The prosthetic mangement of an edentulous patient having/ dental courses

THE PROSTHETIC
MANGEMENT OF AN
EDENTULOUS PATIENT HAVING
CLEFT INVOLVING BOTH HARD
AND SOFT PALATE.
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
Introduction
Historical development.
Classification.
Diagnosis and Treatment Planning
Indication for Prosthodontic treatment
Contraindication

Treatment Phases
1) Early Phase.
a) Neonatal Prosthesis
b) Maxillary orthopedic prosthesis
c) Speech aid prosthesis.
2) Adjunctive Phase.
3) Adult Phase.
Design Principle
-Support
-Retention.
-Stability.
Obturator in complete dentures.
Summary and conclusion.
References.

INTRODUCTION
In response to congenital or acquired defects, man has
continually sought to cope with his debilities by using his
genius and the material resources available for restoration
The design and construction of speech appliances and
obturators have changed much in last 40 years, thanks mainly
to improved materials and methods. Greater coordination of
our interdisciplinary team efforts has helped in establishing a
more ideal prosthetic concept, one that assures that fixed or
removable partial denture prostheses are so managed as to
preserve the integrity of all remaining teeth and the
surrounding soft and hard oropharyngeal structures.

HISTORICAL DEVELOPMENT

CLASSIFICATION
(W. R Laney)

DEFINITIONS:
CLEFT PALATE: CONGENITAL DEFECT OF THE ROOF
OF THE MOUTH WHERE THE STRUCTURES
ENTERING INTO ITS FORMATION DO NOT UNITE IN
THE MIDLINE THUS RESULTING IN AN ABNORMAL
COMMUNICATION BETWEEN THE NOSE AND THE
MOUTH.
OBTURATOR :DEVICE USED IN THE TREATMENT OF
ACQUIRED DEFECT
SPEECH APPLIANCE: AN APPLIANCE EMPLOYED IN
R TREATMENT
OF CONGENITAL CLEFTS

DIAGNOSIS AND TREATMENT
PLANNING
Case history
Impressions for study casts
Radiographs: Intraoral radiographs,
Cineradiographs, Laminography, pantomography,
cephalometry
Photographs

Speech recording
Sound spectrographic recording
Measurement of Oral and Nasal flow
Otologic and Hearing considerations
Psychologic and social considerations

INDICATIONS FOR PROSTHODONTIC
TREATMENT:
In unoperated patients
Wide cleft with deficient soft palate
Wide cleft with deficient hard palate
Neuromuscular deficit of soft plate and pharynx
Delayed surgery
Expansion prosthesis
Prosthesis and orthodontic appliance

In operated patients
Incomplete palatopharyngeal mechanism
Surgical failure
CONTRAINDICATIONS FOR PROSTHODONTIC
TREATMENT
The mentally retarded patient
The uncooperative patient/parent
The patient with rampant caries
 Lack of an experienced /skilled
prosthodontist

PHASES OF PROSTHODONTIC
CARE:
It can be divided into three phases:
1. Early phase
Neonatal prosthesis
Maxillary orthopedics
Speech aid prosthesis
2.The adjunctive phase
3.The adult phase

Neonatal Prosthesis:
During the first several days after birth and before the
mother and baby are discharged from the hospital,
impressions can be made and casts of the newborn infants
lip and palate
Adapting flexible plastic of the type used for mouth
guards directly to the cast of the maxillary arch.
Does not extend onto the soft palate
No direct, immediate orthopedic effect is expected
A more normal tongue position is attained by the use of
the prosthesis.

]
Maxillary orthopedics:
Presurgical orthopedics ( McNell)
-Impression-cut the model-reposition the model- plate
-Use of extra oral appliance
Post surgical orthopedics
-correction of malocclusion
-the Hyrax appliance –concept of RME
-Chin cap?

]
SPEECH APPLIANCE
SPEECH CHARECTERICS.
Speech characteristics common to patients with
palatopharyngeal incompetence and palatopharyngeal
insufficiency are
Hypernasality
Nasal emission and
Decreased intelligibility of speech due to weak consonant
production.

]
ACHIEVING ACCEPTABLE SPEECH.
 Speech and myofuctional therapy
 Surgical procedures to reduce the palatopharyngeal gap
using soft palate-lengthening techniques, pharyngeal flaps,
implants cartilage, bone,silicone,Teflon), and combination
of these methods.
 Faradizations and electrical vibration massage to
stimulate palatal function.
 Prosthetic elevation and stimulation of the
palatopharyngeal lumen for the patients with
palatopharyngeal insufficiency.
 A cpmbination of surgery and a prosthesis.www.indiandentalacademy.com

• There are two prosthodontic procedures available in the
treatment of patients with palatopharyngeal inadequacies.
There are the palatal lift prosthesis and a combination
palatal lift/pharyngeal section prosthesis.
• The palatal lift prosthesis is used to elevate the soft palate
to its maximal position during normal speech and deglutition.
• The combined palatal lift/ pharyngeal section type of
prosthesis is preferable if the soft palate is insufficient to
achive proper palatopharyngeal closure. The prosthesis will
elevate the soft palate, obdurate the palatopharyngeal gap,
and stimulate palatopharyngeal activity and pharyngeal
muscle contraction.

