Obturators/ orthodontic seminars

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ObturatorsObturators
INDIAN DENTAL ACADEMY
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ContentsContents
 IntroductionIntroduction
 DefinitionsDefinitions
 Maxillofacial defect classificationMaxillofacial defect classification
 Care for patient with acquired defectsCare for patient with acquired defects
 Intraoral Prosthesis design considerationsIntraoral Prosthesis design considerations
 Benefits of surgical preservationBenefits of surgical preservation
 Obturator prosthesisObturator prosthesis
 Speech aid prosthesisSpeech aid prosthesis
 ConclusionConclusion
 ReferencesReferences

IntroductionIntroduction

DefinitionsDefinitions
 Obturator: are maxillofacial prosthesis used to close aObturator: are maxillofacial prosthesis used to close a
congenital or acquired tissue opening, primarily of thecongenital or acquired tissue opening, primarily of the
hard palate and/ or contiguous alveolar/soft tissuehard palate and/ or contiguous alveolar/soft tissue
structures – GPT 8structures – GPT 8
 Surgical obturator: a temporary maxillofacial prosthesisSurgical obturator: a temporary maxillofacial prosthesis
inserted during or immediately following surgicalinserted during or immediately following surgical
traumatic loss of a portion or all of one or both maxillarytraumatic loss of a portion or all of one or both maxillary
bones and continuous alveolar structures (i.e. gingivalbones and continuous alveolar structures (i.e. gingival
tissue, teeth). – GPT 8tissue, teeth). – GPT 8

 Interim obturator: a maxillofacial prosthesis which IsInterim obturator: a maxillofacial prosthesis which Is
made following completion of initial healing followingmade following completion of initial healing following
surgical resection of a portion or all of one or bothsurgical resection of a portion or all of one or both
maxillae; frequently many or all teeth in the defect areamaxillae; frequently many or all teeth in the defect area
are replaced by this prosthesis. GPT 8are replaced by this prosthesis. GPT 8
 Palatal augmentation prosthesis : a removablePalatal augmentation prosthesis : a removable
maxillofacial prosthesis which alters the hard and/or softmaxillofacial prosthesis which alters the hard and/or soft
palate's topographical form adjacent to the tongue. GPTpalate's topographical form adjacent to the tongue. GPT
88

 Palatal lift prosthesis: on maxillofacial prosthesis whichPalatal lift prosthesis: on maxillofacial prosthesis which
elevates the soft palate superiorly and aids in restorationelevates the soft palate superiorly and aids in restoration
of soft palate functions which may be lost due to anof soft palate functions which may be lost due to an
acquired, congenital or developmental defect. GPT 8acquired, congenital or developmental defect. GPT 8
 Speech aid prosthesis: a removable maxillofacialSpeech aid prosthesis: a removable maxillofacial
prosthesis used to restore an acquired or congenitalprosthesis used to restore an acquired or congenital
defect of the soft palate with a portion extending into thedefect of the soft palate with a portion extending into the
pharynx to separate the oropharynx and nasopharynxpharynx to separate the oropharynx and nasopharynx
during phonation and deglutition, thereby completing theduring phonation and deglutition, thereby completing the
palatopharyngeal sphincter. GPT 8palatopharyngeal sphincter. GPT 8

Maxillofacial classificationMaxillofacial classification
 Patients can be categorized by maxillofacial defects thatPatients can be categorized by maxillofacial defects that
are acquired, congenital, or developmental.are acquired, congenital, or developmental.
 Acquired: e.g. include soft or hard palate defectsAcquired: e.g. include soft or hard palate defects
resulting from removal of SCC of that region.resulting from removal of SCC of that region.
 Congenital defects: e.g. include various degrees ofCongenital defects: e.g. include various degrees of
clefts of hard and soft palate.clefts of hard and soft palate.
 Developmental defectsDevelopmental defects

Classification based onClassification based on
prosthesis underprosthesis under
considerationconsideration
Extraoral : cranial orExtraoral : cranial or
facial replacementfacial replacement
Intraoral : involvingIntraoral : involving
the oral cavitythe oral cavity

Duration and time of use
Treatment
Interim
Definitive

Etiology of palatal and PNS defectsEtiology of palatal and PNS defects
 Almost all acquired palatal defects a result of resectionAlmost all acquired palatal defects a result of resection
of neoplasms.of neoplasms.
-Curtis (JPD 1967:18;70)-Curtis (JPD 1967:18;70)
 Head & Neck Cancer inflicts a formidable physical,Head & Neck Cancer inflicts a formidable physical,
psychological and socio-economic burden on patients,psychological and socio-economic burden on patients,
their families and on health care providers.their families and on health care providers.
 Relatively unknownRelatively unknown
 Lack of public awarenessLack of public awareness
 60% late presentation60% late presentation
 Dental profession has an important role to play in theDental profession has an important role to play in the
prevention and early detection of HNCprevention and early detection of HNC

