Obturator prosthesis for management of maxillary defects

Editor's Notes

• #7: Delbarre -constructed rubber Prosthesis with bands and clasps that utilized the palatal muscles to move the velar section of the prosthesis mineral teeth were attached to the palate by means of springs movable part made of elastic gum was attached to restore the velum and uvula .
• #8: Fauchard's winged obturator, showing the different parts and the key used to operate the wings after insertion of the appliance. used two wings attached to the superior surface of the plate. These wings were folded together and passed through the cleft, They were spread apart by a screw after seating of the appliances. The idea was to utilize the nasal undercuts
• #9: Bourdet in 1757 improved palatal obturators by fixing them not to the palate itself or inside the nose but by means of lateral clasps. Delbare- This appliance was carved of metal, the superior surface had a depression to accommodate the nasal palatine process. Mineral teeth were attached to the palate by means of springs. He attached a moveable part made of elastic gum to restore the velum and uvul
• #10: He explained the anatomy and physiology of the pharyngeal area, and he was the first to draw attention to the action of the superior constrictor of the pharynx in velopharyngeal closure. kingsley-in 1880 kingsley was the first to advocate speech therapy following the construction of an obturator
• #11: for a fully edentulous patient with nickel-titanium wires joining the velar lamina to the complete denture
• #14: Must apply the basic principles of support, retention and stability so as to minimize the stress generated to the structures of the mouth.
• #20: Dislodging and rotational forces The weight of the nasal extension of the obturatorThe weight of the nasal extension of the obturator exerts dislodging and rotational forces on abutmentexerts dislodging and rotational forces on abutment teeth.teeth. To resist these forcesTo resist these forces -weight of the obturator be minimal-weight of the obturator be minimal -direct retention-direct retention -extending the buccal wall of the nasal-extending the buccal wall of the nasal extension superiorly.extension superiorly.
• #44: The classification is as follows- Class 1:- Resection is performed in the anterior midline of the maxilla, with abutment teeth present on one side of the arch. Class 2:- The defect is unilateral, retaining the teeth on the contralateral side. Class 3:- Defect occurs in the central portion of the hard palate and may involve part of the soft palate. Class 4:- Defect crosses the midline and involves both sides of the maxilla, with abutment teeth present on one side. Class 5:- Defect is bilateral and lies posterior to abutment teeth. Class6:- Anterior maxillary defect with abutment teeth present posterior to the defect on either sides of the remaining maxilla.
• #45: Support is provided and shared by the remaining nat-ural teeth, the palate, and any structures in the defectthat may be contacted for this purpose. The goal is to en-sure that the functional load is distributed as equally aspossible to each of these structures via a rigid major con-nector. The natural teeth are aided in this action whenthe support regions of the palate and the defect are
• #59: 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
• #68: A definitive cast was made and digitally scanned, and the framework as well as hollow obturator bulb was planned using a computer-aided design (CAD) (Exocad software). A contemporary three-dimensional (3D) design technique [Figure 5] was considered rather than the conventional wax-up to facilitate a holistic analysis of the final prosthesis. Further, the designed obturator bulb was milled in a poly (methyl methacrylate) (PMMA) material [Figure 6] before final fabrication to facilitate a definitive trial in the patient's mouth The design of the obturator bulb included a peripheral undercut 2.5 mm in width, encompassing the entire outer diameter of the bulb as it joined the underlying palatal framework. This aided in retention of the silicone cap. Five grooves, 1.5-mm deep, were provided on the surface of the bulb to allow correct orientation and additional retention of the removable cap.Once the trial was approved, the designed prosthetic components were printed in a castable material (Juell 3D UV resin) [Figure 7] using a 3D printing machine (O3D Orchestrate), invested and casted in Class 1 pure titanium using a vacuum pressure casting system (Titec F205M, OROTIG). The titanium components were polished and laser welded (LASER Welder, EVO 125) [Figure 8] together, hence providing a complete hollow-bulb titanium framework he maxilla–mandibular relationship was recorded, and the teeth arrangement is done in accordance with the mandibular natural teeth, followed by trial placement [Figure 10] to assess the patient's phonetics and esthetics. he prosthesis was acrylized in heat-cured denture base resin.A flexible cap was fabricated extraorally in the definitive cast using medical-grade silicone