• Prerequisites of the palatal lift/ pharyngeal section
combination prosthesis
• the maxillary portion of the prosthesis is designed to
achieve optimal retention and stability.
• The lift portion of the prosthesis should be place so that
palatal elevation occurs in the area where normal
palatopharyngeal closure takes place.
• The pharyngeal section should be placed in the region where
constriction of the posterolateral pharyngeal wall takes
place to encourage muscle stimulation and activity.
• Elevation of the soft palate should be gradual so that the
soft palate becomes less resistant to displacement.
• The reduction of pharyngeal section when indicated should
be gradual.

• Speech therapy, including lip, tongue and palatal exercises
and placement, should be instituted in conjunction with the
construction and insertion of the prosthesis.
• Objectives of making palatal lift and combination
prosthesis.
• to reduce hypernasality and escape of nasal air by palatal
elevation.
• To reduce the degree of palatal disuse atrophy.
• To increase palatopharyngeal function by constant and
continuous stimulation
• To increase neuromuscular response by gentle stimulation
and speech exercises, and
• To assist in the repositioning of the tongue.
•

• It has the following parts :
• The anterior part
• The palatal part
• The pharyngeal part
• Preliminary impressions.
• Final impression
• Velar portion.
• In the unoperated clefts with the help upper prosthesis in
position the extension of the tailpieces over the margin of
the cleft is marked on the posterior part of the appliance.
The tail piece extends posteriorly to the anterior margin of
the uvula.

• In operated palates that are short and requires a
prosthesis the position of the tail piece extends 3 mm
behind the posterior margin of the soft palate the width of
the tail piece is 5mm and its reinforced thickness is app
1,5mm
• Pharyngeal section.
• Two holes are drilled in the posterior part of the tailpiece. a
piece of separating wire is drawn through the holes in such
a manner that a loop is formed to extend superoposteriorly
beyond the superior part of the tailpiece

• The patient is asked to swallow and the wire is
adjusted so that it does not contact the pharyngeal
walls at any time while mouth is open. a spray of
water with a syringe will stimulate posterior and
lateral pharyngeal wall activity
• Green compound is added around the wire loop to
reinforce the wire and its attachments to the
tailpiece. The appliance is inserted into the mouth
and the patient is asked to swallow some water.
Adaptol is softened in water at 150 to 160 deg F,
for four to five min, is added green compound and
the appliance is inserted into the mouth. Again the
patient is instructed to swallow some water to
produce muscle activity that will mold the
impression material.www.indiandentalacademy.com

• The prosthesis is reinserted a number of times
with more Adaptol gradually added to the mass on
the wire loop until a functional impression is made
of the lateral and posterior pharyngeal walls. The
impression material is molded by instructing the
patient to place his chin against his chest and to
move his head from side to side. In the rest
position the patient swallows water and speaks the
muscular activity this further molding the
impression material

• OBTURATORS DESIGN PRINCIPLES.
• Some of the basic design principles are to
achieve optimum stability, retention, and
support
• SUPPORT.
• Support is the resistance to movement of
prosthesis towards the tissues. The support
available from the residual maxilla and from
within the defect both must be considered.

• Residual maxilla support.
• Alveolar ridge
• Residual hard palate
• Within the defect support
• Floor of the orbit
• Pterygoid plate/temporal bone
• The nasal septum

• RETENTION
• Retention is the resistance to vertical displacement of the
prosthesis. Both direct and indirect retention is important.
• Residual maxilla retention
• Teeth
• Alveolar ridge;
• Within the defect retention
• Residual soft palate
• Residual hard pale
• Anterior nasal aperture
• Lateral scar band
• Height of the lateral wall

• STABILITY
• Is the resistance to prosthesis displacement by functional
forces. Principles of obturator design must minimize
rotation around the horizontal plane and minimize movement
within the horizontal plane itself must be considered.
• residual maxilla stability
• Within the defect stability

• Weight reduction:
• The retention and stability of the appliances appear to be
improved by weight reduction. Lightening the obturator
portion improves the cantilever mechanics of the suspension
and avoids overtaxing the remaining supportive structures.
Construction of providing a thin walled hallow chambered
speech plate markedly reduces amount of the material
needed to seal the cleft. Contours should be made so as to
shed secretion and to prevent odors pooling of fluid and
added weight.

Further types of removable prostheses for adult partially
edentulous/ fully edentulous maxilla:
SNAP ON PROSTHEIS WITH NO SPEECH BULB:
The abutment teeth are fully prepared to receive full
coverage. A gold framework is designed and cast to overlay
the bicuspids and clasp the molars. The clip attachment
engages the anterior cross bar. Thus the occlusion is
restored and the middle face esthetics are achieved.
REMOVABLE PARTIAL PROSTHESIS WITH NO SPEECH
BULB:
With a large ridge defect and extremely poor occlusion more
teeth may be salvaged to increase the retention and
stability of the prosthesis. This prosthesis restores the
vertical, facialand occlusal dimensions.

