maxillofacial prosthesis

1. Maxillo- Facial Prosthesis
DLT – 413
Unit II
Obturators

2. INTRODUCTION
The most common of intra oral defects are in the form of cleft or opening in the palate.
These defects may be acquired or congenital. Acquired is due to injuries or surgical
excision of tumor. Congenital is due to malformation.
This condition require restoration with fixed or removable prosthesis to replace
missing teeth, to stabilize and align the arch segment, restore the occlusal function and
to provide facial support and help in speech.All this is usually aided with the help of an
obturator.
An Obturator can be defines as “ A prosthesis used to close a congenital or acquired
tissue opening, primarily of the hard palate and /or contagious structures. Prosthetic
restoration of the defect often includes use of a surgical obturator, interim obturator, and
definative obturators .”
 Ambroise Pare (1541) : was the first person to close a palatal defect. Pare has given
excellent description of a simple but a very practical obturator for closing a perforation
of the hard palate. He is also known as father of facial prosthesis.

3. MATERIALS USED FOR OBTURATOR
Primitive man used stone, wood, gum, cotton, to obturate the defect.
Towards the end of the nineteenth century, vulcanite was introduced in prosthodontics
and maxillofacial prosthetics and replaced most of the earlier materials.
.
The most common material is used for the fabrication of the intra and extra oral
prostheses are polymeric in nature.
These includes : vinyl chloride polymer and copolymers, acrylic resins and silicon rubbers
introduced by Braley. (heat-vulcanizing and room temperature vulcanization (RTV)).
FUNCTIONS OF AN OBTURATOR
1. The obturator can be used as a stent to hold dressing or packs post surgically.
2. It can be used to keep the wound or defective area clean, and it can enhance the
healing of traumatic or post surgical defects.
3. It can help to reshape or reconstruct the defect.
4. It reduces the flow of exudates into the mouth.
5. It also prevents regurgitation of food in mouth
6.It also improves or in some instances makes speech possible.

4. CLASSIFICATION OF OBTURATORS
Dr. Mohammed Aramany1978 : has classified partially edentulous maxillectomy
dental arches into six groups
Class I - Resection in this group is performed along the midline of the maxilla, teeth
are maintained on one side of the arch.
Class II
Defect is unilateral, retaining the anterior teeth on the contra lateral side

5. Class III
Palatal defect occurring on the central portion of the hard palate and may
involve part of the soft palate. Dentition is preserved.
Class IV
Defect crosses the midline and involves both sides of the maxilla. Few teeth
remain which lie in the straight line.

6. Class V
surgical defect in this case is bilateral and lies posterior to the remaining abutment
teeth.
Class VI
maxillary defect anterior to the remaining abutment teeth. This occurs mostly in trauma
or congenital defects rather than in planned surgical intervention.

7.  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 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.

8. OBTURATORS OF ACQUIRED DEFECTS
• Immediate temporary obturator (surgical obturator)
• Temporary obturator (treatment or transitional obturator)
• Permanent obturator (definitive obturator)

9. Surgical Obturators :
Defined as “ A temporary prosthesis used to restore the continuity of the hard palate
immediately after surgery or traumatic loss of a portion or all of the hard palate
and/or contiguous alveolar structures (I,e gingival tissue, teeth ).
It is of two types :
•Immediate surgical obturator : it is inserted at the time of surgery
•Delayed surgical obturator : it is insertes 7-10 days after surgery.

10. Interim Dentures
It is defines as “ A Prosthesis that is made several weeks or months following the
surgical resection of a portion of one or both maxillae . It frequently includes
replacement of teeth in the defect area. This prosthesis, when used, replaces the
surgical obturators that is placed immediately following the resection and may be
subsequently replaced with a definative obturator “

11. Definative Obturators
It is defined as “ A prosthesis that artificially replaces part or all of the maxilla and
the associated teeth lost due to surgery or trauma “.

12. Based on the material used
•Metal Obturators
•Resin Obturators
•Silicone Obturators.
Based on the area of the Restoration :
•Palatal Obturator
•Meatal Obturator

13. Fabrication of Palatal Obturator :
Diagnosis and treatment Planning:
The type of the defect will determine the size , location and extent of the obturator.
Preliminary impression using alginate :
Care should be taken to record the undercuts.
Junction of the graft and the mucosa should be properly located as it is important
retentive feature.

14. Fabrication of Custom tray :
A custom tray is fabricated .
Additional care should be taken to orient the tray into the defect.
Final Impresstion with elastic impression materials .
Tray should be positioned properly and scar band area must be properly reproduced.

