Max/prosthodontic courses

Treatment modalities
in maxillectomy
patents
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

• Introduction
• Functions of obturators
• Classification of maxillary defects
• Pre operative evaluation
• Biomechanics
• Types of obturators
• Design considerations
• Impression Procedures
• Hollow bulb obturator
• Conclusion
• References

INTRODUCTION
• Most common defect in maxilla
• In the form of an opening into the nasopharynx.
• The prosthesis needed to repair the defect is termed a
maxillary obturator.
• An obturator (latin: obturare, to stop up) is a disc or plate, natural
or artificial, which closes an opening.
• A prosthesis used to close a congenital or acquired tissue
opening, primarily of the hard palate and/or contiguous
structures.-GPT-8

FUNCTIONS OF OBTURATORS
 It can serve in lieu of a Levin tube for feeding purposes.
 It can be used to keep the wound or defective area clean
 It can enhance the healing of traumatic or post surgical
defects.
 It can help to reshape and reconstruct the palatal contour
and/or soft palate.
 It also improves speech or, in some instances, makes speech
possible.

 It can benefit the morale of patients with maxillary defects.
 When deglutition and mastication are impaired, it can be used to
improve function.
 It reduces the flow of exudates into the mouth.
 The obturator can be used as a stent to hold dressings or packs post
surgically in maxillary resections.

CLASSIFICATION OF
MAXILLARY DEFECTS

ARAMANY CLASSIFICATION
• Dr. Mohammed Aramany
• 1978
• Developing optimum obturator design
• Enhances communication among prosthodontists
• 6 designs
• “Prosthodontic principles in the framework design of
maxillary obturator prosthesis”
• Parr GR, Tharp GE and Rahn AO, in J Prosthet Dent
1989

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.

• Class I
– Linear design
– Tripodal design

Linear design
Anterior teeth are not included in the design.

Support- located in a linear fashion.
Stability –palatal surface of premolars ;
buccal surface of molars.
Retention –buccal surface of
the premolar.
palatal surface of molars.

Tripodal
2 or 3 anterior teeth are splinted.

Retention –from labial surface
of anterior teeth with gate
design or an I bar
-Buccal surface of the molars
Stability –from molars palatally
Support – rest on the distal
surface of the first premolar

• Defect is unilateral, retaining the anterior teeth on the
contra lateral side .
• This type of resection is favored prosthodontically
and should therefore be advised to the surgeon
Class II

• Support- perpendicular to the fulcrum line rest is
placed
• Stability –from palatal surfaces of abutments
• Retention – from buccal surfaces of the abutment
teeth

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

•The design is based on quadrilateral configurations.
•Support is widely distributed on both premolars and molars.
•Retention is derived from the buccal surfaces and stabilization
from the palatal surfaces.

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.

• The design is linear
• Support –on the center of all remaining teeth.
• Stability-palatal on the premolars;
buccal on the molars.
• Retention- mesially on the premolars.
palatally on the molars.www.indiandentalacademy.com

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

•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.
• Stabilization and support are located on the palatal surfaces.www.indiandentalacademy.com

Class VI
• Least frequently occurring class.
• This occurs most in trauma or in congenital
defects rather than as a planned surgical
intervention.

• 2 anterior teeth are splinted bilaterally and connected
by a transverse splint bar.
• A clip attachment may be used without an elaborate
partial framework.
• If the defect is large,or the remaining teeth are in
less than optimal condition,a quadrilateral
configuration design is followed.www.indiandentalacademy.com

Classification by okay et al.(2001)
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.

• 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 .

Class I b
• Defects
that involved any portion of the maxillary alveolus and
dentition posterior to the canines
or that involved the premaxilla .

• 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.

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.

• Prosthetic rehabilitation of class II defects was less
predictable than that of class I defects.
• Some class II defects are best reconstructed and
rehabilitated by vascularized bone containing free
flaps .

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.

• These defects left little or no residual palate
or dentition for the secure retention of an
obturator,which led to a poor prosthetic
prognosis.

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.

• According to Origin of discrepancy :
- congenital defect obturator
- acquired defect obturator.
• According to Location of defect:
i. labial or buccal obturator
ii. alveolar obturator
iii. hard palate obturator
iv. soft palate obturator
v. pharyngeal obturator
• According to the Type of to the basic maxillary
prosthesis attachment
1) Fixed obturator
2) Hinged or movable obturator
3) Detachable obturator.www.indiandentalacademy.com

• According to physiological movement of the
surrounding tissue.
a. Static obturator
b. Functional obturator.
Obturators covering defects in the area from the lips to
the junction of the hard and soft palates are static
Obturators.
Those Obturators which provide closure in the soft
palate and pharyngeal areas are functional
Obturators.

Other classifications
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.
•Davison et al: reconstruction algorithm based on the
review of 108 patient treatments. They are divided into 2
broad categories as “complete” and “partial”.

Preoperative evaluation
 Psychological support : the patient should be aware
of the potential physiologic and cosmetic
deficiencies that will result from his treatment and
subsequent prosthodontic management.
 Preoperative dental management.
 1. Temporary restoration of teeth with severe
carious lesions
 2. Removal of diseased or malposed teeth at
the time of the operation.
 3. Treatment for acute oral infections such as
necrotizing ulcerative gingivitis.

 Preoperative impressions:for diagnostic
casts and for fabrication of temporary
obturator.
 Suggestions to the surgeon

BIOMECHANICS
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.

• 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.

Retention
• Muscular control.
• Size of surgical cavity
• Availability of tissue undercut around the
cavity
• Direct and indirect retention provided by any
remaining teeth.

