2- Restore symmetrically the shape of inner and outer corners of the eye.
3- Distance from bridge of the nose to the Pupil of the remaining eye should be equal.
4- The eye should be centrally located in the clay.
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Dr. Mahmoud Ramadan
Cranial and Facial Implants

Prerequisites of successful implant:
- The tissue bed should be free of infection.
- The tissue should be able to be closed over the implant without pressure.
- The tissue should have adequate blood supply.
Ideal characteristics of cranial implant:
1- It must be non carcinogenic:
- Physical rather than chemical factors are responsible for the change from normal to
tumor cells in the implanted animal.
- The implant should have a configuration which allows for the fibrosing of the tissue
through it and thereby disturbs cellular function less.
2- It must not cause excessive inflammation or foreign body reactions:
- A slight amount of inflammatory process is desired. This serves 2 functions in implant
patient:
st
1 : aids in fixating the implant in position.
2nd : it provides barriers to infection spreading the length of the prostheses.
3- It must be biostable:
- The ideal material should be biodegradable. But, it is not available so, the biostable
material is the one of choice.
4- It must be strong enough to withstand stresses:
- The stresses shouldn't cause implant fatigue and cause fracture.
5- It must be small enough to require a minimum tissue to cover:
- In both traumatic and surgical defects, the amount of tissue coverage has been decreased
or compromised.
6- It must be readily available and easy to fabricate.
7- It must be capable of being sterilized:
- This will prevent infection and subsequent complications.
Materials used for implant:
a) Tantalum:
- Contains: 18:8 stainless steel and chrome cobalt alloy.
- Comes in the form of sheets, wire, ribbon and mesh.
b) Chrome cobalt alloys:
- Well accepted by the body and have high rate of success.
c) Methyl methacrylate, Polyethylene and Silicone:
- They are mostly used because, they don't cause body reactions and are easily manipulated
in the dental laboratory.
d) Animal shells, Grounds, Coconut shells, Hard rubber, Plaster of Paris and Gummed
cork.
Cranioplasty:
- The greatest progress in cranioplasty has been made in the development and application
of various plastic and non metallic alloplastic materials.
- Gold plates were inserted into skull defects. Then, inert metals were used such as
Vitallium, Ticonium, Tantalum and Stainless steel.
- The use of acrylic resin (Methyl methacrylate) is the most recent development in this
field.
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Dr. Mahmoud Ramadan
Indications for cranioplasty:

