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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.

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Obturators/ orthodontic seminars Presentation Transcript

  • 1. Obturators . INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. • Definitions and types • Anatomy of maxilla • biomechanics • Classification of maxillary defects • Types of Obturators • Clinical steps • Laboratory procedures www.indiandentalacademy.com
  • 3. Defination of obturator • GPT –7: a prosthesis used to close a congenital or acquired tissue opening ,primarily of the hard palate and /or contiguous alveolar structures. Prosthetic restorations of the defect often includes use of a surgical obturator, interim obturator, and definitive obturator. www.indiandentalacademy.com
  • 4. Anatomy of maxilla made of maxillary bone and palatine bone Maxillary bone. It has the following parts A. Body­­ it’s a hollow pyramid, enclosing the maxillary sinus. B. Processes­ there are four in number, out of which alveolar and palatine processes along with body provide support the upper denture www.indiandentalacademy.com
  • 5. 1. Frontal process 2. Zygomatic process 3. Alveolar process: It arises from lower surface of maxilla and with its fellow of the opposite side it forms the alveolar arch. www.indiandentalacademy.com
  • 6. 4. Palatine process: Thick, strong, and plate like, projects horizontally medially from the lower part of medial surface of the body of maxilla. with its fellow of the opposite side it forms the anterior ¾ of hard palate and thus forms greater part of roof of mouth cavity and floor of nasal cavity, fusing in midline to form the mid palatal suture. www.indiandentalacademy.com
  • 7. • Palatine bones; It resembles the letter L in shape .The two palatine bones lie together at the posterior part of nasal cavity between the maxillae and the pterygoid processes of sphenoid bone. www.indiandentalacademy.com
  • 8. • It has the following parts A.     Processes I. Pyramidal: projects backward downward, and laterally from the junction of horizontal and perpendicular plates and lies between the tuberosity of maxilla and the pterygoid plates of sphenoid bone. II. Orbital III. Sphenoidal www.indiandentalacademy.com
  • 9. • B.     Plates i. Perpendicular plate ii. Horizontal plate : quadrilateral in shape it projects horizontally medially from the lower border of the perpendicular plate. Together with the opposite side it forms the posterior ¼ th of bony (hard) palate. www.indiandentalacademy.com
  • 10. Soft palate Muscles of soft palate • Tensor palati • Levator palati • Muscular uvulae • Palatoglossus • Palatopharyngeus www.indiandentalacademy.com
  • 11. Movements and functions of soft palate: Palate separates the nasopharynx from the oropharynx,and is looked upon as the traffic controller at the crossroads between the food and air passages. It can completely close them, or can regulate their size according to requirements .Its few specific roles are: www.indiandentalacademy.com
  • 12. 1.it isolates the mouth from the oropharynx during chewing, so that breathing is unaffected. 2.it separates the oropharynx from the nasopharynx during the second stage of swallowing, so that food does not enter the nose. www.indiandentalacademy.com
  • 13. 3.by varying the degree of closure of the pharyngeal isthmus, the quality of voice can be modified and various consonants correctly pronounced. 4.during sneezing, the blast of air is appropriately divided and directed through the nasal and oral cavities without damaging the narrow nose. Similarly during coughing it directs air and sputum into the mouth and not into the nose. www.indiandentalacademy.com
  • 14. Functions of obturator 1) Can be used to keep the wound area clean and to enhance healing 2) To reshape or reconstruct the palatal contour/or soft palate 3) Improves speech 4) Can be used to correct lip and cheek position 5) Improves mastication. 6) Reduces the flow of exudates in the mouth www.indiandentalacademy.com
  • 15. Types of obturator. • Obturators for congenital defects are of 3 types 1. A simple base plate type helps to correct the swallowing,feeding,and speech. 2. Obturator with a tail: consisting of a speech appliance or a speech aid prosthesis which restores soft and hard palate defects and a velopharyngeal extension which corrects the speech. 3. A type of overlay or superimposed denture www.indiandentalacademy.com
  • 16. • Obturators for aquired defects. www.indiandentalacademy.com
  • 17. Surgical obturator • Facilitates oral function immediately after surgery,significantly reducing the hospital stay and rehabilitation time. • Patient may regain speech within a normal range . • Wrought wire clasps are used • Acrylic resin facilitates modification by adjustment or by addition with tissue conditioning material at the time of surgery. • Constructed from preoperative impression cast. • It eliminates the need for the nasogastric tube. • It can serve as matrix for surgical dressing. • Some surgeons dispute the necessity of surgical prosthesis. www.indiandentalacademy.com
  • 18. Temporary obturator • After 7­10 days ,the prosthesis is removed and reprocessed with new acrylic resin.this becomes a temporary obturator and serves for 4­6 months of healing period. • Periodic modifications with tissue conditioners • Multiple wrought wire clasps are used • Mastication on the surgical side are avoided • Prosthetic teeth may be added to enhance esthetics. www.indiandentalacademy.com
  • 19. Definitive obturator. • Constructed from the post surgical maxillary cast. • Has a false palate ,false ridge ,teeth ,and a closed bulb which is hollow. www.indiandentalacademy.com
  • 20. Speech aids • These are prosthesis that are functionally shaped to the velopharyngeal musculature to restore or compensate for areas of the soft palate that are deficient because of surgery or congenital anomaly. • Such prosthesis consists of following 3 parts www.indiandentalacademy.com
  • 21. The palatal part ,which provide stability and anchorage for retention. The palatal extension,which crosses the residual soft palate; The pharyngeal part,which fills the velopharyngeal part during muscular function www.indiandentalacademy.com
  • 22. • Pediatric speech aid- made of materials that can be easily modified as growth or orthodontic treatment progresses. • Adult speech aid- when velopharyngeal insufficiency is a result of a cleft palate or palatal surgery. • Both of above are based on the principle of posterior retention and anterior indirect retention. www.indiandentalacademy.com
  • 23. Palatal lifts. • Prosthesis which lift the flaccid palate posteriorly and superiorly to narrow the Velopharyngeal opening. • Velopharyngeal incompetency; patients with normal,intact anatomy but with hypernasality and nasal emission of air. www.indiandentalacademy.com
  • 24. • This condition results from a paralysis of the activating muscles and soft tissues. www.indiandentalacademy.com
  • 25. Palatal augmentation • If a part of tongue is lost ,the ability of the tongue to reach the palate for appropriate speech and swallowing is compromised. • The contour of palate can be augmented by a prosthesis to fill the space of donder so that a food bolus can be more easily moved posteriorly into the oropharynx. www.indiandentalacademy.com
  • 26. Stability of obturator • The terminal abutment teeth of the remaining arch determine the fulcrum line . • 2 lines are drawn from the fulcrum line to the canine away from the defect,a stable triangle is established. www.indiandentalacademy.com
  • 27. • When the defect enlarges and the remaining palate and dental arc decreases, the area within the triangle diminishes, as does the stability of the prosthesis. www.indiandentalacademy.com
  • 28. Quality of retention depends on • Muscular control. • Size of surgical cavity • availability of tissue undercut around the cavity • Direct and indirect retention provided by any remaining teeth. www.indiandentalacademy.com
  • 29. Retentive regions are • Fibrous tissue scar bands in the buccal sulcus. • Rolled edge of the palatal remnants • Base of the nasal mucosa of the nasal septum. www.indiandentalacademy.com
  • 30. Forces on Obturators These forces can be • Vertical dislodging force • Occlusal vertical force • Torque or rotational force • Lateral force • Anterior posterior force. www.indiandentalacademy.com
  • 31. dislodging and rotational forces The weight of the nasal extension of the obturator exerts dislodging and rotational forces on abutment teeth. To resist these forces -weight of the obturator be minimal -direct retention -extending the buccal wall of the nasal extension superiorly. www.indiandentalacademy.com
  • 32. • Coronal view of a typical maxilloectomy area . www.indiandentalacademy.com
  • 33. • As defect side of prosthesis is displaced ,lateral wall of obturator will engage scar band and aid in retaining the prosthesis. Value of the lateral wall height in design of partial denture obturator www.indiandentalacademy.com
  • 34. • Variance in vertical displacement which two different radius lengths produce when arcing through a given horizontal dimension. www.indiandentalacademy.com
  • 35. Relation of the scar band to the lateral portion of the obturator. • Buccal scar band will develop at height of previous vestibule where buccal mucosa and skin graft in surgical defect join. www.indiandentalacademy.com
  • 36. Occlusal vertical forces • Activated during mastication and swallowing. • Wide distribution of occlusal rests will help counteract such force www.indiandentalacademy.com
  • 37. Lateral forces. It can be minimized by • Covering the medial wall of the defect by a palatal flap. • Proper selection of the occlusal scheme • Elimination of premature occlusal contacts • Wide distribution of the stabilizing components. www.indiandentalacademy.com
  • 38. Classification of maxillectomy defects • By Aramany (1978) • The classification is divided into 6 different groups based on the relationship of the defect area to the remaining abutment teeth. • class sequence reflects the frequency of occurrence in a patient population of 123 patients treated during a 6 year period at univ of Pittsburgh. www.indiandentalacademy.com
  • 39. Rationale for classification 1. The increase in the no of partially edentulous patients undergoing partial resection of the maxilla 2. The increase in the life expectancy after surgery,creating a need for definitive restorations, 3. An ever increasing percentage of younger patients in the maxillary resection patient population. www.indiandentalacademy.com
  • 40. Class I • This is the most frequent maxillary defect and most patients fall into this category. • The dentition and the alveolar bone are removed along the midline. www.indiandentalacademy.com
  • 41. Prosthetic design • Two designs are possible Linear Anterior teeth are not included in the design. Support- located in a linear fashion. Stability –palatal surface of premolars ; buccal surface of molars. www.indiandentalacademy.com
  • 42. Retention –buccal surface of the premolar. palatal surface of molars. www.indiandentalacademy.com
  • 43. Tripodal 2 or 3 anterior teeth are splinted. Retention –from labial surface of anterior teeth with gate design or an I bar on the central incisor; -Buccal surface of the molars Stability –from molars palatally Support – rest on the distal surface of the first premolar www.indiandentalacademy.com
  • 44. Class II • Defect is unilateral, retaining the anterior teeth on the contra lateral side . • This type of resection is is favored prosthodontically and should therefore be advised to the surgeon www.indiandentalacademy.com
  • 45. Prosthetic design • The bilateral design is similar to a Kennedy class II RPD design • Splinting of the 2 teeth adjacent to the defect is advisable • Abutments : tooth nearest the defect and the most posterior molar. www.indiandentalacademy.com
  • 46. • Support- perpendicular to the fulcrum line rest is placed • Stability –from palatal surfaces of abutments • Retention – from buccal surfaces of the abutment teeth www.indiandentalacademy.com
  • 47. Class III • The palatal defect occurs in the central portion of the hard palate and may involve part of the soft palate. • Surgery does not involve the remaining teeth. www.indiandentalacademy.com
  • 48. Prosthetic design • The design is based on quadrilateral configurations. • Support is widely distributed on both premolars and molars. www.indiandentalacademy.com
  • 49. • Retention is derived from the buccal surfaces and stabilization from the palatal surfaces. www.indiandentalacademy.com
  • 50. Class IV • The defect crosses the midline and involves both sides of the maxillae. • There are few teeth remaining which lie in a straight line. www.indiandentalacademy.com
  • 51. Prosthetic design • The design is linear • Support –on the center of all remaining teeth. • Stability-palatal on the premolars; buccal on the molars. www.indiandentalacademy.com
  • 52. • Retention- mesially on the premolars. palatally on the molars. www.indiandentalacademy.com
  • 53. Class V • Surgical defect is bilateral and lies posterior to the remaining abutment teeth. • Posterior teeth,hard palate,and portions of the soft palate are resected. www.indiandentalacademy.com
  • 54. Prosthetic design • Tripodal configuration • Splinting of at least two terminal abutment teeth on each side is suggested. • I –bar clasps are placed bilaterally on the buccal surface of the most distal teeth. www.indiandentalacademy.com
  • 55. • A gate prosthesis is a viable alternative for these patients . •Stabilization and support are located on the palatal surfaces. www.indiandentalacademy.com
  • 56. Class VI • Least frequently occurring class. • This occurs most in trauma or in congenital defects rather than as a planned surgical intervention. www.indiandentalacademy.com
  • 57. Prosthetic design • 2 anterior teeth are splinted bilaterally and connected by a transverse splint bar. • A clip attachment may be used without an elaborate partial framework. www.indiandentalacademy.com
  • 58. • If the defect is large,or the remaining teeth are in less than optimal condition,a quadrilateral configuration design is followed. www.indiandentalacademy.com
  • 59. Surgical considerations • Efforts should be directed towards conversion a potential class I maxillary defect into a class II defect to provide a superior prosthesis both functionally and esthetically. www.indiandentalacademy.com
  • 60. Recommendations to surgeon. 1. Preservation of the contra lateral anterior teeth,if it does not compromise tumor eradication. 2. If the palatal mucosa is not invaded by the tumor,it is preserved and reflected to cover the medial wall. this procedure provides superior tissue quality coverage for the nasal septum. www.indiandentalacademy.com
  • 61. 3. Preservation of the posterior hard plate on the defect side if the tumor is situated anteriorly or laterally. 4. Resection through the socket of the tooth closest to the specimen allows for maintenance of the proximal alveolar bone adjacent to the abutment tooth. www.indiandentalacademy.com
  • 62. Classification by okay et al. (2001) • New prosthodontic guidelines that relate to surgical reconstruction of the maxilla seem o be mandated as a result of advancements in micro vascular surgical techniques. • Micro vascular free flap surgery allows the transfer of muscle ,connective tissue,skin,and bone to recipient sites. www.indiandentalacademy.com
  • 63. Class I a • Defects that involve the hard palate but not the tooth –bearing alveolus. • Prosthesis created for prosthetic obturation were stable and well tolerated. www.indiandentalacademy.com
  • 64. • Patient can be rehabilitated by Local island flap- in defects involving less than one –third of the hard palate. Fasciocutaneous free flap- in large defects and irradiated patients . www.indiandentalacademy.com
  • 65. Class I b • Defects that involved any portion of the maxillary alveolus and dentition posterior to the canines or that involved the premaxilla . www.indiandentalacademy.com
  • 66. • Soft tissue flap without osseous reconstruction because the remaining dentition and palate were considered able to support occlusal contacts over the reconstruction with a removable partial denture. www.indiandentalacademy.com
  • 67. Class II • Defects -that involved any portion of the tooth- bearing maxillary alveolus but included only 1 canine . - anterior trans verse palatectomy defects that involved less than one half of the palatal surface. www.indiandentalacademy.com
  • 68. • Prosthetic rehabilitation of class II defects was less predictable than that of class I defects. • Factors for instability Fewer teeth for clasping Reduces arch size and form Diminished supporting palate. www.indiandentalacademy.com
  • 69. • Some class II defects are best reconstructed and rehabilitated by vascularized bone containing free flaps . www.indiandentalacademy.com
  • 70. Class III • Defects that involved any portion of the tooth- bearing maxillary alveolus and included both canines,total palatectomy defects,and anterior transverse palatectomy that involved more than half of the palatal surface. www.indiandentalacademy.com
  • 71. • These defects left little or no residual palate or dentition for the secure retention of an obturator,which led to a poor prosthetic prognosis. • These defects were best restored with VBCFF. www.indiandentalacademy.com
  • 72. Subclass f and z • F- defects involving inferior orbital rim. • Z – defects involving body of the zygoma. • The orbital floor and zygomatic body play both functional and cosmetic roles. • These defects are best restored with VBCFF. www.indiandentalacademy.com
  • 73. www.indiandentalacademy.com
  • 74. • The defect – oriented approach of this system is intended to facilitate and coordinate treatment planning among surgeons and prosthodontists. • New surgical reconstruction techniques may or may not provide a more conventional setting for prosthodontic rehabilitation. www.indiandentalacademy.com
  • 75. Other classifications • Ohngren’s classification(1933) • Spiro et al (1997): a relatively simple classification in which defects can be termed as “limited” or “subtotal” on the basis of the number of maxillary “walls” involved in the resection. www.indiandentalacademy.com
  • 76. • Davison et al: reconstruction algorithm based on the review of 108 patient treatments. They are divided into 2 broad categories as “complete” and “partial”. • Brown : first to discuss a multi disciplinary (surgical and prosthodontic) approach to palatomaxillary reconstruction. based on both the vertical and horizontal dimensions of a defect. www.indiandentalacademy.com
  • 77. Preoperative evaluation 1) Psychological support : the patient should be aware of the potential physiologic and cosmetic deficiencies that will result from his treatment and subsequent prosthodontic management. 2) Preoperative dental management. 1. Temporary restoration of teeth with severe carious lesions 2. Removal of disesed or malposed teeth at the time of the operation. 3. Treatment for acute oral infections such as necrotizing ulcerative gingivitis.www.indiandentalacademy.com
  • 78. 3) Preoperative impressions:for diagnostic casts and for fabrication of temporary obturator. 4) Suggestions to the surgeon www.indiandentalacademy.com
  • 79. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com