The document discusses surgical and interim obturation following maxillectomy. It describes how an immediate surgical obturator (ISO) provides benefits such as serving as a matrix for surgical packing and enabling speech and swallowing postoperatively. Principles for designing and fabricating ISO's are presented, along with examples of ISO use. Interim obturation is also discussed as a way to serve patients until wound healing is complete.

1. 12. Surgical and Interim Obturation
John Beumer III DDS, MS
Distinguished Professor Emeritus
UCLA School of Dentistry
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2. Surgical Obturation -Benefits
At most institutions the
defect is obturated
prosthetically at the
time of tumor resection
with an immediate
surgical obuturator
(ISO). There are
several advantages to
this approach.

3. Surgical Obturation -Benefits
The ISO:
 Provides a matrix upon
which the surgical
packing can be placed
 Reduces contamination
of the surgical wound
immediately
postoperatively
 Enables relatively normal
speech in the immediate
postoperative period

4. Surgical Obturation -Benefits
The ISO:
 Permits deglutition
postoperatively,
eliminating the need for a
nasogastric tube
 Lessens the
psychological impact of
the surgery
 Reduces the period of
hospitalization

5. Basic principles of design and fabrication
 The obturator should terminate short of the skin graft mucosal junction.
 It should be kept simple, lightweight, and inexpensive.
 It should be perforated in the interproximal areas so the prosthesis can be
wired to residual dentition.
 Normal palatal contours should be reproduced.

6. Basic principles of design and fabrication
 Posterior occlusion should not be established on the defect side.
 In edentulous patients, it should be designed like a record base, with no
replacement teeth.
 In some instances, the existing complete or partial denture can be
adapted for use as an immediate surgical obturator.

7. Impressions
 The impression must extend onto the middle
third of the soft palate

8. Laboratory Procedures
a b c d
f
e h
g
a: Cast obtained and mounted. b,c: Margins of proposed
surgical resection outlined on presurgical maxillary cast. d,e,f:
Teeth removed and anterior labial portion of the alveolus
trimmed. Note the occlusal clearance. g,h: Anterior teeth have
been added to this ISO.

9. Patient presents with a large squamous carcinoma
of the left hard palate
A cast is made. Note
the tumor distorted
palatal contours.
Cast is altered to
restore normal palatal
contours

10. Patient presents with a large squamous carcinoma
of the left hard palate
Note the nature of the
extension through the
hamular notch and onto the

11. An immediate surgical obturator
(ISO) for another patient
Note the reduction of the anterior alveolus and
the extension through the hamular notch and
onto the soft palate.
Overextension through the hamular notch
will cause significant discomfort
postoperatively.
The anterior extension of
the ISO should not extend
labial to the preexisting
contours of the alveolus
and the anterior teeth.
Anterior
teeth can
be added

12. Radical Maxillectomy Defects
Results of over contoured anterior
extensions of the ISO.
The mucosal side of the incision may dehisce, leading to
the obvious lip deformity

13. Radical Maxillectomy
Skin incisions (Weber-Fergusson) are used to expose the maxilla to be
resected. Oral mucosal incisions are made through the palate and the buccal
vestibule. Bony cuts are made through the palate, alveolar ridge, lateral nasal
bones, floor of the orbit, malar eminence, pterygoid plates and zygomatic arch.
After the remaining soft tissues are detached and removed with the specimen,
the raw tissues of the defect are lined with a split thickness skin graft. The skin
incision is then closed.

14. Radical Maxillectomy
The surgical specimen is removed and the immediate surgical
obturator (ISO) is placed in position. In this patient it was
wired to residual dentition. The prosthesis serves as a platform
for the surgical packing. When the wound is closed the facial
contours are nearly normal

15. Buccal inlay technique
 Primarily used in total
palatectomy defects
 Requires that the ISO be
border molded at surgery.
Black gutta percha was used
here
 Principle advantage
 Improved survival of skin
grafts
 More profound soft tissue
undercuts

16. In this edentulous patient the immediate surgical
obturator was wired to the alveolar ridge.
We prefer not to use the existing denture at this stage. Usually
the extension onto the soft palate is insufficient and the
denture may be damaged when wiring or securing it to the
palate or alveolar ridge.

17. Radical Maxillectomy
Patient presented with an adenoid cystic carcinoma of
the right maxillary sinus. Note the proptosis.
Preop Postop
A radical
maxillectomy
and orbital
exenteration
was
required.
Note the lack of muscular tonus on the resected side represented by the
drooping of the facial tissues and the corner of the mouth.

18. Radical Maxillectomy
The patient five months later without his obuturator
prosthesis (A).
A B
The complete
denture and
obturator
prosthesis has
been inserted
(B).
Facial nerve function has returned to near normal and the
obturator prosthesis restores lip and midfacial contours.

19. Interim Obturation
Purpose:
b) Serve the patient until the
wound has healed and becomes
dimensionally stable.
c) In most patients the ISO can be
relined with Rim Seal* and
anterior teeth added with
autopolymerizing acrylic resin.
*Rim Seal, Harry J.
Bosworth Co., Skokie, IL

20. Interim Obturation
a
a: ISO removed. Note
appearance of skin graft.
b, c and d: Upon removal
of the surgical packing the
ISO is extended into the
defect with temporary
denture reliner.
b c d

21. Trismus: Particularly a concern if patient is to
receive postoperative radiotherapy
a b
a and b: Dynamic bite openers are particularly useful
in preventing trismus if the patient is to receive
postoperative radiation therapy.

22. a
aa b c
d
a and b. Typical border defect.
More frequent adjustments are
expected. c and d: Soft palate
margin of resection is subject to
rapid contraction anteriorly and
superiorly during first three weeks
following surgery. On rare occasions
velopharyngeal closure can be
compromised.

23. Interim Obturation
Purpose
 Enable speech and swallowing during the
immediate postoperative and healing periods
In edentulous patients the existing denture can be relined
with a temporary denture reliner and used as an interim
obturator. In this patient Rim Seal* was used. *Rim Seal, Harry J.
Bosworth Co., Skokie, IL
Bosworth Co., Skokie, IL

24. Interim Obturation
The patient’s existing denture required significant
modification to serve as an interim obturator
The posterior extension onto the soft palate was developed
with Rim Seal* (arrows). The anterior flange of the denture on
the defect side needed to be shortened significantly and this
area remolded with Rim Seal* (oval).
*Rim Seal, Harry J. Bosworth Co., Skokie, IL

25. Interim Obturation
a b c
e
d
a; Maxillectomy defect 1 month post surgery. b and c: Centric relation
record made, posterior teeth added and the prosthesis relined, rebased and
reinserted. d and e: Prosthesis in position.

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