1- Trauma.
2- Osteomyelitis of the skull.
3- Gun shoot wound.
4- Congenital defects.
5- Neoplasm of both cranial and intracranial origin.
6- Epilepsy.
7- Pulsating and painful defects.
8- Danger of trauma at site of defect.
9- Deforming and unsightly defects.
10- Headache, pain and tenderness at site of defect.
Precautions for cranioplasty:
1- Cranioplasty was not performed in presence of wound contamination or acute chronic
inflammation.
2- In one stage method of cranioplasty : methyl methacrylate has been almost exclusively for
both small and moderate large skull defects.
3- Split rib grafts have been used for large defects (Osteomyelitis).
Techniques of Cranial implant:
a) Technique of Methyl methacrylate cranial implant:
- Skin incision is designed to allow complete exposure of the margins of the bone defect.
- Care must be taken to avoid lacerating the underlying dura and brain.
- Periosteal elevator is used to fee the dura from the bone edges.
- If the dura is full or tense, hyperventilation of the patient is required to decrease intracranial pressure.
- The bone edges is freshened, rounded, and slightly beveled with rongeurs. This also may
be done using high speed drill to provide a ledge which provide greater stability of the
plastic plate.
- When the preparation has been completed, a sterile liquid monomer and powder polymer
are mixed and takes 5 to 6 minutes to obtain doughy mass that can be conveniently
molded.
- The material is placed over moistened cotton and shaped with fingers or a small roller to
a size approximating the defect and to the thickness of the surrounding bone.
- A thin flange of acrylic around the periphery of the defect will provide increased stability
and also safety in that it prevents the implant from sinking into the underlying tissue as a
result of external pressure.
- The plate is then removed, and final hardening occurs outside the skull (Heat generation).
- Many surgeons feel that a better fit is obtained if the plate isn't removed and final
hardening occurs in situ.
- Cooled Ringer's or normal saline irrigant should be continuously directed onto the plate
and surrounding tissue until the heat generated by polymerization has been dissipated.
(7:9 min.)
- All rongeur or dental burs are used to trim rough and sharp edges and to remove excess
material.
- For greater stability as well as for cosmetic purposes, wire may be used to bridge a defect
and may then be incorporated into the methyl methacrylate plate.
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Dr. Mahmoud Ramadan
Advantages:
1. Excellent cosmetic results and easy to achieve.
2. Have same density and strength as bone.
3. Transparent to x-rays.
4. The material is inert and lacks the physical effects of metal plates as temperature change
and electric phenomena.
b) Split rip graft cranioplasty:
- Indicated for larger defects.
- Portions of the 9th or 10th ribs are generally used.
- After proper length of rib has been resected, the piece is split longitudinally with a sharp
thin chisel.
- The technique of exposing the skull defect and dura is the same as previous technique.
- Part of the outer table is removed from the defect margins to form a ledge into which the
ends of the rib are inserted.
- Fixation is obtained with wire inserted through small holes drilled into the rib.
- The wound is closed in the usual manner.
- Head protection is recommended for several weeks until stabilization occurs.
Disadvantages:
1. The necessity of a separate incision.
2. Incomplete coverage of the defect.
3. There is a period required for stabilization.
c) Technique of Polyethylene Cranial Implant:
Advantages:
1. High density and high impact strength.
2. It is available in sheets and with proper compression molding.
3. Very strong and stress free product.
4. Inert.
5. Light in weight.
6. Radiolucent.
7. Easily trimmed at the time of surgery.
8. Cover large skull defects with good cosmetic results.
Steps of obtaining prostheses:
1. Impression taking with alginate impression material.
2. Modeling in stone.
3. Patterning with wax.
4. Flasking.
5. Compression molding at approximately 300 F.
6. Finishing.
7. Cold sterilization.
d) Technique of Tantalum Cranial Implant:
- To obtain the natural shape of the skull, it is important that the head be shaved before the
impression is made.
- The defect is palpated and the peripheral border is marked with indelible pencil at a
margin of approximately 1 to 2 cm from the penciled lines.
- The area is boxed in with boxing wax.
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Dr. Mahmoud Ramadan
- The impression is made by applying irreversible hydrocolloid to the entire surface of the
-
boxed-in area.
Pre-bent paper clips opened to an L shape are inserted in the impression material for
reinforcement.
After setting of the irreversible hydrocolloid, quick setting plaster of Paris is added for
backing.
When the plaster has set, the impression is gently removed from the skull and the pencil
line is reoutlined with indelible pencil.
Dental stone is then poured slowly into the impression.
Once the stone has set, the impression is separated from the moulage.
At this stage, the prosthodontist study the moulage to determine whether an inlay or
onlay implant should be used.
With an Inlay implant, a shoulder rest is prepared around the defect at the periphery line
1mm deep to compensate for the tissue overlying the defect.
The depressed area of the moulage is filled in with modeling clay or plaster to bring the
contour out to normal.
One baseplate thickness of wax is applied to the pencil line as a pattern to cutout the
tantalum metal.
The moulage is used as a die and after using separating medium, a counter die is poured
using a thick mix of stone.
After setting, the 2 halves of the mold are separated and the tantalum pattern is placed
between the dies and the dies are inserted under press.
After molding of the tantalum, it is peforated by the use of round burs size 5 : 8 to allow
the connective tissue to penetrate the implant and neutralize its physical property.
After making perforations, the implant is finished by rubber points, polished, scrubbed,
and immersed in nitric acid to eliminate contamination.
The tissue bed is prepared in the same manner as described for methyl methacrylate.
The sterilized perforated tantalum implant is then seated over the cranial defect and fixed
with 4 to 6 stainless steel wires to the surrounding skull.
The wound is closed in layers as usual manner.
Complications of cranioplasty:
1. Infection.
2. Instability of the prosthesis.
3. Erosion of the overlying skin.
4. C.S.F. leakage through dural laceration.
5. Epidural granuloma.
6. Hematoma.
7. Pneumothorax following rib removal.
8. Thermal damage to the surround tissue from the heat of polymerization of methyl
methacrylate.
Perforated Tantalum Implants for Reconstruction of Facial Bones:
- Used for reconstructing other defected facial bones, such as the infraorbital bone, the
zygomatic orbital malar bone, the symphysis and associated mandibular defects.
- Used in case of T.M.J. ankylosis after accident.
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Dr. Mahmoud Ramadan
Silicone Implant for Reconstruction of Facial Bones:

- Used for reconstruction of the dorsum of the nose, the floor of the orbit, the malar bone,
the forehead, and the mandibular ridge.
- Used to build out the retrognathic chin and to build the helix of the ear.
- The silicone implant material must be perforated to provide tissue growth which will
retain the prosthesis in place.
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Maxillofacial Notes DR - Mahmoud Ramadan

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Maxillofacial Notes DR - Mahmoud Ramadan

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Maxillofacial Prosthodontics

Dr. Mahmoud Ramadan

Objectives of maxillofacial prosthesis.

Types of maxillofacial defects.

Diagnosis and treatment planning .

Congenital cleft palate.

Congenital cleft palate.

Radiation and Radiotherapy prosthesis.

Acquired Mandibular Defects.

Dr. Mahmoud Ramadan

Dr. Mahmoud Ramadan

Essentials of maxillofacial Prosthesis:

Types of Maxillofacial defects :

Classification of Maxillofacial Restorations :

Dr. Mahmoud Ramadan

IV. Cranial and facial restorations :

Dr. Mahmoud Ramadan

2- Periodontist help to maintain periodontal health .

Contraindications of surgery in maxillofacial defects :

Indications of maxillofacial prosthesis :

Diagnosis and treatment planning :

Dr. Mahmoud Ramadan

Dr. Mahmoud Ramadan

Congenital Cleft Palate

Embryology of primary palate:

Dr. Mahmoud Ramadan

Classification of cleft lip and palate:

Disabilities (Problems associated with cleft palate):

Dr. Mahmoud Ramadan

Anatomy and physiology of palatal and pharyngeal muscles:

Dr. Mahmoud Ramadan

Dr. Mahmoud Ramadan

Dr. Mahmoud Ramadan

Objectives of cleft palate prosthesis:

Indications of maxillofacial prosthesis in unoperated cases (speech aid prosthesis):

Dr. Mahmoud Ramadan

Indications for A prosthesis in operated cases:

Contraindications to maxillofacial prosthesis:

Dr. Mahmoud Ramadan

3- Uncooperative patient and parents.

Diagnosis and treatment planning:

Preparation of the case for prosthetic treatment:

Dr. Mahmoud Ramadan

Prosthetic management of cleft palate:

2- Expansion type prosthesis:

B. Cleft palate prosthesis for adults:

Dr. Mahmoud Ramadan

3- Fixed pharyngeal obturator (speech aid):

Dr. Mahmoud Ramadan

Clinical steps of construction:

Dr. Mahmoud Ramadan

Dr. Mahmoud Ramadan

4- Silicone retentive obturator:

5- Palatal Lift Prosthesis (Improve speech):

Dr. Mahmoud Ramadan

Acquired Cleft Palate

Etiology of acquired clefts:

Rehabilitation of acquired cleft palate:

Dr. Mahmoud Ramadan

Obturation may be accomplished with the placement of an immediate surgical obturator at

Immediate Surgical Obturation

Advantages of the immediate surgical obturation:

Principles relative to the design: