Treatment of Velo-pharyngeal Defects

Congenital velo-pharyngeal defects due to palatal insufficiency can be restored by surgical

reconstruction followed with the insertion of an obturator to correct the residual palatal
insufficiencies.
Congenital velo-pharyngeal defects due to poor structural integrity can be treated with palatal
surgery.
Acquired velo-pharyngeal defects due to surgical resection can be treated by surgical
reconstruction and prosthodontic rehabili-tation (E.g. obturator).
Acquired velo-pharyngeal defects due to trauma and neurological deficiencies can be treated by
prosthodontic rehabilitation using a palatal lift prosthesis.

EXTRAORAL DEFECTS
Extraoral defects occur due to trauma, neoplasm or congenital malformation. Extraoral defects that
occur due to trauma are dealt separately under traumatic defects.
The common neoplasia of the head and neck include:
Epithelial tumours: epithelial facial tumours may have a melanocytic, keratinocytic or adrenal
origin.
Connective tissue tumours: adenomas, fibromas, leiomyomas and lymphomas.
After surgical resection, the patients are referred for prosthodontic rehabilitation. The types of
prosthesis required vary according to the size, extent and location of the tumours.
Extraoral congenital malformations that require maxillofacial prostheses include:
Auricular defects:
— Microtia (small ear) associated with atresia of the external auditory meatus.
— Anotia (complete absence of the auricle).
— Smaller ear defects.
Nasal defects: The defects arising due to surgery are known as Rhinotomy defects.
Ocular defects: It involves the defects in the eyeball with intact eyelids (lacrymal appara-tus. An
orbital defect involves both the eyeball and the eyelids. Most of the ocular defects are acquired (by
surgical procedures like evisce-ration–removal of the eyeball preserving the sclera, enucleation
and excentration).
Lip and cheek defects like double lip, hemifacial microsomia etc.
Combination of the above mentioned defects.
Aesthetics is the major principle behind the placement of these prosthetic appliances. Hence, most
of these prostheses are non-functional. Commonly used extraoral maxillofacial pros-theses are
described in the next chapter.

TRAUMATIC DEFECTS

Common causes of trauma include physical trauma and trauma due to heat and electrical agents.
Trauma can be classified under Inter-national classification of diseases as intentional and
unintentional. Suicide, an intentional injury is the second most common cause for death. The common
causes for unintentional injuries are listed below according to their order of incidence:
Moving vehicle accidents or Road traffic accidents
Falls
Fires and burns
Drowning
Poisoning
Aspiration of objects
Fire arms
Air plane crashes
Water transport
Electric current
 Traumatic defects differ from neoplastic
defects in the following ways:
They do not occur in predictable locations
The patient usually does not have any associated systemic problems (the patients with neoplastic
defects are often accompanied with systemic complications). Hence, these patients respond
favourably to reconstruction than neoplastic defects.
Patients with traumatic defects are more critical about their aesthetics than those with neoplastic
defects.
Types of Maxillofacial Injuries
Maxillofacial trauma can be grossly grouped as
follows:
• Fracture of the hard tissues include cranial
fractures, orbital fractures, nasal fractures, jaw
fractures.
• Soft tissue injuries involving the temporo-
mandibular joint and other soft tissues adja-
cent to the trauma site.
As mentioned before, the extent of damage
and rehabilitation required for a trauma case is
unpredictable. A comprehensive knowledge
about maxillofacial trauma and its management
is essential for a prosthodontist to restore these
defects.
The significance of these injuries becomes pro-
minent especially when they occur for partially
or completely edentulous patients. In these
patients, the prosthetic appliance may have to be
used as splints to approximate the fractured
segments.
Treatment Goals for a Trauma Patient
There are six main treatment goals for rehabi-
litation of a trauma patient.
1. Oral intake: It is the primary goal of rehabili-
tation. It is important for the patient to masti-
cate a normal diet apart from fluid intake.
2. Closure of palate: It should be achieved by
surgery or by an interim prosthesis.
3. Sensation and mobility of the tongue: It is essential
for functioning of the tongue during masti-
cation and speech. Scar bands which limit the
movement of the tongue should be removed
4. Circumoral competence: The lip should be
mobile and competent in order to control the
saliva and the bolus. This is also essential for
obtaining access during maintenance.
5. Maxillary and mandibular realignment: Skeletal
and dental realignment is essential to obtain
proper occlusion (masticatory function).
6. Appearance: Last but not the least, appearance
is the ultimate goal of rehabilitation.
Traumatic patients are usually managed in
four phases. The first phase is the initial stabili-
zation of the patient, which lasts for 2 weeks. At
this stage, the physician determines the prognosis
and the treatment plan.
The next phase is the early management phase,
which extends for 2 to 8 weeks. Treatments like
inter-maxillary fixation, splinting, root canal
treatment etc are done here.
The third phase is the phase of intermediate
management that extends for 3 to 8 months. In this
phase a treatment prosthesis is provided and
other defects are rectified to bring the tissues to
normal contour.
The fourth phase is the phase of definitive
management, which extends from 6 months to
three years. A permanent prosthesis like complete
denture, fixed partial denture, implant, etc. is
fabricated in this phase.