• #69: Sectional maxillary prosthesis, including a complete denture and an inflatable obturator, was used to restore the extensive maxillary defect. The definitive maxillary denture (Luciton 199 denture base material; Dentsply, York, Pennsylvania, USA) was made according to the mandibular dentition with proper occlusion contact. On the intaglio side of the denture, an appropriate undercut that imitated an edentulous ridge contour was made so that the complete denture could be retained afterwardsThe impression was poured with dental stone (Die-Stone Type III; Heraeus, South Bend, Indiana, USA) to form the working cast, and a one-way air valve (Botou Shengwei Factory, Botou City, Hebei Province, China) was fixed on the palatal surface of the obturator when the obturator prosthesis was made. Odontosil (Dreves, Unna, Germany) silicone material was used to process the hollow silicone obturator prosthesis in the laboratory (Figure 5). The obturator prosthesis and the definitive denture were then trialed by the patient, and an adequate vertical dimension and retention of the prosthesis was demonstrated (Figure 6). When the patient tried the sectional maxillary prosthesis by himself, the compressed obturator was firstly seated in the defect, and the patient could inflate it using a portable air pump (Figure 7) to connect the installed air-valve on the palatal surface of the obturator. When inflated, the obturator was well-fitted with extending evenly into the undercuts. The denture was then seated on the inflated obturator by engaging the suitable undercuts on the palatal surface of the obturator formed during the manufacture of the denture. When the patient wishes to remove the obturator, the compressed air pump is connected directly with the valve to deflate it after the denture is removed.
• #70: his new hollow and inflatable obturator is completely customized according to the configuration and size of defects and has been proven clinically. With this advantage, an obturator with the same shape as the defect can extend into the undercut area and engage the undercut more evenly. The inflatable hollow obturator is lightweight, can be retained well and creates an adequate oral–nasal seal. Deglutition, pronunciation and mastication can be improved and the psychological impact of extensive maxillectomies on patients can therefore be minimized
• #71: A two-piece maxillary obturator is indicated in patients with trismus and in large maxillary defects. It has a bulb component and a maxillary plate which can be with or without artificial teeth. This article describes rehabilitation of a large maxillary defect with two piece maxillary obturators, which are assembled by different mechanisms of adherence. (a) Obturator with a silicon bulb, (b) obturator with embedded magnets, This acrylic surface houses the north pole of the magnet with the help of autopolymerizing acrylic resin. The south pole of the magnet is embedded on the inner surface of the maxillary plate in approximation with the opposite pole of the magnet in the bulb. closed field, permanent, rare earth neodymium-iron-boron, commercially available magnet (Ambika Corporation, New Delhi, India) having 4.5 mm length and 1.3 mm breadth is incorporated into a maxillary prosthesis without interference. It has sufficient attractive force (7.2 N) to prevent displacement of the prosthesis and assist in easy orientation and placement of the maxillary plate.closed field, permanent, rare earth neodymium-iron-boron, commercially available magnet (Ambika Corporation, New Delhi, India) having 4.5 mm length and 1.3 mm breadth is incorporated into a maxillary prosthesis without interference. It has sufficient attractive force (7.2 N) to prevent displacement of the prosthesis and assist in easy orientation and placement of the maxillary plate.
