Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
5. DefinitionsDefinitions
Obturator: are maxillofacial prosthesis used to close aObturator: are maxillofacial prosthesis used to close a
congenital or acquired tissue opening, primarily of thecongenital or acquired tissue opening, primarily of the
hard palate and/ or contiguous alveolar/soft tissuehard palate and/ or contiguous alveolar/soft tissue
structures – GPT 8structures – GPT 8
Surgical obturator: a temporary maxillofacial prosthesisSurgical obturator: a temporary maxillofacial prosthesis
inserted during or immediately following surgicalinserted during or immediately following surgical
traumatic loss of a portion or all of one or both maxillarytraumatic loss of a portion or all of one or both maxillary
bones and continuous alveolar structures (i.e. gingivalbones and continuous alveolar structures (i.e. gingival
tissue, teeth). – GPT 8tissue, teeth). – GPT 8
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6. Interim obturator: a maxillofacial prosthesis which IsInterim obturator: a maxillofacial prosthesis which Is
made following completion of initial healing followingmade following completion of initial healing following
surgical resection of a portion or all of one or bothsurgical resection of a portion or all of one or both
maxillae; frequently many or all teeth in the defect areamaxillae; frequently many or all teeth in the defect area
are replaced by this prosthesis. GPT 8are replaced by this prosthesis. GPT 8
Palatal augmentation prosthesis : a removablePalatal augmentation prosthesis : a removable
maxillofacial prosthesis which alters the hard and/or softmaxillofacial prosthesis which alters the hard and/or soft
palate's topographical form adjacent to the tongue. GPTpalate's topographical form adjacent to the tongue. GPT
88
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7. Palatal lift prosthesis: on maxillofacial prosthesis whichPalatal lift prosthesis: on maxillofacial prosthesis which
elevates the soft palate superiorly and aids in restorationelevates the soft palate superiorly and aids in restoration
of soft palate functions which may be lost due to anof soft palate functions which may be lost due to an
acquired, congenital or developmental defect. GPT 8acquired, congenital or developmental defect. GPT 8
Speech aid prosthesis: a removable maxillofacialSpeech aid prosthesis: a removable maxillofacial
prosthesis used to restore an acquired or congenitalprosthesis used to restore an acquired or congenital
defect of the soft palate with a portion extending into thedefect of the soft palate with a portion extending into the
pharynx to separate the oropharynx and nasopharynxpharynx to separate the oropharynx and nasopharynx
during phonation and deglutition, thereby completing theduring phonation and deglutition, thereby completing the
palatopharyngeal sphincter. GPT 8palatopharyngeal sphincter. GPT 8
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8. Maxillofacial classificationMaxillofacial classification
Patients can be categorized by maxillofacial defects thatPatients can be categorized by maxillofacial defects that
are acquired, congenital, or developmental.are acquired, congenital, or developmental.
Acquired: e.g. include soft or hard palate defectsAcquired: e.g. include soft or hard palate defects
resulting from removal of SCC of that region.resulting from removal of SCC of that region.
Congenital defects: e.g. include various degrees ofCongenital defects: e.g. include various degrees of
clefts of hard and soft palate.clefts of hard and soft palate.
Developmental defectsDevelopmental defects
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9. Classification based onClassification based on
prosthesis underprosthesis under
considerationconsideration
Extraoral : cranial orExtraoral : cranial or
facial replacementfacial replacement
Intraoral : involvingIntraoral : involving
the oral cavitythe oral cavity
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10. Duration and time of use
Treatment
Interim
Definitive
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11. Etiology of palatal and PNS defectsEtiology of palatal and PNS defects
Almost all acquired palatal defects a result of resectionAlmost all acquired palatal defects a result of resection
of neoplasms.of neoplasms.
-Curtis (JPD 1967:18;70)-Curtis (JPD 1967:18;70)
Head & Neck Cancer inflicts a formidable physical,Head & Neck Cancer inflicts a formidable physical,
psychological and socio-economic burden on patients,psychological and socio-economic burden on patients,
their families and on health care providers.their families and on health care providers.
