|Year : 2017 | Volume
| Issue : 2 | Page : 78-83
Aruna Jawahirlal Bhandari
Department of Prosthodontics, Pravara Institute of Medical Sciences (DU), Rural Dental College, Ahmednagar, Maharashtra, India
|Date of Web Publication||6-Dec-2017|
Dr. Aruna Jawahirlal Bhandari
Department of Prosthodontics, Pravara Institute of Medical Sciences (DU), Rural Dental College, Loni, Ahmednagar - 413 736, Maharashtra
Source of Support: None, Conflict of Interest: None
Defects in the maxillary jaw can be congenital, developmental, acquired, traumatic or surgical involving the oral cavity and related anatomic structure. Absence or loss of some or all of the soft palate and / or hard palate results in insufficient structure or altered function of the remaining tissues. Defects can cause disruption of articulation and airflow during speech production and also nasal reflux during deglutition. Patients after surgical resection have altered anatomy due to scaring, tissue contracture, lack of bony support and tissue edema. These patients have problem of regurgitation of water and food through nose and difficulty in speech. These changes require the fabrication of prosthesis and also sometimes repeated prosthesis adjustments to confirm to the soft tissue changes. To prevent this and to help the patient in deglutition and speech defects must be restored with prosthesis. In such situation an obturator is designed to close the opening between the residual hard and / or soft palate and the pharynx. The prosthesis provided for these patients are called as obturators. An obturator is a prosthesis which is fabricated for the patients with the palatal defects in the form of cleft lip and palate, oroantral fistula or surgical resection after removable of pathology like tumor or cancer. This review article will highlight on the Prosthetic Rehabilitation of the maxillary defects and the types of obturators.
Keywords: Definitive prosthesis, interim prosthesis, maxillary defects, maxillary obturator, speech prosthesis, surgical obturator
|How to cite this article:|
Bhandari AJ. Maxillary obturator. J Dent Allied Sci 2017;6:78-83
| Introduction|| |
Most common intraoral defects in the maxilla are in the form of an opening into the antrum and nasopharynx. Maxillary defects can be congenital, developmental, acquired, traumatic, or surgical involving the oral cavity and related anatomic structure.
Absence or loss of some or all of the soft palate and/or hard palate results in insufficient structure or altered function of the remaining structure. Defects can cause disruption of articulation and airflow during speech production and nasal reflux during deglutition. Nasal sounds such as “n,” “m,” and “ng” are seen due to the absence of closure of the pharyngeal wall. Patients after surgical resection have altered anatomy due to scaring, tissue contracture, lack of bony support, and tissue edema. Surgical resection can lead to the restricted opening of the jaws and altered range of mandibular movements with fibrosis and trismus. These patients have the problem of regurgitation of water and food through nose. There may be difficulty in speech, deglutition, maintaining oral hygiene, and prosthetic treatment.
To prevent this and to help the patient in deglutition and speech, defects must be restored with prosthesis. In such situations, a prosthesis called as an obturator is designed to close the opening between the residual hard and/or soft palate and pharynx. These changes require the fabrication of prosthesis and sometimes repeated prosthesis adjustments to confirm the soft tissue changes. Obturator is derived from the Latin word “obturate” which means to close or shut off.
Prosthesis facilitates speech, and deglutition by replacing those tissues lost due to the disease process and can, as a result, reduce nasal regurgitation and hypernasal speech, improve articulation, deglutition, and mastication.
- An obturator is a prosthesis which is fabricated for the patients with the palatal defects in the form of cleft lip and palate, oroantral fistula, or surgical resection after removable of pathology-like tumor or cancer
- Chalian in 1971 described an obturator as a disc or plate, natural or artificial which closes an opening or defect of the maxilla as a result of cleft palate or partial or total removal of the maxilla for a tumor mass
- According to Glossary of Prosthodontic Terms, obturator is a prosthesis used to close a congenital or acquired tissue opening primarily of the hard palate and/or contiguous alveolar/soft tissue structures
- Obturator is that component of a prosthesis that fits into and closes a defect within the oral cavity or other body defect
- Obturator is a maxillofacial prosthesis used to close, cover, or maintain the integrity of the oral and nasal compartments resulting from a congenital, acquired, or developmental disease process, i.e. cancer, cleft palate, osteoradionecrosis of the palate. It helps to restore the continuity of the hard palate and oral cavity from nasal cavity, maxillary sinus, and orbit from the oral cavity.