• #76: An analysis of a frozen tissue section was suggestive of myxoma. Although the tumor was extending into the orbit and infiltrating the periorbita, the eye was spared because of the benign nature of the tumor and the patient refused consent for enucleation. An immediate surgical obturator was inserted, and the patient was started on oral feeds. Two weeks following the operation, a delayed surgical obturator was fabricated to both support the flap and eyeball due to the extensive resection involving the orbital floor and enable the patient to feed without nasal regurgitation. Usually, a delayed surgical obturator is a single piece prosthesis. Due to the extensive nature of this intraoral defect (as shown in Figure ​Figure2),2), the obturator was fabricated in two parts, consisting of a hollow antral part and an oral part.
• #77: . The hollow antral part was split into two pieces: a superior hollow bulb that occupied the superior two-thirds of the defect and an inferior hollow part that occupied the inferior one-third of the defect and was an extension of the oral part of the obturator. The oral part of the obturator included a splinted metal ceramic prosthesis with a ball attachment (Rhein 83, New York, USA) on the left maxillary central incisor. The cast partial framework included a complete palate design with embrasure clasps on the remaining posterior abutment teeth on the left side of the maxillary arch. Informed consent was obtained from the patient after the treatment sequence, and the limitations of maxillary obturators were explained to him. : The antral part of the delayed surgical obturator was used as a tray to record the finer details after adequate healing of the defect area had occurred. The impression obtained was processed (heat-cure clear acrylic, DPI, Mumbai, India) to obtain a hollow bulb. The hollow bulb was finished and tried on the defect. It was modified to engage only the superior two-thirds of the defect. The lid (fabricated with a self-cure acrylic material, DPI, Mumbai, India) was perforated in the center to help the patient easily remove the bulb with his finger, The superior part of the antral bulb was passive. It functions only when pushed by the second inferior part to engage the defect and support the eyeball. This inferior one-third of the antral bulb is an extension of the oral part. This split-antral bulb design is self-retentive within the defe
• #78:  The oral part comprised a cast partial maxillary removable denture replacing the teeth from the right central incisor to right maxillary second molar, and was retained with a ball attachment on the left central incisor and an acrylic part to engage one-third of the defect area. Tooth preparation was done on teeth 21, 22, and 23 to receive a ceramic metal prosthesis with a ball attachment. A final impression was recorded for the fabrication of the prosthesis. The final metal ceramic prosthesis with the male component was tested for fit, The superior part of the antral bulb was inserted. The final impression was recorded with a polyvinyl siloxane (Aquasil, Dentsply, Germany), which included the inferior one-third of the defect, the remaining teeth, and the prosthesis with attachment,
• #79: The superior part of the antral bulb was inserted. The final impression was recorded with a polyvinyl siloxane (Aquasil, Dentsply, Germany), which included the inferior one-third of the defect, the remaining teeth, and the prosthesis with attachment,
• #87: Hypernasality and decreased intelligibility of speech are a result of congenital or acquired defects of the velopharyngeal mechanism
• #88: hard and/or soft palate which affect velopharyngeal closure, but with movement of the remaining tissues within normal physiological limits. Palatal incompetence refers to patients with essentially normal velopharyngeal structures, but in whom the intact mechanism is unable to affect velopharyngeal closure. It is seen in patients with neurological diseases such as myastenia gravis or neurological deficits which are secondary to cerebrovascular accidents or closed head injuries.