Relatively unknownRelatively unknown
Lack of public awarenessLack of public awareness
60% late presentation60% late presentation
Dental profession has an important role to play in theDental profession has an important role to play in the
prevention and early detection of HNCprevention and early detection of HNC
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12. Primary Prevention
Education
Largely preventable disease
Tobacco use, along with alcohol, accounts for 75% -
90% oral, pharyngeal, laryngeal, esophageal cancers
(US Surgeon General 2000)
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13. Secondary preventionSecondary prevention
Informed Public
Non healing ulcer
Red/white speckled area
Red velvety area
Pigmented area or lump
Neck mass
Speech changes
Swallowing difficulty
Unilateral sore throat
Dental Profession
Opportunistic Screening
High index of suspicion
Quick early diagnosis
Early appropriate referral
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15. Prosthetic treatment for patientsProsthetic treatment for patients
with acquired surgical defectswith acquired surgical defects
Prosthodontic treatment can be an arbitrarily divided intoProsthodontic treatment can be an arbitrarily divided into
- initial phase- initial phase
- secondary phase- secondary phase
Acquired defects of the hard and soft palate can beAcquired defects of the hard and soft palate can be
managed by the use ofmanaged by the use of
Removable prosthesisRemovable prosthesis
Surgical closureSurgical closure
Implant supportedImplant supported
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16. Care for patient with acquiredCare for patient with acquired
defectsdefects
Initial emphasis is on surgical requirements,Initial emphasis is on surgical requirements,
later prosthetic requirementslater prosthetic requirements
Divided intoDivided into
•
Pre operativePre operative
•
IntraoperativeIntraoperative
•
InterimInterim
•
Definitive careDefinitive care
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17. Pre and Intraoperative carePre and Intraoperative care
Planning should begin before surgeryPlanning should begin before surgery
Patients should be seen by the Prosthodontist beforePatients should be seen by the Prosthodontist before
the surgerythe surgery
Dental objectivesDental objectives
- Removal of potential dental, postoperative ComplicationsRemoval of potential dental, postoperative Complications
- Planning for subsequent prosthetic treatmentPlanning for subsequent prosthetic treatment
- Make recommendations for surgical site preparation thatMake recommendations for surgical site preparation that
may improve surgical integritymay improve surgical integrity
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18. - Temporary restoration for large carious lesionsTemporary restoration for large carious lesions
- Treatment of acute conditionsTreatment of acute conditions
- Extraction of hopeless teethExtraction of hopeless teeth
- Impression is made for fabrication of surgical obturatorImpression is made for fabrication of surgical obturator
- Initiation of planning for definitive prosthesisInitiation of planning for definitive prosthesis
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19. Surgical obturationSurgical obturation
Accomplished by a variety of restorations and materialsAccomplished by a variety of restorations and materials
James- Raines 1955: spongesJames- Raines 1955: sponges
Steadman 1957: gutta perchaSteadman 1957: gutta percha
Hammond 1966, King 1978: inflatable bulbHammond 1966, King 1978: inflatable bulb
It may be either delayed surgical obturation {six to tenIt may be either delayed surgical obturation {six to ten
days later} or immediate surgical obturation, indicated fordays later} or immediate surgical obturation, indicated for
most patientsmost patients
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20. Immediate surgical obturatorImmediate surgical obturator
Objective is to separate oral and nasal cavitiesObjective is to separate oral and nasal cavities
AdvantagesAdvantages
- Prosthesis acts as a matrix for dressingProsthesis acts as a matrix for dressing
- Reduced wound contaminationReduced wound contamination
- Speech is betterSpeech is better
- Deglutition, nasogastric tube can be removed earlyDeglutition, nasogastric tube can be removed early
- Psychological supportPsychological support
Surgical prosthesis not removed- seven to ten days postSurgical prosthesis not removed- seven to ten days post
surgicallysurgically
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24. Delayed surgical obturationDelayed surgical obturation
Placed seven to ten days post surgicallyPlaced seven to ten days post surgically
Patient is the edentulous and surgical effect is extensivePatient is the edentulous and surgical effect is extensive
this approach is the treatment of choicethis approach is the treatment of choice
Posterior occlusal ramps helps keep the prosthesis inPosterior occlusal ramps helps keep the prosthesis in
place for edentulous patientsplace for edentulous patients
Existing dentures may also be usedExisting dentures may also be used
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26. Common complicationsCommon complications
Mostly related to tissue trauma and associatedMostly related to tissue trauma and associated
discomfortdiscomfort
Inadequate retentionInadequate retention
Incomplete obturation with associated leakageIncomplete obturation with associated leakage
Tissue effects of radiotherapy and chemotherapyTissue effects of radiotherapy and chemotherapy
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27. Defect and oral hygieneDefect and oral hygiene
Following surgical pack removal, the defect site willFollowing surgical pack removal, the defect site will
mature with time.mature with time.