Prosthetic intervention with maxillary obturator prosthesis is necessary to restore the contours of the resected palate and to recreate the functional separation of the oral cavity and sinus and nasal cavities. This should occur at the time of surgical resection, and it will be necessary for the remainder of the patient's life. Hence, proper understanding and knowledge of the obturator is a must to make awareness of the efficacy of the treatment modality. Followings are the objectives of maxillary obturator.,,
- Restoration of esthetics or cosmetic appearance of the patient
- Restoration of function
- Protection of tissues
- Therapeutic or healing effect
- Psychological therapy.
Ideal requirements for maxillary obturator
- Help the patient to carry out natural functions such as phonation, deglutition, and mastication
- Should exhibit life-like appearance to aid function
- Design of the prosthesis should be such that it is easily and swiftly placed and held in position both comfortably and securely
- Prosthesis should be durable for a reasonable period of time, retain its polish and finish
- Should be easy to clean so as to maintain hygiene.
There are various functions of obturator.
- To close the defect
- For feeding purpose
- To keep the wound or defective area clean, thus enhance the healing of traumatic or postsurgical defects
- As a stent to hold dressings or packs post surgically
- To reduce the possibility of postoperative hemorrhage
- Help to reshape and reconstruct the palatal contour and/or soft palate
- Improve speech or in some instances, makes speech possible
- Help in reducing the flow of exudates, saliva, and fluids from the mouth into the nasopharynx
- To improve the esthetics and correct lip and cheek contour
- To benefit the morale of the patient with maxillary defects
- To improve function when deglutition and mastication are impaired.
- To act as a framework over which tissues may be shaped by the surgeon
- To serve as a temporary prosthesis during the period of surgical correction
- When surgical primary closure is contraindicated
- When patient's age contraindicates surgery
- When size and extent of the deformity contraindicates surgery
- When local avascular condition of the tissues contraindicates surgery
- When a patient is susceptible to the recurrence of original lesion that produced the deformity.
Classification of obturator
Obturator may be classified
- According to origin of the discrepancy
- For congenital defect
- To close the opening of hard palate, a simple base plate type of palatal plate helps to correct the swallowing, feeding, and speech
- An obturator with a tail, consisting of speech appliance or speech aid prosthesis, which restores soft and hard palate defects and a velopharyngeal extensions that correct the speech
- An overlay denture or a superimposed denture.
- For acquired defect
- Immediate temporary obturator or surgical obturator is a base plate type of prosthesis which is constructed from the preoperative active impression cast and inserted at the time of surgery, i.e. resection of the maxilla in the operating room
- Interim obturator, temporary obturator, treatment obturator, or transitional obturator is constructed from the postsurgical master cast
- Permanent obturator or definitive obturator.
- According to location of the defect
- Lateral or buccal obturator: Closes a defect on the labial or buccal ridge areas
- Alveolar obturator: Closes opening on the alveolar ridge, either on the anterior or the posterior side of the upper jaw
- Hard palate obturator: Closes opening continued within the anatomical limits of the hard palate whereas soft palate obturator closes the opening on the soft palate
- Soft palate obturator: Closes the opening on the soft palate
- Palatal lift prosthesis or obturator: Used to raise the soft palate to the level of the hard palate. When palatopharyngeal incompetence is encountered, rehabilitative efforts are designed to elevate the soft palate. This elevation places the junction of the middle and posterior third of the soft palate in close proximity to the posterior to the pharyngeal wall creating a muscular seal that prevents nasal regurgitation of fluid and food during deglutition. The prosthesis also prevents the escape of air into the nose when speaking,
- Pharyngeal obturator or speech aid prosthesis: It is used in palatopharyngeal insufficiency. This type of prosthesis extends beyond the residual soft palate to create separation between the oropharynx and nasopharynx. Obturator is designed to close the opening between the residual hard and/or soft palate and the pharynx insufficiency. It provides a fixed structure against which the pharyngeal muscles can function to affect palatopharyngeal closure. They establish contact with the musculature comprising the lateral and posterior pharyngeal walls and the soft palate and involve the most difficult functional requirements.