• #89: For obtaining impressions for diagnostic casts, the palatal portion of the stock tray should be extended with wax, so that the defect will be recorded. The cast will assist diagnostic procedures and tray preparation, and it will aid in establishing the appropriate design for the obturator. If the defect was extensive, Tray resin would be added to the cast retention loops to approximate the area of the defect. There had to be no contact between the lateral and posterior walls when the patient said “ah”. Modeling plastic would be added to the tray resin. Border molding would be started with the anterior margins of the defect. After the warm modeling, plastic would be placed in the mouth, the patient would be instructed to move the head in a circular manner from side to side, to extend the head as far forward and backward as possible, and to swallow. These movements would activate the remaining velopharyngeal musculature and mold the modeling plastic. A mouth temperature thermoplastic wax is added to the obturator, heated, tempered and the patient is instructed to repeat the head and the swallowing movements. The prosthesis is removed from the mouth and chilled in cold water. Over extended areas are identified where the wax is displaced, which exposes the modeling plastic The altered cast impression is boxed and the master cast is completed. The obturator is processed in a customary manner with heat activated or auto polymerizing methyl methacrylate. The superior surface should be convex and well polished, to facilitate deflection of nasal secretions into the oropharynx. The tongue side of the prosthesis should be slightly concave. If the obturator is bulky, it should be hollowed, with lid added, or an open top obturator can be fabricated. A pressure indicator paste is helpful for identifying areas of extension. Partial denture designs used for patients with defects or functional deficiencies of the soft palate are similar to partial denture designs used for non surgical patients. A long lever arm is created by the extension of the obturator. The extension of the obturator increases the weight, length, the effect of gravitational force and the potential for rotation around the fulcrum line. For patients requiring class I or class II partial dentures, multiple indirect retainers are suggested. These will resist the downward displacement of the obturator and increase the stability of the prosthesis. Covering as much of the hard palate as feasible will also enhance stability and support
• #90: On the basis of examination and testing, a magnetically retained, sectional prosthesis was indicated for this patient. Magnets were used to allow horizontal movement between the prosthesis and obturator parts in order to reduce trauma in the lateral walls of the defect. The defect area was isolated with a gauze-covered sponge coated with petroleum jelly to prevent the movement of impression material into the breathing passage. A preimpression topical anesthetic was also used. A preliminary impression of the dental arch was obtained with irreversible hydrocolloid impression material (Cavex Impressional; Cavex, Haarlem, Holland). The diagnostic cast was poured with type 3 dental stone (Giludur; BK Giulini, Ludwigshafen, Germany). An autopolymerizing acrylic resin tray was prepared on the stone cast. The border, including the pharyngeal part, was molded. Zinc-oxide paste (Impression was placed on the tray (excluding the defect area), and an impression was taken. The impression of the defect was taken by irreversible hydrocolloid material in a latex condom with finger pressure, and master casts were poured. The master cast’s shape revealed that the inner surface of the defect was suitable for an undercut to retain and support an obturator. The obturator part was fabricated with heatpolymerized acrylic resin (Paladent 20; Heraeus-Kulzer GmbH, Hanau, Germany). The correct path of insertion of the obturator was deemed to be from posterior to anterior (Fig. 2). The denture section, which included the teeth, was produced in the usual manner by using heat-polymerized acrylic resin. A pair of neodium magnets (NdFe B magnets; Aksamagnet, Adapazari, Turkey) covered with thin epoxy resin to prevent leakage were embedded in the acrylic resin parts of the denture portion and obturator (Fig. 3). The sectional obturator and pharyngeal component were combined with a special hinge system and were attached to the obturator section in the defect area with the help of a pair of magnets (Fig. 4). A special hinge system was produced with 1-mm diameter orthodontic round wire (Remanium laboratory coils–round; Dentaurum Group, Ispringen, Germany) that allowed for the flexible connection of the dynamic pharyngeal part of the prosthesis. Positive pressure against the palatopharyngeal tissues is generated by the spring-orthodontic loop connected with