Patient’s apprehensions regarding his new oral findingsPatient’s apprehensions regarding his new oral findings
must be addressedmust be addressed
As they become more familiar with the defect theyAs they become more familiar with the defect they
should be encouraged to clean the defect of food debrisshould be encouraged to clean the defect of food debris
and mucous secretions routinelyand mucous secretions routinely
Defect hygiene will allow timelier healing and ability toDefect hygiene will allow timelier healing and ability to
adequately fit a prosthesisadequately fit a prosthesis
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28. Defect and oral hygieneDefect and oral hygiene
Common hygiene practices include;Common hygiene practices include;
- Lavage procedures, including rinsing, using bulb syringeLavage procedures, including rinsing, using bulb syringe
or modified oral irrigation deviceor modified oral irrigation device
- Manual cleaning with sponge-handled cleaning aidManual cleaning with sponge-handled cleaning aid
- Daily Fluoride application for radiotherapy patientsDaily Fluoride application for radiotherapy patients
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29. Interim obturatorInterim obturator
Interim prosthesis are wireInterim prosthesis are wire
retained do not have teethretained do not have teeth
initially but later may be addedinitially but later may be added
after a period ofafter a period of
accommodationaccommodation
Duration of interim phase isDuration of interim phase is
three monthsthree months
Primary objective is to allowPrimary objective is to allow
the patient to pass from activethe patient to pass from active
surgical phase to observationalsurgical phase to observational
phase with minimumphase with minimum
complicationscomplications
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30. Definitive careDefinitive care
3-4 months post surgery3-4 months post surgery
depending on size of defect,depending on size of defect,
progress of healing, tumorprogress of healing, tumor
prognosis, presence orprognosis, presence or
absence of teeth, definitiveabsence of teeth, definitive
obturator is planned.obturator is planned.
Defect is engaged moreDefect is engaged more
aggressively for edentulousaggressively for edentulous
patients hence healingpatients hence healing
period is prolonged.period is prolonged.
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31. GoalsGoals
Well supported, stable, retentive prosthesis that isWell supported, stable, retentive prosthesis that is
acceptable in appearance and exhibits minimumacceptable in appearance and exhibits minimum
movement under function.movement under function.
Thereby preserving maximum amount of supportingThereby preserving maximum amount of supporting
tissuetissue
Can be achieved by:Can be achieved by:
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32. Surgical preservation for prosthetic
benefit
Surgical outcomes that
impact prosthetic
success:
- Those that impact the
amount of max. structure
removed
- Those that impact the
structural integrity and
quality of defect
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33. Primary prosthetic
objectives are:
- Restoration of physical
separation of oral and
nasal cavities to restore
- Mastication
- Deglutition
- Speech
- Facial contour
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34. When possibleWhen possible
preservation of as muchpreservation of as much
of inferior sinus floor,of inferior sinus floor,
hard palate, alveolus andhard palate, alveolus and
teeth should beteeth should be
consideredconsidered
If resection leaves <1/3If resection leaves <1/3rdrd
soft palate entire softsoft palate entire soft
palate must be removedpalate must be removed
except in edentulousexcept in edentulous
patientspatients
Use of split thickness skinUse of split thickness skin
graftsgrafts
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35. Types of prosthesisTypes of prosthesis
Obturator prosthesis
Speech aid prosthesis
Others
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37. Obturator prosthesisObturator prosthesis
The defining characteristic of an obturatorThe defining characteristic of an obturator
prosthesis is that it serves to restore separationprosthesis is that it serves to restore separation
of the oral and adjacent cavities following surgicalof the oral and adjacent cavities following surgical
resection of tumors of nasal and paranasal regionresection of tumors of nasal and paranasal region
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41. Treatment concepts
Factors to be
considered
- Movement of the
prosthesis
- Tissue changes
- Covering prosthesis
- Extension into
defect
- Teeth
- Weight of prosthesis
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43. Edentulous patients with totalEdentulous patients with total
maxillectomy defectsmaxillectomy defects
With any large defect restoration in the classical sense isWith any large defect restoration in the classical sense is
not possiblenot possible
According to Desjardins (1978) the contours of theAccording to Desjardins (1978) the contours of the
defect must be used to maximize RSS for the prosthesisdefect must be used to maximize RSS for the prosthesis
In most patients acceptable RSS can be gained from:In most patients acceptable RSS can be gained from:
- Residual palatal structureResidual palatal structure
- Engaging the defectEngaging the defect
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45. The defectThe defect
Acceptable retention canAcceptable retention can
be gained by engagingbe gained by engaging
key areas in the defectkey areas in the defect
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46. Lateral portion of the
obturator exhibits
greatest degree of
movement, retention can
be improved by
appropriate obturator-
tissue contact
superolaterally.