- According to the type of obturator attachment to the basic maxillary prosthesis
- Fixed: Fixed type is stationary and directed toward the Passavant's pad. It depends on the forward movement of the pharynx to effect closure. This obturator is generally preferred to hinge and meatus type as it is relatively efficient. Fixed type will not impede the residual function and also will not compromise the integrity of resting tissues
- Hinged: Hinged type is connected to the main maxillary prosthesis by means of a hinge. Its bulk is located along the cleft edges and supposedly serves an anatomic purpose, in that, it moves up and back, supported by the soft palate edges, as does the normal soft palate to affect velopharyngeal closure
- Meatus: Meatus type of obturator prosthesis extends obliquely upward from the hard soft palate junction to occlude against the turbinate and superior aspect of nasal cavity up to the nasal meatus. It separates the oral and the nasal cavities. It is a speech aid prosthesis designed to close the posterior nasal conches through a vertical extension from the distal aspect of the maxillary prosthesis. This is indicated when entire soft palate has been lost. It is most applicable to the fully edentulous patient who has undergone a total soft palate resection,
- Detachable obturator: The detachable type of obturator is one, in which the maxillary prosthesis and obturator parts are held together by some attachment. The patient can detach the parts for the purpose of insertion and removal, cleaning, and can unite them in the mouth. It is used in patients with restricted opening
- Magnetically retained obturator: Two portions are connected to each other with the magnets. Magnets are placed as laterally and posteriorly as possible to provide maximum amount of leverage in the denture and retention that is available
- Implant retained obturator: Implant is more commonly used in the anterior maxillary segment as the bone loss in the anterior segment is approximately threefold more than the posterior segment placement of implant at the time of surgery due to the high rate of recurrence rate and morbidity.
- According to the physiologic movement of oral, nasal, and pharyngeal tissues adjacent to or functioning against the obturator
- Static obturator: This obturator covers defects in the area from the lips to the junction of the hard and the soft palates and are essentially covering prostheses
- Functional obturator: This obturator provides closure in the soft palate and pharyngeal areas and provides surfaces against which movable tissue function. A functional obturator is more difficult to construct since it must maintain contact during muscular activity and should not interfere with it.
- Depending on the material used
- Metal obturator
- Resin obturator
- Silicon obturator.
- Mohamed Aramany in 1978 classified obturators for maxillectomy patients who are partially edentulous into seven groups. It takes into consideration only the hard palate defects [Figure 1].
- Class I: Resection or defect is performed along the midline of the maxilla; teeth are maintained on one side of the arch. It is the most frequent maxillary defect
- Class II: Defect is unilateral, retaining the anterior teeth on the contralateral side
- Class III: Palatal defect occurs in the central portion of the hard palate and may involve part of the soft palate. The surgery does not involve the remaining teeth
- Class IV: Defect crosses the midline and involves both sides of the maxilla. There are few teeth remaining which lie in a straight line. This may create a unique design problem similar to the unilateral design of conventional removable partial dentures
- Class V: Surgical defect is bilateral and lies posterior to the remaining abutment teeth
- Class VI: Defect occurs mostly in trauma and the defect lies anterior to the bilaterally standing abutments. Surgical intervention of anterior midpalatal pathology can cause such type of defects
- Class VII: This situation is similar to Kennedy Class II, but the defect is small unilaterally posterior to the standing abutments. This situation usually arises as a result of minor surgery for removal of pathology or can occur as squeal of multiple extractions in the posterior regions.
Depending on the phase of treatment or prosthetic rehabilitation of acquired hard palate defects
Patient who undergoes maxillary resection is rehabilitated in three phases by an obturator prosthesis that supports the patients through various stages of healing. These three phases are immediate temporary surgical obturator, interim obturator, and definitive obturator.
It involves three phases of treatment
- Immediate surgical obturator
- Transitional obturator
- Definitive obturator
- Immediate surgical obturator or maxillary surgical prosthesis or immediate temporary obturator: Surgical obturator is 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 structure - GPT
- This is a base plate type of prosthesis which is constructed without a definite extension into the defect
- It is fabricated on casts obtained from the preoperative active impression and is inserted at the time of surgery, i.e., resection of the maxilla in the operating room
- It is used primarily in conjunction with a surgical procedure to resect the maxillae and adjacent structures totally or in parts
- After initial healing and removal of the pack after 7–10 days, the immediate obturator is usually discarded and replaced by a transitional or temporary prosthesis having a definite bulbous extension and occasionally anterior artificial teeth
- Objective of the obturators is to restore and maintain oral functions at reasonable levels during the postoperative period until healing is substantially completed
- Historically, there has been some disagreement as to the value of the surgical obturator. Lang and Bruce (1967) and Zarb (1967) have advocated the use of immediate surgical obturator in most patients.
