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Definitions :
Maxillofacial prosthetics is the branch of Prosthodontics
concerned with the restoration and or replacement of
intra-oral and associated facial structures by artificial
substitutes.
The structures may be missing or mutilated as a result of
surgery, trauma, and congenital or developmental
defects.
Congenital defects as cleft palate, cleft l:p, missing ear
and facial cleft .
Acquired defects may be caused by surgery, pathology or
accidents.
Developmental defects as prognathism or retrognathism.
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Classification of Maxillofacial prostheses

Intra-oral prosthesis such as obturators, stents, splints,

and resection appliances.
Extra-oral prosthesis such as radium shield, restoration
of missing eye , nose or ear and ear plug as a hearing
aid.
Combination of intra and extra-oral prosthesis in cases
of missing parts of maxilla or mandible with the facial
structures.
Cranial prosthesis to restore lost cranial bone in case of
skull injury by cranium inlays or onlays.

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 Intra-oral prosthesis

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 Extra-oral prosthesis

An artificial nose is attached Ocular prosthesis replaces

7with medical-grade a missing right eye.
adhesive
 Combination prosthesis

Patient after operation with

extensive maxillary-facial defect

Left (facial Facial prosthesis and The patient;s face and

prosthesis) Right obturator held chewing function have
8 obturator)
(an together by magnets been restored
 . Obturator in place
closes soft palate
defect and replaces
missing hard palate
and maxillary teeth.

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 CONGENITAL CLEFT LIP AND PALATE
Cleft Lip and Palate - structural defect caused by a lack of
tissue fusion during embryonic development.
However, other structural defects can be included in the
category of craniofacial anomalies and may cause disruptions
in normal speech and language development.
Congenital clefts of lip and palate are defined as lack of
fusion of the embryologic processes which would normally
unite during inter-uterine growth to form the lip and palate.
Congenital cleft palate is the lack of continuity of the roof of
the mouth through the whole or part of its length in the form
of fissure extending anteroposteriorly.
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 Formation of the Upper Lip and Premaxilla
(Primary Palate)
Primary palate consists of all structures anterior to the incisive
foramen (Upper lip, alveolar process - premaxilla)
Merging of three processes
- Frontonasal process - Right and Left nasomedial process
Week 5 - 6 - lip closure is completed
Formation of the Secondary Palate
Merging of two palatal shelves from maxillary processes Week 8-9
Secondary palate consists of all structures posterior to the incisive
foramen
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 The union of the primary palate , the secondary
palate and the nasal septum begins at the meeting point of
the premaxilla and the two lateral palatine processes
(incisive foramen).

From this point of meeting union progress anteriorly

and posteriorly in a Y- shaped suture. Anteriorly, to form the
premaxilla, anterior alveolar ridge and upper lip and
posteriorly to form hard and soft palate.

Congenital clefts occur during embryological growth

due to arrest of development and failure of fusion between
the embryonic processes.
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Structures of the Hard Palate
Premaxilla
Incisive Foramen
Palatine Processes
Horizontal Plate (horizontal part of the palatine bone.
Posterior Nasal Spine

Structrures of the Soft Palate

Velum (Soft Palate itself)
Muscular Uvula
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 Development of the secondary palate

Palatal shelves grow downward and adjacent to the tongue.

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 Palatal shelves assume a level above the tongue and
assume a horizontal position. Fusion of the 3 processes
forms the normal secondary palate.

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 Embryology processes of abnormal palatal development.
Ordinarily, the palatal shelves assume a vertical orientation
and are directed downward. There is free communication
between the oral cavity and the nose at 7 weeks.

Thus, the tongue is in

direct contact with the inferior
border of the nasal septum.
The palatal shelves move
horizontally as the process of
fusion commences. Failure of
fusion of the palatal shelves
(medial extensions of the
maxillary prominence), from
any cause, may lead to cleft
palate.
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Incidence of Cleft Lip and Palate
Approximately one in every 700-750 births internationally
(when it is an isolated problem) will have cleft palate or cleft lip
with cleft palate. (No racial differences of clefts of lip only).
More females than males have cleft palate only.
More males than females have clefts of the lip and palate
Differences due to differences in timing of embryological
development
Racially - highest incidence in Asians. Next highest -
Caucasians. Lowest - Africans/African-Americans
Unilateral clefts are more common than bilateral clefts of the
lip and palate.
Left side cleft forms 70 % of unilateral clefts.
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Types of Clefts
Clefts of the Lip
# Bilateral/Unilateral # Complete/Incomplete