COMPLETE SUPERIMPOSED DENTURRE WITH NO SPEECH
BULB:
In cases with normal mandibular development and collapsed
maxillary arch with a partially dentate configuration full
crowns can be placed with precision clasps and framework .
This prosthesis restores the vertical dimension of the face
and gives an ideal arch form to the maxillary arch with a full
compliment of teeth.
SNAP ON PROSTHESIS WITH A SPEECH BULB. : This is
similar to the earlier prosthesis that we discussed earlier
except that it has a speech bulb attached to it.
CONVENTIONAL SPEECH PROSTHESIS WITH BULB:
Patients with a full compliment of teeth may need only a
framework clasping the healthy abutment teeth.

COMPLETE SUPERIMPOSED DENTURE WITH SPEECH BULB:
This is basically an overlay denture which may or may not have
a pharyngeal bulb section.

• REVIEW OF LITERATURE:
• In 1952 Nathaniel A. Olinger discussed the prosthetic
rehabilitation of cleft palate. He discussed the anatomy,
physiology and embryology of the oral structures and also
the etiology of clefting. He explained the diagnosis and
treatment planning for cleft patients and also the different
modalities of treatment including the palatal extention
prosthesis, the pin lock hinge and fabrication of vomer. He
stressed the importance of speech and psychological
rehabilitation of the patient.
• In 1964 Mohammed Mazhaheri discussed the role of
prosthodontics in cleft palate treatment and research. He
discussed the objectives of cleft palate treatment , th3e
indications contraindications of speech appliance and also
the technique of fabrication of the speech appliance.
•

• Kenneth E. Brown in 1968 dicussed the peripheral
considerations in improving obturator retention. It was his
observation that when a surgical defect is conditioned by
surgical reconstructive grafts the peripheral contours of an
obturator may be developed to create a butteress like
effect. To obtain a maximum of lateral retentiveness, the
buttress effect of the obturator’s lateral border should be
placed as high and as far away from the retentive axis as is
possible. The contouring should never impinge on any
delicate unprotected structure.
• Ronald P. Desjardins in 1975 discussed the prosthodontic
management of the cleft palate patient. He described the
indications and contraindications of prosthodontic care of
cleft palate patients. It was he who described the three
phases of cleft palate treatment : the early, adjunctive and
the adult phase. www.indiandentalacademy.com

• SUMMARY AND CONCLUSION:
• A thorough understanding of the advantages and limitations
of different approaches to cleft management i.e., surgical,
orthopedic/ orthodontic or prosthodontic is essential and a
multidisciplinary approach is more often than not the best
recourse.
• The prosthodontist should make a careful diagnosis
and treatment planning of the patient, understand the
indications and limitations of different appliances and treat
the functinal (missing teeth, reduced vertical dimension,
collapsed midface) physiologic ( phonation, nasal
regurgitation) and esthetic ( collapsed midface, smile)
demands of the patient through various treatment
modalities discussed. www.indiandentalacademy.com

• REFERENCES
• Kenneth E.Brown;Peripheral consideration in improving
obturator retention; J Prosthet Dent,20.176-181,1968.
• Kenneth E.Bron; Clinical consideration improving obturator
treatment. J Prosthet Dent.24.461-466.1970.
• Ronald P. Desjardins; prosthodontic management of the
cleft palate patient; J Prosthet Dent,33,655-665.1975.
• Dorsey J.Moore;The continuing role of the prosthosontists
in the treatment of patients with cleft lip and palate; J
Prosthet Dent.36,186-192,1976.
• Mohammed Mazheri; prosthodontic aspects of palatal
elevation and palatopharyngeal stimulation, J Prosthet
Dent.35;319-327,1976.
• Ronald P. Desjardins; Obturator design for acquired
maxillary defect; J Prosthet Dent.39.424-435.1978.

• Victor Matalon;A simplified method for making a hollow
obturator; J Prosthet Dent;36,58-583,1976.
• Norman G.Schaaf;Obturators on complete dentures;
DCNA !977 , Complete denture.
• Herert K. Cooper Sr etal; Cleft palate and cleft lip; A team
approach to clinical management and rehabilitation of the
patient; W.B.Saunders company;1979.
• WilliamR.Laney; Maxillofacial prosthetics ;vol 4, PSG
publishesing,1979.
• Thomas J.Vergo Jr etal; Maximizing support for maxillary
defect. J Prosthet Dent,45,179-182,1981.
• Glenn E.Misley etal;An alternative method for fabrication
of a closed hallow obturator; J Prosthet Dent 55,485-
490,1986.
• Rhoda F Jacob; Clinical management of the edentulous
maxillectomy patient.
• .

•
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