Surgical obturator is not a requisite for maxillectomy surgery but does offer distinct advantages for the patient when compared with surgery performed without an obturator.
Advantages of immediate surgical obturator
- Surgical obturator, placed at the time of tumor resection in the operating room, provides the surgeon with an anatomically accurate, stable, clean scaffold upon which to support the surgical dressing that, in turn, supports the facial flap and keeps pressure on the skin graft placed over the denuded internal surface of the facial flap
- It provides a barrier between the surgical dressing and the oral cavity so that the patient does not feel the extent of the defect or dressing with his or her tongue during the initial healing period
- It reduces the oral contamination of the wound during the immediate postsurgical period and may thus reduce the incidence of oral infection
- It allows the patients to perform deglutition and hence the nasogastric tube can be removed at an early date
- It enables the patients to speak normally by reproducing normal palatal contours and by covering the defect
- It minimizes the initial feelings of loss that occur when patients realize the extent of their surgical defects
- Prosthesis may reduce the period of hospitalization.
Design of the surgical obturator should be based on the understanding that it is actually a stent rather than an obturator. It should also be designed and fabricated with the understanding that it cannot be tried in and adjusted preoperatively but must fit and function as intended without adjustment. Followings are the priciples of design of a surgical obturator.
- The obturator should terminate short of skin graft-mucosal junction
- Prosthesis should be simple, lightweight, and inexpensive
- Normal palatal and alveolar contours should be reproduced to facilitate postoperative speech and deglutition
- Posterior occlusion should not be established on the defect side until the surgical wound is well organized
- The obturator for dentate patients should be perforated at interproximal extensions to allow for it to be wired with the remaining teeth
- In some patients, existing complete denture or removable partial denture may be adapted for use as a surgical obturator. Procedure of fabrication of surgical obturator in edentulous patients is as follows.
- An alginate impression of the maxilla is made, and cast is obtained
- If any tumor bulk is present on the alveolus or hard palate, that area of the cast is reduced to normal contour
- Ensure that the prosthesis will not be overextended at the peripheries of the surgical defect, and prosthesis should have border extensions identical to a complete denture
- Avoid estimating the extent of the surgical peripheries, especially in the soft palate and pterygoid area
- Surgical packing will close any discrepancies in the surgical defect margin and the prosthesis margin
- Prosthesis can be fabricated with heat-cure resin or autopolymerizing resin. A heat cure base plate is not necessary as the prosthesis will be used for <10 days. It is most commonly fabricated in clear resin to facilitate visualization of the underlying tissues at the time of placement and during the initial healing period
- Use of an immediate surgical obturator is less common for the edentulous patient than the dentate patient because of the seemingly invasive method of securing the prosthesis.
Use of the existing maxillary denture as surgical obturator: Patient's existing denture can be used as a surgical obturator or subsequent interim obturator prosthesis, edentulous obturator patient has greater problems in retention, speech, and mastication than the conventional maxillary patients. These patients would benefit from implants placed, but lack of suitable bone quality and quantity on the surgical sites preclude the widespread use of implants. Sometimes, both grafts and sinus lifts are usually needed in the remaining arch, but patients are reluctant to undergo surgery. Moreover, adjuvant radiotherapy leads to increased implant failure and also cost is still prohibitive.
Surgical obturator in dentulous patients
- Basic approaches that can be considered in designing a surgical obturator for the dentate patient.
- One can fabricate the obturator according to the most conservative line of resection, which will still allow the obturator to be used for larger resections with the understanding that surgical dressing may be needed to fill the space between the obturator and the final line of resection. This method allows the surgeon to utilize the obturator regardless of the size of the defect and does not require the surgeon (or the prosthodontist) to perform intraoperative adjustments to the obturator
- Other option is to design and fabricate the surgical obturator for the most extreme surgical resection, thereby making it fit best in the worst case situation. With this approach, the surgeon must be willing and able to modify the obturator to accommodate the teeth that are not resected but have been removed from the cast during obturator fabrication. The prosthodontist can guide at the time of surgery to perform the modifications
- It is the surgeon's preference that dictates the design and placement of the lines of resection on the cast, type of retentive mechanism built into the surgical obturator, and where the holes need to be placed in the obturator
- Prosthodontic rehabilitation of the dentate patient is a lengthy and involved process. However, if attention is paid to the proper sequencing and details of treatment, it can be one of the most satisfying procedures.