Primary Prevention
 Education
 Largely preventable disease
 Tobacco use, along with alcohol, accounts for 75% -
90% oral, pharyngeal, laryngeal, esophageal cancers
(US Surgeon General 2000)

Secondary preventionSecondary prevention
Informed Public
 Non healing ulcer
 Red/white speckled area
 Red velvety area
 Pigmented area or lump
 Neck mass
 Speech changes
 Swallowing difficulty
 Unilateral sore throat
Dental Profession
 Opportunistic Screening
 High index of suspicion
 Quick early diagnosis
 Early appropriate referral

Multidisciplinary team approachMultidisciplinary team approach

Prosthetic treatment for patientsProsthetic treatment for patients
with acquired surgical defectswith acquired surgical defects
 Prosthodontic treatment can be an arbitrarily divided intoProsthodontic treatment can be an arbitrarily divided into
- initial phase- initial phase
- secondary phase- secondary phase
 Acquired defects of the hard and soft palate can beAcquired defects of the hard and soft palate can be
managed by the use ofmanaged by the use of

Removable prosthesisRemovable prosthesis

Surgical closureSurgical closure

Implant supportedImplant supported

Care for patient with acquiredCare for patient with acquired
defectsdefects
 Initial emphasis is on surgical requirements,Initial emphasis is on surgical requirements,
later prosthetic requirementslater prosthetic requirements
 Divided intoDivided into
•
Pre operativePre operative
•
IntraoperativeIntraoperative
•
InterimInterim
•
Definitive careDefinitive care

Pre and Intraoperative carePre and Intraoperative care
 Planning should begin before surgeryPlanning should begin before surgery
 Patients should be seen by the Prosthodontist beforePatients should be seen by the Prosthodontist before
the surgerythe surgery
 Dental objectivesDental objectives
- Removal of potential dental, postoperative ComplicationsRemoval of potential dental, postoperative Complications
- Planning for subsequent prosthetic treatmentPlanning for subsequent prosthetic treatment
- Make recommendations for surgical site preparation thatMake recommendations for surgical site preparation that
may improve surgical integritymay improve surgical integrity

- Temporary restoration for large carious lesionsTemporary restoration for large carious lesions
- Treatment of acute conditionsTreatment of acute conditions
- Extraction of hopeless teethExtraction of hopeless teeth
- Impression is made for fabrication of surgical obturatorImpression is made for fabrication of surgical obturator
- Initiation of planning for definitive prosthesisInitiation of planning for definitive prosthesis

Surgical obturationSurgical obturation
 Accomplished by a variety of restorations and materialsAccomplished by a variety of restorations and materials
 James- Raines 1955: spongesJames- Raines 1955: sponges
 Steadman 1957: gutta perchaSteadman 1957: gutta percha
 Hammond 1966, King 1978: inflatable bulbHammond 1966, King 1978: inflatable bulb
 It may be either delayed surgical obturation {six to tenIt may be either delayed surgical obturation {six to ten
days later} or immediate surgical obturation, indicated fordays later} or immediate surgical obturation, indicated for
most patientsmost patients

Immediate surgical obturatorImmediate surgical obturator
 Objective is to separate oral and nasal cavitiesObjective is to separate oral and nasal cavities
AdvantagesAdvantages
- Prosthesis acts as a matrix for dressingProsthesis acts as a matrix for dressing
- Reduced wound contaminationReduced wound contamination
- Speech is betterSpeech is better
- Deglutition, nasogastric tube can be removed earlyDeglutition, nasogastric tube can be removed early
- Psychological supportPsychological support
Surgical prosthesis not removed- seven to ten days postSurgical prosthesis not removed- seven to ten days post
surgicallysurgically

Design considerationsDesign considerations

FabricationFabrication

Delayed surgical obturationDelayed surgical obturation
 Placed seven to ten days post surgicallyPlaced seven to ten days post surgically
 Patient is the edentulous and surgical effect is extensivePatient is the edentulous and surgical effect is extensive
this approach is the treatment of choicethis approach is the treatment of choice
 Posterior occlusal ramps helps keep the prosthesis inPosterior occlusal ramps helps keep the prosthesis in
place for edentulous patientsplace for edentulous patients
 Existing dentures may also be usedExisting dentures may also be used