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.

Forces on Obturators
These forces can be
• Vertical dislodging force
• Occlusal vertical force
• Torque or rotational force
• Lateral force
• Anterior posterior force.

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.

• As defect side of
prosthesis is
displaced ,lateral
wall of obturator
will engage scar
band and aid in
retaining the
prosthesis.

Occlusal vertical forces
• Activated during mastication and swallowing.
• Wide distribution of occlusal rests will help
counteract such force

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.

Types of obturator.
• Obturators for congenital
defects are of 3 types
 A simple base plate type
helps to correct the
swallowing,feeding,and
speech.
 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.
 A type of overlay or
superimposed denturewww.indiandentalacademy.com

Obturators for aquired defects.

Meatal obturator.
• A meatal obturator is static.
• It extends obliquely upward from the hard-soft
palate junction to occlude against the
turbinates and the superior aspect of the
nasal cavity.
• It may be preferable obturator when the cleft
is wide,few undercuts exist,and the patient
has an active gag reflex.

Surgical obturator
• Facilitates oral function immediately after
surgery,significantly reducing the hospital stay
and rehabilitation time.
• Patient may regain speech within a normal
range .
• Acrylic resin facilitates modification by
adjustment or by addition with tissue
conditioning material at the time of surgery.
• It eliminates the need for the nasogastric tube.
• It can serve as matrix for surgical dressing.

Temporary obturator
• After 7-10 days ,the prosthesis is removed and
reprocessed with new acrylic resin.this becomes a
temporary obturator and serves for 4-6 months of
healing period.
• Periodic modifications with tissue conditioners
• Mastication on the surgical side are avoided
• Prosthetic teeth may be added to enhance esthetics.

Definitive obturator.
• Constructed from the post surgical maxillary
cast.
• Has a false palate ,false ridge ,teeth ,and a
closed bulb which is hollow.

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

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

• 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.

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.
• This condition results from a paralysis of the
activating muscles and soft tissues.

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 so that a food
bolus can be more easily moved posteriorly
into the oropharynx.

Design considerations

• Obturator prosthesis design for
acquired maxillary defects
• Desjardins RP, JPD 1978
• Support
– Residual maxilla
• Teeth
• Alveolar ridge
– Structures within the defect
• Floor of orbit
• Pterygoid plate or temporal bone

• Retention
– Residual maxilla retention
– Alveolar ridge
• Retention within the defect
– Residual soft palate
– Residual hard palate
– Anterior nasal aperture
– Lateral scar band
– Height of lateral wall

• Stability
– Natural teeth remaining
– Bracing components of prosthesis
– Within the defect

HOLLOW BULB OBTURATOR
• A permanent obturator fabricated from
postsurgical master cast
• It contains
– False palate
– False ridge
– Teeth
– Closed bulb which is hollow

General considerations concerning
the bulb design
• A bulb is not necessary
– Small to average size defect
– Surgical or immediate temporary prosthesis
• Need of hollow
– To aid in speech resonance
– Light weight
– Provide facial esthetics
• It should not be high as to cause the eye to move
during mastication
• It should be one piece
• It should be closed superiorly always
• It should not be large as to interfere with insertion if
the mouth opening is restricted

Obturators for edentulous mouth
• Old denture uses
• Immediate temporary device
• Construction of permanent obturator

Procedure for construction of obturator for
edentulous mouth
• Before impressions
– Fistulas or smaller defects must be blocked
• Priliminary impression

• Construction of special tray
• Final impression
• Rubber base impression material
• Master cast
• Wax lid is fitted over the defect area
• Stabilized base plates
• Wax occlusal rims are attatched
• Records are obtained using denture
adhesives
• Teeth arrangement done
• Try in stage
• Processing the denture

Procedure for immediate temporary obturator

Procedure for one piece hollow
obturator

Other techniques
• Procedure for two piece obturator
• Snap on prosthesis for marginal defects

Conclusion
• “The love our face is next only to the love
of our life and thus the mutilated cry for
help”
• As a prosthodontist our aim should be to
render the best service possible to the patient
in regard to the restoration and continuity of
the defect to its most natural form
• Basic knowledge of the technique, materials
is the basic requirements for any
rehabilitation procedure

Referances
Aramany MA. Basic principles of obturator design for
partially edentulous patients. Part I: classification. J
Prosthet Dent 1978;40: 554-7.
2. Rahn AO, Goldman BC, Parr CR. Prosthodontic
principles in the surgical planning for maxillary and
mandibular resection patients. J Prosthet Dent
1979;42:429-33.
3. Brown KE. Peripheral considerations in improving
obturator retention. J Prosthet Dent 1968;20: 176-80.

4. Beumer J, Curtis TA, .Firtell DN. maxillofacial
rehabilitation. St. Louis Mosby; 1979. p. 188-243.
5, Aramanv MA. Basic principles of obturator design for
partially edentulous patients. Part II: design
principles. J Prosthet Dent 1978;40:656-62.
6. Firtell DN, Grisius RI. Retention of obturator
removable partial dentures: a comparison of buccal
and lingual retention. J Prosthet Dent 1980;43:212-7.

7. Desjardins RP. Obturator prosthesis design for
acquired maxillary defects. J Prosthet Dent
1978;39:424-32.
8. Fiebiger GE, Rahn AO, Lundquist DO, Moise PK.
Movement abutments by removable partial denture
frameworks with a hemimaxillectomy obturator. J
Prosthet Dent 1975,34:555-60.
9. Stewart KL, Rudd KD, Kuebker WA. Clinical
removable partial prosthodontics. St. Louis: Mosby;
1983. p. 663.

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