(Brown, 1968)
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47. Steps in fabricationSteps in fabrication
Preliminary impressionPreliminary impression
Master impressionMaster impression
Vertical dimension of occlusionVertical dimension of occlusion
Occlusal scheme selectionOcclusal scheme selection
ProcessingProcessing
Delivery and follow upDelivery and follow up
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49. Edentulous patients with partialEdentulous patients with partial
maxillectomy defectsmaxillectomy defects
More of the hard palateMore of the hard palate
may be available formay be available for
supportsupport
Retention may beRetention may be
compromised as accesscompromised as access
to the defect is limitedto the defect is limited
Defect should beDefect should be
optimally utilized, softoptimally utilized, soft
silicones are especiallysilicones are especially
usefuluseful
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50. Dentulous patients with total or
partial maxillectomy defects
Prognosis improves with
availability of teeth to assist
with RSS
Treatment concepts
- Location of the defect
- Movement of the
prosthesis
- Length of the lever arm
- Arch form
- Teeth
- Partial denture design
- Prosthetic procedures
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51. Basic principles of obturator deignBasic principles of obturator deign
The system of forces :The system of forces :
- Vertical dislodging force – reduce weight of prosthesisVertical dislodging force – reduce weight of prosthesis
- Occlusal vertical force – multiple rests and maximumOcclusal vertical force – multiple rests and maximum
coveragecoverage
- Lateral forces – proper occlusal schemeLateral forces – proper occlusal scheme
- Anterior – posterior movement counteracted by proximalAnterior – posterior movement counteracted by proximal
guide planesguide planes
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63. Speech considerationsSpeech considerations
Surgical removal of a portion of maxilla if not restored,Surgical removal of a portion of maxilla if not restored,
surgically / prosthodontically, can create a serioussurgically / prosthodontically, can create a serious
problem for speaker for several reasons:problem for speaker for several reasons:
- Oral- nasal resonance balance lost leading to hypernasalOral- nasal resonance balance lost leading to hypernasal
speechspeech
- Articulation of speech lost with loss of palatal tissueArticulation of speech lost with loss of palatal tissue
- Loss of anterior teeth further complicates speechLoss of anterior teeth further complicates speech
articulationarticulation
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64. Bloomer and Hawk, 1973, suggested that maxillaryBloomer and Hawk, 1973, suggested that maxillary
resection affects palatopharyngeal function by,resection affects palatopharyngeal function by,
- Destroying attachment for pharyngeal musculatureDestroying attachment for pharyngeal musculature
- Denervation of pharyngeal musculatureDenervation of pharyngeal musculature
- Relative shrinkage and immobilization of soft palateRelative shrinkage and immobilization of soft palate
through scar contractionthrough scar contraction
When maxillectomy is confined to the bony palate,When maxillectomy is confined to the bony palate,
speech following placement of a prosthesis is withinspeech following placement of a prosthesis is within
normal limits.normal limits.
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65. Restoration of soft palate defectsRestoration of soft palate defects
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66. Palatopharyngeal functionPalatopharyngeal function ::
Hypernasality and decreased intelligibility of speechHypernasality and decreased intelligibility of speech
may result from congenital or acquired defects ofmay result from congenital or acquired defects of
palatopharyngeal mechanism.palatopharyngeal mechanism.