Common complicationsCommon complications
 Mostly related to tissue trauma and associatedMostly related to tissue trauma and associated
discomfortdiscomfort
 Inadequate retentionInadequate retention
 Incomplete obturation with associated leakageIncomplete obturation with associated leakage
 Tissue effects of radiotherapy and chemotherapyTissue effects of radiotherapy and chemotherapy

Defect and oral hygieneDefect and oral hygiene
 Following surgical pack removal, the defect site willFollowing surgical pack removal, the defect site will
mature with time.mature with time.
 Patient’s apprehensions regarding his new oral findingsPatient’s apprehensions regarding his new oral findings
must be addressedmust be addressed
 As they become more familiar with the defect theyAs they become more familiar with the defect they
should be encouraged to clean the defect of food debrisshould be encouraged to clean the defect of food debris
and mucous secretions routinelyand mucous secretions routinely
 Defect hygiene will allow timelier healing and ability toDefect hygiene will allow timelier healing and ability to
adequately fit a prosthesisadequately fit a prosthesis

Defect and oral hygieneDefect and oral hygiene
 Common hygiene practices include;Common hygiene practices include;
- Lavage procedures, including rinsing, using bulb syringeLavage procedures, including rinsing, using bulb syringe
or modified oral irrigation deviceor modified oral irrigation device
- Manual cleaning with sponge-handled cleaning aidManual cleaning with sponge-handled cleaning aid
- Daily Fluoride application for radiotherapy patientsDaily Fluoride application for radiotherapy patients

Interim obturatorInterim obturator
 Interim prosthesis are wireInterim prosthesis are wire
retained do not have teethretained do not have teeth
initially but later may be addedinitially but later may be added
after a period ofafter a period of
accommodationaccommodation
 Duration of interim phase isDuration of interim phase is
three monthsthree months
 Primary objective is to allowPrimary objective is to allow
the patient to pass from activethe patient to pass from active
surgical phase to observationalsurgical phase to observational
phase with minimumphase with minimum
complicationscomplications

Definitive careDefinitive care
 3-4 months post surgery3-4 months post surgery
depending on size of defect,depending on size of defect,
progress of healing, tumorprogress of healing, tumor
prognosis, presence orprognosis, presence or
absence of teeth, definitiveabsence of teeth, definitive
obturator is planned.obturator is planned.
 Defect is engaged moreDefect is engaged more
aggressively for edentulousaggressively for edentulous
patients hence healingpatients hence healing
period is prolonged.period is prolonged.

GoalsGoals
 Well supported, stable, retentive prosthesis that isWell supported, stable, retentive prosthesis that is
acceptable in appearance and exhibits minimumacceptable in appearance and exhibits minimum
movement under function.movement under function.
 Thereby preserving maximum amount of supportingThereby preserving maximum amount of supporting
tissuetissue
 Can be achieved by:Can be achieved by:

Surgical preservation for prosthetic
benefit
 Surgical outcomes that
impact prosthetic
success:
- Those that impact the
amount of max. structure
removed
- Those that impact the
structural integrity and
quality of defect

 Primary prosthetic
objectives are:
- Restoration of physical
separation of oral and
nasal cavities to restore
- Mastication
- Deglutition
- Speech
- Facial contour

 When possibleWhen possible
preservation of as muchpreservation of as much
of inferior sinus floor,of inferior sinus floor,
hard palate, alveolus andhard palate, alveolus and
teeth should beteeth should be
consideredconsidered
 If resection leaves <1/3If resection leaves <1/3rdrd
soft palate entire softsoft palate entire soft
palate must be removedpalate must be removed
except in edentulousexcept in edentulous
patientspatients
 Use of split thickness skinUse of split thickness skin
graftsgrafts

Types of prosthesisTypes of prosthesis
Obturator prosthesis
Speech aid prosthesis
Others

Obturator
Speech aid prosthesis

Obturator prosthesisObturator prosthesis
 The defining characteristic of an obturatorThe defining characteristic of an obturator
prosthesis is that it serves to restore separationprosthesis is that it serves to restore separation
of the oral and adjacent cavities following surgicalof the oral and adjacent cavities following surgical
resection of tumors of nasal and paranasal regionresection of tumors of nasal and paranasal region

Armany classification

Treatment concepts
 Factors to be
considered
- Movement of the
prosthesis
- Tissue changes
- Covering prosthesis
- Extension into
defect
- Teeth
- Weight of prosthesis

