Maxillofacial prosthesis

MAXILLOFACIAL PROSTHESIS

DR RITESH SHIWAKOTI

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History

Artificial facial parts found on Egyptian mummies long time ago.

Ancient Chinese known to have made facial restorations.

1953 -- American Academy of Maxillofacial Prosthetics founded.

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Overview

Maxillofacial prosthetics is a branch of prosthodontics in dentistry.

Main aim is to restore the function and esthetics of an individual.

Its also approve a psychological state of a patient after a trauma or surgery.

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Maxillofacial Prosthetics

The art and science of anatomic, functional, or cosmetic reconstruction by means of nonliving substitutes of those regions in the maxilla, mandible, and face that are missing or defective because of surgical intervention, trauma, pathology, or developmental or congenital malformations.

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Type of M.F.P

Intra-Oral

Extra-Oral

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Indications of MFP After surgical intervention.

After trauma.

Congenital defects.

Acquired defects.

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Prosthetic vs. Surgical Rehabilitation

Individualized decision between patient and doctor.

Removable prosthesis allows for cancer surveillance.

Destruction amount.

Malignancy recurrence.

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Intraoral vs. Extraoral

Intraoral -- mostly functional

◦ Mandible

◦ Maxilla

Extraoral -- cosmetic

◦ Ear

◦ Nose

◦ Orbit

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Management of patient for MFP.

Personal history of a patient should be obtained.

Dental and medical history also should be obtained.

Intra and external examination of a patient by a maxillofacial surgeon and prosthodontics should be done.

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Management of patient for MFP.

Patients risk assessment should be done.

A surgeon should consulate with a dentist about a surgery so that there should be a team work.

All surgical alterations should be demonstrated for a dentist on a cast and obturator should be made for a day of a surgery.

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Psychosocial Issues

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Dental Impression

Surgeon has marked resection for prosthodontic planning.

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Post surgical management.

After a surgery and even before it’s a team work for a rehabilitation of a patient that includes:

1. Maxillofacial surgeon.

2. Prosthodontics.

3. Orthodontist.

4. Phyciastrist.

5. Speech rehabilitation specialist.

6. Oncologist.

7. Plastic surgeon specialist

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Congenital defects

Lip and palate development:

Upper lip develop by coalescence of the premaxilla and maxillary growth centers on either sides to produce the complete lip.

Fusion of the of the lip developing from growth centers commences around each nostril floor and spreads downwards towards the lower border of the lip uniting the premaxilla and maxillary process in each side.

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Congenital defects

Failure of this union will result in a cleft lip that varies from a notch on one side to complete bilateral cleft of the lip that may extend up to into each nostril.

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Congenital defects

The palate:

Palate develops from the max. and premix. growth centers, union of the three segments commencing at the region of the nasal floor presented in full development by the nasal foramen.

Union from this point proceeds backwards until both the hard and soft palates and uvula have united, and forwards along the of the future maxillary and premaxillary structures eventually.

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Congenital defects

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• Lack of fusion of the palatal shelves either completely or partially occurs during embryonic growth side.

• Failure of union of palatine processes at any stage will result in a cleft palate which may be pre-alveolar ( cleft lip ) or post alveolar ( cleft palate ) .

• Cleft palate between 6th – 9th wk. of the embryonic life.

Congenital defects

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Classification of cleft palate Pre-alveolar e.g. cleft lip Post alveolar any cleft from uvula up to incisive

foramen. Alveolar cleft extending from uvula to alveolar ridge

and lip either unilateral or bilateral.

Congenital defects

Effects of cleft palate and lip

1. Speech – lack of valvopharyngeal closure leads to escape of air through the nose (nasal speech)

2. Deglutition – greatly impede the feeding, regurgitation and escape of fluids through the nose takes place .

3. Mastication – impaired due to escape of food through the nasal cavity and due to missing teeth and malocclusion .

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Congenital defects

4. Esthetics – is effected seriously especially in cleft palate and / or lip.

5. Deterioration of the general health

6. Psychological trauma .

7. Recurrent infection of the air ways and middle ear .

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Congenital defects

Management of cleft lip and palate Include the following:

A. Surgical closure

It is the treatment of choice for palatal cleft closure. It superior to prosthetic closure by obturator.

If cleft involves the lip, it is advisable to repair it as early as possible (6 wks. after birth) to facilitate feeding and improve appearance.

Surgical closure of palatal cleft is better to be done before the end of the second year of age.

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Congenital defectsB. Prosthetic restoration

oFeeding appliances.

oSimple palatal plate to close cleft.

oSpeech aid obturator.

oOver denture.

C. Orthodontic

oTo correct the malaligned teeth or expand the maxillary arch.

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Congenital defects

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Reason for early closure of cleft palate

1. To produce longer and more mobile soft palate with better muscular development and

2. velopharyngeal closure.3. To habilitate the patient for normal speech. 4. To allow undisturbed growth of maxilla.

ACQUIRED PALATAL DEFECTS

DEFINITION:

Lack of continuity of originally intact palatal structures through the whole or part of its length.

Etiology:

Surgical e.g. tumor removal.

Traumatic fracture of maxilla.

Pathological conditions e.g. osteomyelitis, T. B., and syphilis .