Palatopharyngeal deficiency may result from:Palatopharyngeal deficiency may result from:
Congenital malformations such as cleft palateCongenital malformations such as cleft palate
Short hard or soft palateShort hard or soft palate
Deep nasopharynxDeep nasopharynx
Acquired neurological deficitsAcquired neurological deficits
Surgical resection of Neoplastic diseaseSurgical resection of Neoplastic disease
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67. Palatal insufficiencyPalatal insufficiency andand palatal incompetencepalatal incompetence are oftenare often
used to define palatopharyngeal deficitsused to define palatopharyngeal deficits
Palatal insufficiency: patients with inadequate length ofPalatal insufficiency: patients with inadequate length of
soft palate affect palatopharyngeal closure butsoft palate affect palatopharyngeal closure but
movement of remaining tissue is under normal limitsmovement of remaining tissue is under normal limits
Deficiency is secondary to structural limitation. ExampleDeficiency is secondary to structural limitation. Example
patients with congenital developmental deficiency andpatients with congenital developmental deficiency and
acquired soft palate defectsacquired soft palate defects
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68. Palatal incompetence: refers to patients withPalatal incompetence: refers to patients with
essentially normal palatopharyngeal structure, butessentially normal palatopharyngeal structure, but
intact mechanism is unable to effectintact mechanism is unable to effect
palatopharyngeal closure.palatopharyngeal closure.
Example : patients with neurological disease suchExample : patients with neurological disease such
as bulbar poliomyelitis, myasthenia gravis, oras bulbar poliomyelitis, myasthenia gravis, or
neurological deficiency secondary toneurological deficiency secondary to
cerebrovascular accidentcerebrovascular accident
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70. Normal PalatopharyngealNormal Palatopharyngeal
Function For SpeechFunction For Speech
When impairment of the palatopharyngeal port isWhen impairment of the palatopharyngeal port is
present, speech is typically characterized by excessivepresent, speech is typically characterized by excessive
nasal resonance (hypernasality), inappropriate audiblenasal resonance (hypernasality), inappropriate audible
nasal air emission, and a decrease in intraoral airnasal air emission, and a decrease in intraoral air
pressure during the production of oral speech sounds.pressure during the production of oral speech sounds.
Speech may be only partially intelligibleSpeech may be only partially intelligible
Velopharyngeal incompetence is the functional inabilityVelopharyngeal incompetence is the functional inability
of the soft palate to effect complete seal with theof the soft palate to effect complete seal with the
posterior and / or lateral pharyngeal wallsposterior and / or lateral pharyngeal walls
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71. Clinical Features ofClinical Features of
velopharyngeal incompetencevelopharyngeal incompetence
Escape of air resulting in nasal speech that may beEscape of air resulting in nasal speech that may be
unintelligible.unintelligible.
Middle ear infections like otitis media due to obstructionMiddle ear infections like otitis media due to obstruction
of eustachian tube.of eustachian tube.