- Temporary or transitional or postsurgical or interim Obturator
- It is defined as a prosthesis that is made several weeks or months following the surgical resection of a portion of one or both maxillae. It is frequently included replacement of teeth in the defect area. This prosthesis when used replaces the surgical obturator that is placed immediately following the resection and may be subsequently replaced with a definitive obturator - GPT
- This obturator is constructed from the postsurgical master cast
- Interim obturator is placed when the surgical dressing that was supported by the surgical obturator is removed from the superior recesses of the maxillectomy defect
- This obturator has a false palate, false ridge, teeth, and a closed bulb which is mostly hollow
- The interim obturator serves the patient for 4–6 months till the maxillary defect heals and matures. Teeth are frequently added to the prosthesis at this juncture to improve function and enhance cosmetics
- Natural teeth selected for abutment are clasped with stainless steel or wrought metal wire retainers to enhance retention and stability
- Patient seen routinely and should be taught about home care procedures for the regular cleaning of the residual defect, remaining teeth, and the prosthesis
- When sutures and surgical pack are removed, the prosthodontist should be present in the operating room to begin or to continue fabrication of the temporary obturator
- Definitive obturator: 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 - GPT.
When surgical interventions are finished, and healing has progressed for 4–6 months following the cessation of all therapy, interim obturator can be replaced with a definitive obturator.
- Timing will vary depending on
- Size of the defect
- Progress of healing
- Prognosis for tumor control
- Effectiveness of the present obturator
- Presence or absence of teeth.
Defect must be engaged more aggressively for edentulous patients to maximize support, retention, and stabilityChanges associated with healing and remodeling will continue to occur in the border areas of the defect for at least 1 year. Dimensional changes are primarily related to the peripheral soft tissues rather than to bony support areasIt is constructed from the postsurgical maxillary cast. This obturator has a false palate, false ridge, teeth, and closed bulb which is hollowTo reduce and improve adhesion and retention, a hollow obturator bulb is required for cleft palate prostheses and for dentures following maxillectomy.
Advantages of a hollow bulb obturator
- Weight of the obturator is reduced, making it more comfortable and efficient
- Light weight improves one of the fundamental problems of retention and increases physiological function so that teeth and supporting tissues are not stressed unnecessarily
- Decrease, in pressure on the surrounding tissues, aids in deglutition and encourages the regeneration of tissue
- Light weight reduces the self-consciousness of wearing a denture
- Light weight does not cause excessive atrophy and physiological changes in muscle balance.
Trouble shooting of obturator
Patients wearing obturators over a period of time complain of nasal reflux and hypernasal speech caused by escape of air. This is mainly due to continued fibrosis of the tissues bordering the prosthesis.
Leakage into the nose
The prosthesis should be disclosed with a tissue-conditioning material, and the patient should perform functional movements. If swallowing and speech improve, the disclosing material should be evaluated for the area where the tissue conditioner is thickest. The speech can be tested by evaluating the “m” and “b” sounds and the word beat. The thickness of the material can be checked with an explorer.
Most areas will be very thin, while other areas will be 2–3 mm or thicker. These thicker areas should be targeted for the reline procedure. This reline can be accomplished chair side with an autopolymerizing or composite acrylic resin (Triad). This procedure satisfies the patient's chief complaint and requires minimal time.
Disclosure of the bulb with a tissue conditioning material often reveals that the surface contact is adequate. In this situation, the prosthesis is adequately closed at the periphery, but the patient's soft palate and pharyngeal closure mechanism are not functional. Observation of the soft palate usually reveals that it is barely elevating on phonation and/or it is quite short in an anterior-posterior dimension. This condition is seen frequently when a portion of the soft palate was also resected due to a lesion located at the hard palate-soft palate junction. Relining of the prosthesis periphery will not alter the hypernasal speech. If there is adequate space to add a pharyngeal bulb to the posterior medial aspect of the prosthesis, this bulb can pass superior to the edge of the soft palate and extend into the larynx. In this way, the minimally functional palate is bypassed by the pharyngeal obturator. The conventional obturator prosthesis will close the hard palate defect, and the extension will close the nasopharynx defect.
| Conclusion|| |
Prosthodontic rehabilitation of the maxillofacial defect patient is a lengthy and involved process. However, if attention is paid to the proper sequencing and details of treatment, it can be one of the most satisfying procedures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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