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ACQUIRED PALATAL DEFECTS

Prosthetic rehabilitation of acquired maxillary defect:

The main priority for the patient with traumatic injury and traumatic surgery is to stabilize the patient and control immediate damage and/or defect.

Three phases of prosthodontic treatment includes:

Surgical procedures + Immediate obturator.

Transitional obturator.

Definitive obturator.25

IMMEDIATE OBTURATOR

IMMEDIATE OBTURATOR

1. It is a prosthesis inserted immediately after operation

2. Lasts 10-14 days after surgery

3. Material used, mostly acrylic

ADVANTAGES:

1. Maintain function (feeding, speech)

2. Promote healing

3. Restore esthetic

4. Act as stint (keep surgical pack and medication close to the wound)

5. Improve psychology of the patient

6. Prevent contamination of the wound26

IMMEDIATE OBTURATOR

Construction:

o Impression/construction of the cast models.

o With the help of the surgeon determine the area to be removed on the cast .

o The appliance is constructed as a plate to close the operation site.

o Prepared cast is waxed, processed using either heat or cold curing resin and wire clasps to retain the obturator.

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IMMEDIATE OBTURATOR

oDuring operation eradication of the involved area, and surgical cavity is filled with surgical pack.

oWe can say, it is simple plate with no teeth and constructed before surgery to be inserted immediately after surgery .

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Temporary Obturators

Temporary/Transitional Obturator:

Constructed few days after operation to help in restoring oro-nasal function. Carries teeth and stays 3-6 months. Making impression is complicated by presence of the wound and presence of the defect.

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Temporary Obturators

The defect is packed with gauze dipped in Vaseline to the level of the remaining tissue, then impression is taken with modified stock tray using elastic impression material.

The steps of construction are the same as in immediate obturator.

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Temporary Obturators

Function: helps in restoring

1. Speech.

2. Feeding.

3. Esthetics.

4. Prevent wound contamination.

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Definitive Obturators

Definitive Obturator:

It is a final prosthetic management construction after complete healing of the operation site .

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Definitive Obturators

Preparation of the mouth for obturator:

I. Extract hopeless teeth.

II. Periodontal therapy.

III. Restore carious teeth.

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Definitive Obturators

Types of obturators:

1. Hollow bulb (Closed).

2. Roofless (Open bulb).

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Definitive Obturators

Construction:

1. Select stock tray, modified with wax according to the size and shape of the defect.

2. Partially, pack the defect with Vaseline gauze, then do primary impression using alginate.

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Definitive Obturators

3. Under cuts are lift to help in retention. Gauze can prevent broken pieces of alginate from escaping into the defect.

4. Construct sp. Trays and do final impression using alginate or rubber base impression material.

5. Outline the master cast to mark the bearing area, blocking severe undercut, leaving small undercut area for obturator retention.

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Premaxilla Preserved

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Premaxilla Preserved

Cut through tooth socket 38

Mucosa Not Preserved

Rough edge uncomfortable for patient 39

Obturator

Restores oro-nasal partition.

At times can be added to prior dentures.

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Skin Grafting of Defect

Less pain while healing.

Less contracture of scar band which obscures cancer surveillance.

Accomodates obturator better.

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Maxillary Prosthesis

Articulates with scar band.

Hollowed to be lightweight.

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Timing

Immediate (Intraoperative)

◦ hold in packs

◦ provide early function

Interim

Definitive

◦ 3 to 6 months

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Maxillary Prosthesis

Can be made with a reservoir to hold artificial saliva.

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Prosthetic Materials

Acrylics

Polyurethanes

Silicone Elastomers

◦ Room-temperature vulcanizing

◦ High-temperature vulcanizing

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Mandible

Mandibular reconstruction revolutionized by microvascular and plating techniques.

Prosthetics mainly restore occlusion and occlusalsurface.

Implants able to restore high degree of function.

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Mandible

Skin graft preserves alveolar ridge for denture support 47

Postoperative Malocclusion

Deviates to surgical side.

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Maxillary Ramp

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Maxillary Ramp

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Adjunctive Preprosthetic Measures

Vestibuloplasty.

Lowering of Floor of Mouth.

Implants.

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Vestibuloplasty

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Lowering the Floor of Mouth

Goal is to reposition mylohyoid muscle.

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Lowering the Floor of Mouth

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Edentulous Mandible

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Mental Foramen

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Implants

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Extraoral Prostheses

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Extraoral Prostheses

General Principles:

Goal is cosmetic.

Retained with :

◦ Adhesives.

◦ Implants.

Skin grafting may help.

Smooth edges.

Extraoral Prostheses Ear:

Retain tragus if possible to camouflage anterior border.

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Extraoral Prostheses --Ear

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Extraoral Prostheses --Ear

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Extraoral Prostheses -- Ear

Tragus hides attachment. 62

Extraoral Prostheses -- Orbit

Skin graft provides base for prosthesis. 63

Extraoral Prostheses -- Orbit

Glasses help hide margin. 64

Extraoral Prostheses -- Nose

Skin graft provides base for prosthesis. Alar tag undesirable. 65

Extraoral Prostheses --Nose

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Extraoral Prostheses --Nose

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Extraoral Prostheses --Nose

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Extraoral Prostheses --Nose

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Conclusion Restore function and cosmesis.

Use techniques during surgery to aid prosthetic management.

Consultation with maxillofacial prosthodontist for optimal rehabilitation.

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