Nasal regurgitationNasal regurgitation
Psychological problemsPsychological problems
Social discriminationSocial discrimination
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72. Indications for prosthodonticIndications for prosthodontic
carecare
For un-operated patientsFor un-operated patients
A wide cleft with a deficient soft palateA wide cleft with a deficient soft palate
A wide cleft of the Hard PalateA wide cleft of the Hard Palate
Neuromuscular deficit of the soft palate and pharynxNeuromuscular deficit of the soft palate and pharynx
Delayed surgeryDelayed surgery
Expansion prosthesis to improve spatial relationsExpansion prosthesis to improve spatial relations
Combined prosthesis and orthodontic applianceCombined prosthesis and orthodontic appliance
In operated patientsIn operated patients
Incompetent palatopharyngeal mechanismIncompetent palatopharyngeal mechanism
Surgical FailuresSurgical Failures
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73. ContraindicationsContraindications
Feasibility of surgical repairFeasibility of surgical repair
Mental RetardationMental Retardation
Uncooperative patient and parentsUncooperative patient and parents
Uncontrolled dental cariesUncontrolled dental caries
Lack of a trained prosthodontistLack of a trained prosthodontist
Objectives in prosthodontic speech applianceObjectives in prosthodontic speech appliance
constructions:constructions:
Restoring socially acceptable speechRestoring socially acceptable speech
Restoration of the masticating apparatusRestoration of the masticating apparatus
Esthetic facial and dental harmonyEsthetic facial and dental harmony
Psychologic adjustment of the patient to the conditionPsychologic adjustment of the patient to the condition
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83. Meatal obturator prosthesis
First described by
Schalit (1946) later
advocated by Sharry
(1958)
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85. Palatal augmentation prosthesisPalatal augmentation prosthesis
When surgical resection involving the tongue and / orWhen surgical resection involving the tongue and / or
floor of mouth limits the mobility, it affects both speechfloor of mouth limits the mobility, it affects both speech
and deglutitionand deglutition
With tongue mobility limitation, the contour of the palateWith tongue mobility limitation, the contour of the palate
can be augmented by a prosthesis to modify the spacecan be augmented by a prosthesis to modify the space
of Dondersof Donders
To allow food manipulation to be more easily transmittedTo allow food manipulation to be more easily transmitted
posteriorly Into the oropharynxposteriorly Into the oropharynx
Prosthesis movement potential as lowProsthesis movement potential as low
Diagnostic resin prosthesis is given, followed by castDiagnostic resin prosthesis is given, followed by cast
metal prosthesismetal prosthesis
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86. Procedures for Building anProcedures for Building an
Intraoral Prosthesis to AssistIntraoral Prosthesis to Assist
Speech or SwallowingSpeech or Swallowing
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87. Preliminary Dental Work-upPreliminary Dental Work-up
Oral HygieneOral Hygiene must be satisfactory or else, prosthesis willmust be satisfactory or else, prosthesis will
increase risk for…increase risk for…
DecayDecay
InflammationInflammation
Fungal infectionFungal infection
Radiographs are needed to…Radiographs are needed to…
Check for adequate bone support for retentionCheck for adequate bone support for retention
• Important for good stability and supportImportant for good stability and support
Check for decayCheck for decay
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88. Examine Preliminary ImpressionsExamine Preliminary Impressions
Determine strategies forDetermine strategies for fitfit && retentionretention::
1. Select teeth for retention1. Select teeth for retention
2. Changing or shaping tooth as needed2. Changing or shaping tooth as needed
3. Adding material to tooth structure, molar bands,3. Adding material to tooth structure, molar bands,
crowns, or resincrowns, or resin
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89. Preliminary Dental WorkPreliminary Dental Work
Crowns: if tooth has large restoration(s) and integrity isCrowns: if tooth has large restoration(s) and integrity is
compromisedcompromised
common in older patientscommon in older patients
Resin: if tooth is small, misshapen, conical, orResin: if tooth is small, misshapen, conical, or
underdevelopedunderdeveloped
resin added to healthy tooth to provide a “notch”resin added to healthy tooth to provide a “notch”
/anchor for wire/anchor for wire
common in younger patientscommon in younger patients
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90. Designing the Prosthesis:Designing the Prosthesis:
Use oral examination of bite to:Use oral examination of bite to:
Place clasps where they do not interfere with dentalPlace clasps where they do not interfere with dental
bitebite
Use an acrylic (plastic) or metal baseUse an acrylic (plastic) or metal base
Acrylic: for young patients who:Acrylic: for young patients who:
• may need several prosthesismay need several prosthesis
• have less certain prognosis for successhave less certain prognosis for success
• may train out of prosthesismay train out of prosthesis
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92. Prosthesis Design continued...Prosthesis Design continued...
Use metal base: with older patientsUse metal base: with older patients
Benefit: more stable and durableBenefit: more stable and durable
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93. Initial Prosthesis:Initial Prosthesis:
There is no soft palate portion yet (inactive)There is no soft palate portion yet (inactive)
Try in mouthTry in mouth
Adjust acrylic for intimate fitAdjust acrylic for intimate fit
Inspect visuallyInspect visually
Pressure indicator paste will identify wherePressure indicator paste will identify where
adjustments are neededadjustments are needed
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94. Initial Prosthesis continued...Initial Prosthesis continued...