• #91: The spring-orthodontic loop was adjusted to lightly touch the resting soft palate. To eliminate complications during insertion and removal of the obturator, approximately 6 cm of dental floss was used to connect the denture and bulb portions; owing to the bulk and the location of the defect, the patient was informed that the bulb/obturator must be inserted first, followed by the denture portion (Figs. 5 and 6). The necessary adjustments were made to ensure that all parts were working cohesively and that the oral and oropharyngeal structures were correctly oriented to the bulb and denture base
• #92: Orbital exenteration along with hemimaxillectomy for malignant tumor of maxilla usually results in continuous orbital and maxil-lary defect. A removable maxillofacial prosthesis with adequate retention and stability during functional movement along with good esthetics is the key for successful rehabilitation of such patients. rimary impression of intraoral maxillary defect was made with alginate and poured with dental stone (type III). Maxillary cast was then surveyed and undesirable undercuts were blocked. Custom tray was thus fabricated, border molding of the defect was done and final impres-sion was made with light body addition silicone. On final working, model of obturator record base was fabricated, jaw relation was made followed by try in patient to check. thetics and function. After try-in was completed, the orbital impression was made with trial denture in place covering the intraoral defect. Patient was draped for impression and extraoral marking was made on the face with indelible pencil so that it can replicate exact position of anatomical landmarks over the cast. Custom tray was fabricated with the help of impression compound with additional relief holes. Alginate was used as a primary impression material. Final impression of orbital defect was made with light body addition silicone with custom acrylic tray. An acrylic conformer of orbital defect was fabricated and trial was made. To provide a mechanical undercut for the retention of orbital prosthesis, a 4 mm thick sprue wax was attached to the base of acrylic conformer. An obtura-tor plate made of cold cure acrylic resin was also adjusted in patient’s mouth. On the base of acrylic conformer, a pin of electric plug was attached and a corresponding socket was attached to the top of bulb of the maxillary obturator and fit of both the parts were checked for easy insertion and removal of prosthesis. Flasking, dewax-ing, and packing with heat cure acrylic resin was carried out for both acrylic conformer and obturator. Processed heat cure bases were tried on the patient for accurate adaptation, retention, and stability during functional movements
• #93: To replicate pupil-iris size, color, contour, and sclera shape of contralateral eye accurately, a customized ocular prosthesis was fabricated. Its final orientation was first refined on the working model with the help of recorded facial measurement and then tried on patients face. Missing structures like eyelids and associated anatomical structures were sculpted in modelling wax. Final completed wax pattern was tried on the patient face for evaluation of ocular orientation gaze, eyelid perture, size, and volume of sclera visible and pros-thesis margin fit as compared to the contralateral eye (Fig. 3). Patient’s opinion was also taken regarding the esthetics acceptability of prosthesis. This was followed by flasking, dewaxing, and packing in room temperature vulcanizing (RTV) silicone. Retrieved orbital prosthesis was characterized and was delivered to the patient with intraoral obturator in place
• #95: support and retention as they are anchored remotely in the zygomatic bone which is preserved in a low-level maxillary resection.4 These implants can be placed at the time of primary resective surgery5 or at a subsequent timepoint to help with the retention and stability of an obturator prosthesis.6 As confidence in this treatment approach has increased, an early prosthetic loading approach has been undertaken by some clinicians, rather than leanence and sub-mucosal dissection on the medial aspect. Two zygomatic oncology implants (37.5 mm; Southern Implants Ltd, Irene; South Africa) were placed in a horizontal fashion on each side with high initial stability, taking care not to extrude the tips of the implants too far through the zygoma and ensuring prosthetic heads of the implants were in a useful and restorable position (Fig. 5). The intra-oral incisions were closed with resorbable sutures, and Implant abutments were placed and torqued into position on all four implants. Impression copings were attached to the abutments and splinted together with light-cured acrylic tray material (Individo® Lux, VOCO Gmbh, Germany). ving the implants to formally osseointegrate for a number of months prior to using them.