Clefts of the Palate

Complete Unilateral - tip of uvula through alveolar ridge all hard and soft palate
involved - midline to incisive foramen then on one side only
Complete Bilateral - tip of uvula to incisive foramen then through alveolar ridge,
on both sides
Incomplete Unilateral - larger palatal segment attached to vomer
Incomplete Bilateral - neither palatal segment is attached to vomer
Soft palate only - tip of uvula to nasal spine
Submucous cleft - cleft of palatal muscles and notch in edge of hard palate.
Mucosa is intact. Can be diagnosed by palpation or by viewing bluish
discoloration .
Occult submucous cleft - cleft or absence of musculus uvulae without oral
manifestations
19 seen in submucous cleft palate. Generally only able to identify
through nasendoscopy
Other Classification Systems
Veau System (1931)
Veau I - Cleft of soft palate only
Veau II - Cleft through hard and soft palate to the incisive foramen
Veau III - Complete unilateral cleft
Veau IV - Complete bilateral cleft

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Olin’s classification:
Group I:
Cleft lip only: unilateral or bilateral with nasal deformity
Group II:
Cleft plate only: pat of the soft plate, or the entire soft and
hard palates may be involved
Group III:
Cleft lip and cleft palate involving the alveolar ridge. Pt may
have unilateral or bilateral clefts.
Group IV:
Clefts of the lip and alveolar ridge not involving the palate.
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This condition is rare occurrence.
Harkins classification:
Pt’s are classified according to the degree of the cleft into:
Bifid uvula.
Cleft of the soft palate
Cleft of the soft and hard palate extending through the
palatal bones.
Cleft of the soft and hard palate extending to the incisive
foramen.
Cleft of the soft and hard palate extending through the
alveolar process and lip on one side (unilateral).
Cleft of the soft and hard palate extending through the
alveolar process and lip on both sides (bilateral).
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 Cleft lip
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25 Cleft lip Cleft palate
 Cleft palate variations

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 Unilateral Bilateral complete Bilateral
incomplete cleft lip cleft lip incomplete cleft lip

Bilateral complete Incomplete cleft palate Horseshoe

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cleft lip and palate cleft palate
Spectrum of cleft palate morphologies (from upper left panning to right).
A. Normal development B- Unilateral clefting of the lip
C. Unilateral clefting of the lip and primary palate
D. Bilateral clefting of the lips and primary palate including the
incisive canal
E. Secondary palate cleft including the incisive canal
F. Unilateral clefting of lip, primary palate, incisive canal, and
secondary palate

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American Cleft Palate Craniofacial Anomalies System
Clefts of the primary palate (anterior to incisive foramen)
Clefts of the secondary palate (posterior to the incisive foramen)

Causal Aspects
Clefts may be isolated malformations or may be a part of a
syndrome.
Syndrome - major malformations which appear unrelated
but are frequently found to have a common etiology.
Sequence - to anomalies occur together the primary anomaly
causes the first to happen.
E.g., Pierre Robin Sequence - failure of mandible to grow in utero
causes
29 a u-shaped cleft of the soft and hard palate but not the alveolar
ridge.
Acquired Disorders
Maxillofacial deformities can result from trauma
(gunshot wounds, ablative surgery.
Congenital neurologic disorders could cause may result
in resonance problems due to VPI.

Psychosocial Factors
Parental reactions at birth
Teacher reactions
Peer reactions
These factors change over time.
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Causes and predisposing factors of
clefts :
The following factors may play a role in inducing cleft
lip and palate :
1- Abnormal position of the embryo.
2- Change in pressure of amniotic fluid.
3- Persistence of epithelium at the junction of
embryonic processes.
4- Failure of the tongue to drop down the palatine
shelves.

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The predisposing factors for cleft lip and palate include :
1- Hereditary.
2- Nutritional deficiency e.g. Vitamin A and riboflavin
deficiency.
3- Infectious diseases of the mother during pregnancy
(German measles).
4- Cortisone therapy and hormonal disturbance (pituitary
dysfunction).
5- Radiotherapy and excessive X-ray exposure during early
pregnancy
6- Chemical irritation e.g. hypervitaminosis A and hypoxia.
7- Stress and anxiety during the first trimester of pregnancy.
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Palato ( velo ) pharyngeal mechanism :
The velopharyngeal mechanism is a coordinated valve formed by the muscles of
the soft palate and pharynx.

Muscles of soft palate:

Tensor palatini muscle (TPMs):
Origin and insertion- base of skull descend more vertically. They terminate in
tendon which pass around the pterygoid hamulus process.
Action – depress the soft palate make it more tense and thus assists its contact
with the tongue.

Levator palatini muscle (LPMs):

Origin and insertion- base of skull and cartilage of the eustachian tube. They
terminate in the midline of the nasal surface of the soft palate along the
palatal aponeurosis.
Action- Works like a sling to pull the velum up and backwards causes the free
margin of the soft palate to touch the posterior pharyngeal wall as in
swallowing or oral breathing.

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Palato-pharyngeal muscle (PPMs):
Actions:

Depress the soft palate

With the LPMs contraction, they retract soft palate slightly
and make it more dome-shaped.
With posterior fibers contracted they form part of pharyngeal
sphincter.
Palato-glossus muscle (PGMs):
Actions:

It acts with the TPMs to depress the soft palate against the
LPMs in swallowing.
Raise the back of the tongue.
Superior constrictor muscle (SCMs):
Actions:
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Causes an inward movement of the lateral walls of the pharynx.
Normal Velopharyngeal Closure
Velum approximates posterior pharyngeal wall.
Lateral pharyngeal walls move in.
Adenoidal tissue may assist in closure
Passavant's ridge may also assist in closure.

Causes for Velopharyngeal Incompetence

Short soft palate
Neuromuscular disorders affecting soft palate
Learned behaviors (including dialectal variations
Timing difficulties
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1- Velopharyngeal closure :
It is required for normal deglutition and the production of
some speech sounds such as P&D. This closure occurs by the
following :
 The middle of the soft palate curves upwards and backwards
an attempt to contact the posterior wall of the pharynx. This
action is done by the levator and tensor palatini muscles.
 The posterior wall of the pharynx moves forward by the
action of the superior constrictor and the palatopharyngeous
muscles forming the ridge of passavant. This ridge is a horizontal
roll of tissues on the posterior wall of the pharynx corresponds to
level of the atlas vertebra. It occurs during speech and swallowing
and serve as a guide for placement of soft palate prosthesis.
 The lateral walls of the pharynx move medially by the action
of the
36 salpino pharyngeous muscle.
2- Velopharyngeal opening :
This occurs during normal breathing and for
pronunciation of vowels and nasal consonants in varying
degrees. It is a relaxed position; the soft palate drops downward
to keep the oropharynx and nasopharynx opened.
Velopharyngeal insufficiency :
Inadequate, short length of the soft palate resulting from
either congenital or developmental defects results in insufficient
palatopharyngeal closure.
Velopharyngeal incompetence :
Adequate and normal amount of palatopharyngeal tissues
but these tissues are functionally impaired resulting in
inadequate
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closure as in patients having neurological disease.
Disabilities associated with cleft lip and palate :
1- Speech :
Components of speech :
A- Respiration: During speech the exhalation phase is prolonged to
produce sufficient volume and pressure of a continuous air stream.
B- Phonation : Expiratory air passing through the vocal cords
producing undifferentiated sounds.
C- Resonation: The laryngeal sound waves are amplified through the
pharynx, oral and nasal cavity.
D- Articulation: Amplified resonated sounds are differentiated into
meaning sounds by articulation of the tongue, teeth, lips, and palate .
E- Neural integration : The central nervous system control speech
production at the peripheral and central level.
F- Audition : Audition is the ability to receive sound signals. Hearing
permits
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reception and interpretation of sound signals and allows the
speaker to monitor and control speech .
Defective speech in cleft patients :
Defective speech is the most obvious sign of cleft palate
subjects. The sound resonance and articulations are most readily
affected by cleft lip and palate. Patients with cleft palate exhibit
a- An excessive nasal resonance because the inadequacy of the
velopharyngeal closure (nasal sounds or hypernasality).
b- The vowels (A,I,E,O,U) and nasal consonants (M,N,NG) not affected
c- The articulation of the other consonants is affected in a varying
degrees, depending on the degree of oral pressure required for each
sound

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2- Improper mastication : The masticatory function is
impaired because babies cannot suck due to lack of negative
pressure, food escape through the nasal cavity and the presence
of missing teeth and malocclusion.
3- Swallowing : Swallowing is impaired when cleft occurs
in both hard and soft palate. The baby should be placed in
upright position and a special nipple is used during feeding.
4- Aesthetics : Abnormal appearance due to the presence
of labial cleft and facial deformity due to improper or early
surgical repair of palatal cleft. Trauma to the growth center of
bone during surgery leads to reduction of the forward growth
& lateral dimension of the maxilla
5- General health : The general health of the child is affected
due to inadequate nutrition and mouth breathing.
6- Psychological problems : Children with clefts have
difficulty in adjusting with society. They may withdraw or turn
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aggressive.
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 Diagnosis and treatment planning are carried out through the
maxillofacial team representing different specialties. Full considerations
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 and antero-posterior
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 naso-
pharynx.
7- Floating pre-maxilla.
8- Number of missing teeth in line of cleft, malformed and mal-posed
teeth and partially erupted teeth.
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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 palate 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
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wait
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 Management of congenital cleft lip and palate

I- Maxillofacial team evaluation : The management of Pts

with acquired or congenital defects involves the cooperation of the
following team members :
1- Plastic surgeon : for surgical reconstruction of deformities
2- Prosthodontist : in case of failed surgery.
3- Speech therapist: to correct defective speech caused by the palatal
defects.
4- Orthodontist : for ttt of malocclusion associated with the clefts.
5- Psychologist: To help the patient to accept the problem, improve
patient’s attitude and cooperation in the course of ttt.
6- Social worker: Discusses the problem with parents, educate
them about the problem and guide the patient for his future life.
7- Dental
45 technician: Construct the prosthetic appliance .
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II- Infant feeding:
In case of cleft lip the infant can feed normally
with a bottle or breast. To prevent milk leakage the finger
is placed over the lip cleft or a broad base nipple is used.
In case of unilateral alveolar cleft the nipple should be
pointed toward the unaffected side.

For cleft palate the infant cannot suck. A syringe is

used or a specially designed bottle and nipples, while the
infant in a semi- upright position. Soft nipples, crosscut
nipples, or long nipples and squeeze bottles can be used.
In a very rare cases an obturators attached to the nipple is
used.
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 Above, left and center: Soft squeezable bottle with cross
cut orthodontic nipple (top right). Above, bottom right:
49 Ross Syringe Nipple.
 Cross cut in top of nipple.

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III- Surgical repair :
Surgical closure is the treatment of choice for
congenital defects. Lip repair usually performed 6-12
weeks after birth to facilitate feeding and improve
appearance.

Repair of the cleft palate is performed after 1-4 years

(usually 2 years). Early repair of the cleft palate should be
avoided to permit for the growth of the palate with
narrowing of the cleft and to permit for development of
enough tissues for closure.

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 Medical Management
• Lip surgery (cheiloplasty) 3 mos (10 + 10)

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 Medical Management
• Palatal surgery (palatoplasty) 6 - 18 mos

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 Cleft palate repair

Cleft palate
repair.
The von
Langenbeck
repair.
Two bipedicle
mucoperiosteal
flaps are
created

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Cleft palate repair. Anatomy of the palate.

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 Cleft palate repair
Two flap palatoplasty. After lateral relaxing incisions are performed

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 Cleft palate repair
Two-flap palatoplasty (continued). Closure of the nasal
mucosa is performed

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CLEFT PALATE ORTHOPEDIC MANAGEMENT
Treatment of this birth
defect condition can begin at
birth by providing the newborn
with an obturator to help with
Before
feeding. Altering the facial
segments (pre-surgically) in
preparation for lip closure may
be elected in special cases.

Early Orthopedic and

Orthodontic treatment is
provided to help the cleft palate
child's face, teeth and jaws After
develop as normally as
possible.
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Extraoral Orthodpedic Intraoral Orthodpedic
Device Device
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 Before After

Some cases may require jaw surgery to resolve. We work

closely with surgeons to coordinate
the orthodontic, orthopedic, dental, and surgical aspects of
62 treatment