If patient is young, has cognitive impairment, orIf patient is young, has cognitive impairment, or
strong gag reflex:strong gag reflex:
take it slowly, ensure patient comfort firsttake it slowly, ensure patient comfort first
wear for 1-2 weeks prior to adding lift or bulbwear for 1-2 weeks prior to adding lift or bulb
portionportion
Educate patient:Educate patient:
oral hygiene and eatingoral hygiene and eating
wearing timewearing time
increased salivaincreased saliva
taking it in and outtaking it in and out
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95. Additions and ModificationsAdditions and Modifications
Prior to adding: oral exam, check for ulcerations, andPrior to adding: oral exam, check for ulcerations, and
make adjustmentsmake adjustments
Acrylic base: add wire loop and small amount ofAcrylic base: add wire loop and small amount of
acrylicacrylic
depending on patient cooperation and tolerance,depending on patient cooperation and tolerance,
use thermo-plastic wax to build “tail”use thermo-plastic wax to build “tail”
Metal base: already has wire loop built inMetal base: already has wire loop built in
add wax for lift or bulbadd wax for lift or bulb
After adding wax, convert to acrylic, polish, andAfter adding wax, convert to acrylic, polish, and
deliverdeliver
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97. Adding/ModificationsAdding/Modifications
continued...continued...
After adding wax for bulb, continue to shape / defineAfter adding wax for bulb, continue to shape / define
for optimal speechfor optimal speech
convert to acrylic, polish, and deliverconvert to acrylic, polish, and deliver
Add or subtract to lift or bulb at any time using waxAdd or subtract to lift or bulb at any time using wax
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101. Palatal Drop FormationPalatal Drop Formation
Similar to process for building lift/bulbSimilar to process for building lift/bulb
Lower palatal vault or create a posteriorLower palatal vault or create a posterior
“ramp” to increase tongue contact“ramp” to increase tongue contact
Add / modify based on:Add / modify based on:
auditory perceptual judgments of speechauditory perceptual judgments of speech
soundssounds
• stronger lingual stops, fricatives, affricatesstronger lingual stops, fricatives, affricates
tongue contact during swallowtongue contact during swallow
• improved bolus controlimproved bolus control
• no leaks / pocketingno leaks / pocketing
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102. Adequacy of ProsthesisAdequacy of Prosthesis
Visual exam of prosthesis in mouthVisual exam of prosthesis in mouth
Auditory-perceptual judgments of speechAuditory-perceptual judgments of speech
Nasendoscopy of speech with prosthesisNasendoscopy of speech with prosthesis
in placein place
Patient report:Patient report:
comfort & stabilitycomfort & stability
speech & swallow improvementsspeech & swallow improvements
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103. Modifying ProsthesisModifying Prosthesis
Add to velar / pharyngeal area withAdd to velar / pharyngeal area with
temporary waxtemporary wax
How much at each visit is dependent uponHow much at each visit is dependent upon
patient tolerancepatient tolerance
Goal is to provide optimal speechGoal is to provide optimal speech
audio-perceptual judgmentsaudio-perceptual judgments
• initially: excessive closure or hyponasality?initially: excessive closure or hyponasality?
nasendoscopy viewnasendoscopy view
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104. ““Training Out” of the ProsthesisTraining Out” of the Prosthesis
Once optimal closure is achieved, wear forOnce optimal closure is achieved, wear for
approximately six monthsapproximately six months
Systematic reduction programSystematic reduction program
1-2 month intervals1-2 month intervals
reduce 1-2 mm each timereduce 1-2 mm each time
Speech bulb: lateral reductionsSpeech bulb: lateral reductions
Palatal lift: top, sides, back reductionsPalatal lift: top, sides, back reductions
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105. ““Training Out” of the ProsthesisTraining Out” of the Prosthesis
Continue reductions as long as the speakerContinue reductions as long as the speaker
can compensate by producing acceptablecan compensate by producing acceptable
speechspeech
total reduction:total reduction:
nonsurgical approach to VP managementnonsurgical approach to VP management
partial reduction:partial reduction:
more permanent closure of VP mechanismmore permanent closure of VP mechanism
requiredrequired
• pharyngeal flap? more permanent prosthesis?pharyngeal flap? more permanent prosthesis?
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