• #96: The maxillary defect undercuts were then blocked out using surgical gauze prior to taking a maxillary impression (Fig. 6). The patient’s initial obturator was cut back to allow it to be seated over the implant heads and it was relined with a soft-lining material (Ufigel SC, VOCO Gmbh; Germany). A subsequent radiograph demonstrated good positioning of the implants within the zygomatic bodies
• #97: The impressions were subsequently poured by the prosthetic technician who then constructed a cobaltchrome based bar construction which incorporated a large central magnet (Technovent; Bridgend; Wales) cured into a central housing (Fig. 8). In addition, an acrylic pick up housing was constructed (Fig. 9) to allow conversion of the patient’s existing obturator prosthesis. One week following implant insertion, the relined obturator was removed and the new zygomatic implant retained bar construction was fitted (Fig. 10). The acrylic pick up housing was then seated over the bar, and the patient’s existing obturator was modified significantly to remove the soft superior components which had previously engaged the sensitive undercuts within the nasal and sinus cavities. Once the prosthesis could be seated into the correct position, the acrylic housing was bonded to the overlying prosthesis using chairside cold-cure acrylic material (Tokuyama Rebase II; Tokuyama dental corporation; Japan) taking care not to extrude unwanted material beneath the bar or around the shafts of the implants (Fig. 11). The occlusion was checked and the patient instructed in the removal and cleaning of the prosthesis and implant bar apparatus
• #98: On review, the patient reported a significant improvement in her previous symptoms and was now able to breathe through her nose and function with her obturator to a much higher level. All intra-nasal discomfort was gone and her chewing was much improved with no
• #101: Digital technologies related to imaging and manufacturing provide the clinician with a wide variety of treatment options. Stereolithography (SLA) offers a simple and predictable way for an accurate reconstruction of congenital or acquired defects. Stereolithography (SLA) is the extension of CAD CAM technology in order to produce 3D prototype models. Originally it emerged from Rapid Prototyping (RP) technology combined with laser technology and nowadays it gives dentistry the possibility to create customized 3D models for each patient adjusted to his needs and anatomical structures. The use of stereolithographic models may progressively replace traditional milled models in the management of craniofacial anomalies . Visualization and communication of pathology involved a 3 dimensional (3D) measurement of a remarkably large palatal defect using a computerized tomography (CT) data and a 3D planning software (SimPlant v14, Materialise Dental N.V., Leuven, Belgium) (Figure 2). The MIMICS software (SimPlant v14, Materialise Dental N.V., Leuven, Belgium) was utilized for a 3D processing of the DICOM images and the preparation of the STL file for manufacturing the model. 116 CT images in a DICOM format were processed and a relevant STL file was developed.
• #102: A 3D-printing Solido SD300 (Solidmodel, Acton, USA) was the rapid manufacturing technology used for building the precise anatomical model within the limits of the defect. It was developed from virtual planning data input. This specific 3D printing machine is cutting thin the layers of PVC plastic (Solidmodel, Acton, USA) which are glued together layer by layer until the complete anatomical model is fabricated (Figure 3). The duration of the process was about 10-12 hours. At the beginning, a wax pattern of the hollow bulb was fabricated using the plastic anatomical model. The wax pattern was invested in stone (Silky Rock, Whip-mix Corp. Whipmix, Louisville, USA) and then boiled out from the mold (Figure 4). The space created, was packed with a heat cured silicone soft liner (Molloplast-B, Detax GmGh and Co., Ettlingen, Germany) for approximately 10 min under bench pressure (100 kPa), into the dummy blank and then heated up to 1000 C in a water bath, followed by curing in boiling water at 1000 C for 2 h according to the manufacturer’s recommendations. A separating agent was applied to the stone surfaces of dental flasks for insulation. Preliminary impressions were obtained using a stock tray with a silicone hollow bulb intraorally. The master cast was used to create a special tray. Border molded impression was obtained through the border molding process by utilizing impression compound (Impression compound, type 1 Kerr Corp. CA, USA) and medium body vinyl polysiloxane (Episil, Dreve, Unna, Germany (Figure 5 and ​and6).6). The next step included the fabrication of a working cast using Type IV (Whip-mix Corp. Whipmix, Louisville, USA) dental die stone (Figure 7). Subsequently, the duplication of the master cast using laboratory silicone (Prestige. Duplex, Vanini Dental Industry, Grassina, Italy) was made with wax pouring inside the silicone obturator and the sealing of the area in terms of a cap (Figure 8). After the silicone curing, a new working cast was invested and reflasked. The model had the borderline of the obturator and the sealant imprinted, hence the gap between the denture and the obturator was preserved (