15. Jaw Relations :
Very challenging to record jaw relations for these patients.
Acrylic denture bases are preffered to other
Teeth arrangement :
should be done so that Balanced Occlusion is obtained.

16. Clinical Considerations
Surgical obturator is inserted on the day of the surgery
A preliminary cast is obtained before surgery on which a mock surgery is performed.
A clear acrylic plate is fabricated and inserted after surgery.
If the patient is dentulous , retention is obtained with simple clasps.
If the patient is edentulous, the obturator is wired into the alveolar ridge and the
zygomatic arch.
The immediate surgical obturator is retained for 7-10 days after surgery.
A delayed surgical obturator is inserted 7-10 days after surgery.
This may be converted into an interim obturator by the addition of the lining material.
This obturator is retained for 3-4 months post surgically.
It is replaced with a definative obturator after complete healing of the surgical wound.

17. To reduce and improve adhesion and retention, a hollow obturator bulb is required
for cleft palate prosthesis and for dentures following maxillectomies.
General considerations regarding bulb design.
A bulb is not necessary with a central palatal defect of small to average size.
It is not necessary in the surgical or immediate temporary obturator.
It should be hollow to aid speech resonance, to reduce the weight on
unsupported side
it should be one piece, if possible, to provide better color matching and
maximal patient acceptance.
It should always be closed superiorly.if the obturator is left open, nasal
secretions,accumulate leading to odour and added weight.
It should not be so large as to interfere with insertion if the mouth opening is
restricted.

18. HOLLOW BULB OBTURATOR
A permanent obturator fabricated from postsurgical master cast.
It contains-
False palate
False ridge
Teeth
Closed bulb which is hollow
Advatages of Hollow Bulb Obturator.
•The weight of the obturator is reduced making it more comfortable and efficient.
•Lightness of obturator improves retention.
•There is decrease in pressure to the adjoining tissues and encourages
regeneration of the tissues.
•The light weight reduces the self – consciousness of wearing a denture.

22. Indications for the use of an obturator
1. To act as a framework over which tissues may be shaped by the surgeon.
2. To serve as a temporary prosthesis during the period of surgical correction.
3. To restore patients cosmetic appearance rapidly for social contacts.
4. When surgical primary closure is contraindicated.
5. When the patient’s age contraindicates surgery.
6. When the local avascular contion of the tissues contraindicates surgery.
Uses :
1. Provides a stable matrix for surgical packing.
2. Reduces oral contamination.
3. Speech will be effective post operatively
4. Permits deglutition
5. Reduces the psychological impact of the surgery .
6. It reduces the flow of exudates into the mouth.
7. The obturator may be used as a stent to hold dressings in maxillary resections.
8. May reduce the period of hospitalisation.

23. Principles of design for Obturators :
•The obturator should terminate short of the skin graft mucosal junction
•The obturator should be kept simple, lightweight, and inexpensive.
•Obturator for dentate patients may be perforated at the interproximal
extensions with a small dental bur to allow the obturator to be wired to the
arch to the teeth at the time of surgery.
•Normal palatal contours should be reproduced to facilitate post – operative
speech and deglutition.
•Posterior occlusion should not be established on the defect side until the
surgical wound is well organised.

25. Meatal Obturator :
•It is a special type of obturator that extends upto nasal meatus.
•It establishes closure with the nasal structures at a level, posterior and superior to
the posterior border of hard palate.
•It seperated the oral and nasal cavitites.
•It is indicated in patients with extensive soft palate defects.
Disadvantages:
1. Nasal air emission cannot be controlled because it is in an area where there is
not muscle function.
2. Nasal resonance will be altered.

26. References :
1. Required Text(s)
Maxillofacial Rehabilitation by Beumer ( 3rd Edition )
Authors : John Beumer, Mark Marunik, Salvatore Esposito
ISBN 9780867154986 Publisher: Quintessence Publishing, 2011
a. Immediate Surgical Obturation; Page 167,233
b. Delayed Surgical Obturation: Page 170,233
c. Interim Obturation: Page 172,234
d. Definative Obturation: Page 173,234
e. Meatal Obturator Prosthesis: Page 248
f. Technique for fabrication of Obturators: Page 178.
2. Essential References
Reconstructive Craniofacial and Maxillofacial Surgery - in children and young adults
by Jeffrey C. Posnick, Allan Ross (Editor), Allan Rose (Editor)
ISBN: 072167710X Publisher: W B Saunders Co., Dec. 2003