Edentulous patients with totalEdentulous patients with total
maxillectomy defectsmaxillectomy defects
 With any large defect restoration in the classical sense isWith any large defect restoration in the classical sense is
not possiblenot possible
 According to Desjardins (1978) the contours of theAccording to Desjardins (1978) the contours of the
defect must be used to maximize RSS for the prosthesisdefect must be used to maximize RSS for the prosthesis
 In most patients acceptable RSS can be gained from:In most patients acceptable RSS can be gained from:
- Residual palatal structureResidual palatal structure
- Engaging the defectEngaging the defect

Residual palatal structure

The defectThe defect
 Acceptable retention canAcceptable retention can
be gained by engagingbe gained by engaging
key areas in the defectkey areas in the defect

 Lateral portion of the
obturator exhibits
greatest degree of
movement, retention can
be improved by
appropriate obturator-
tissue contact
superolaterally.
(Brown, 1968)

Steps in fabricationSteps in fabrication
 Preliminary impressionPreliminary impression
 Master impressionMaster impression
 Vertical dimension of occlusionVertical dimension of occlusion
 Occlusal scheme selectionOcclusal scheme selection
 ProcessingProcessing
 Delivery and follow upDelivery and follow up

Edentulous patients with partialEdentulous patients with partial
maxillectomy defectsmaxillectomy defects
 More of the hard palateMore of the hard palate
may be available formay be available for
supportsupport
 Retention may beRetention may be
compromised as accesscompromised as access
to the defect is limitedto the defect is limited
 Defect should beDefect should be
optimally utilized, softoptimally utilized, soft
silicones are especiallysilicones are especially
usefuluseful

Dentulous patients with total or
partial maxillectomy defects
 Prognosis improves with
availability of teeth to assist
with RSS
 Treatment concepts
- Location of the defect
- Movement of the
prosthesis
- Length of the lever arm
- Arch form
- Teeth
- Partial denture design
- Prosthetic procedures

Basic principles of obturator deignBasic principles of obturator deign
 The system of forces :The system of forces :
- Vertical dislodging force – reduce weight of prosthesisVertical dislodging force – reduce weight of prosthesis
- Occlusal vertical force – multiple rests and maximumOcclusal vertical force – multiple rests and maximum
coveragecoverage
- Lateral forces – proper occlusal schemeLateral forces – proper occlusal scheme
- Anterior – posterior movement counteracted by proximalAnterior – posterior movement counteracted by proximal
guide planesguide planes

Lab proceduresLab procedures
 Fabrication of obturatorFabrication of obturator
- SolidSolid
- Open bulbOpen bulb
- Hollow bulbHollow bulb
-
2-piece2-piece
-
Single pieceSingle piece

One step hollow bulb obturatorOne step hollow bulb obturator

Speech considerationsSpeech considerations
 Surgical removal of a portion of maxilla if not restored,Surgical removal of a portion of maxilla if not restored,
surgically / prosthodontically, can create a serioussurgically / prosthodontically, can create a serious
problem for speaker for several reasons:problem for speaker for several reasons:
- Oral- nasal resonance balance lost leading to hypernasalOral- nasal resonance balance lost leading to hypernasal
speechspeech
- Articulation of speech lost with loss of palatal tissueArticulation of speech lost with loss of palatal tissue
- Loss of anterior teeth further complicates speechLoss of anterior teeth further complicates speech
articulationarticulation

 Bloomer and Hawk, 1973, suggested that maxillaryBloomer and Hawk, 1973, suggested that maxillary
resection affects palatopharyngeal function by,resection affects palatopharyngeal function by,
- Destroying attachment for pharyngeal musculatureDestroying attachment for pharyngeal musculature
- Denervation of pharyngeal musculatureDenervation of pharyngeal musculature
- Relative shrinkage and immobilization of soft palateRelative shrinkage and immobilization of soft palate
through scar contractionthrough scar contraction
 When maxillectomy is confined to the bony palate,When maxillectomy is confined to the bony palate,
speech following placement of a prosthesis is withinspeech following placement of a prosthesis is within
normal limits.normal limits.

Restoration of soft palate defectsRestoration of soft palate defects

Palatopharyngeal functionPalatopharyngeal function ::
 Hypernasality and decreased intelligibility of speechHypernasality and decreased intelligibility of speech
may result from congenital or acquired defects ofmay result from congenital or acquired defects of
palatopharyngeal mechanism.palatopharyngeal mechanism.
 Palatopharyngeal deficiency may result from:Palatopharyngeal deficiency may result from:
 Congenital malformations such as cleft palateCongenital malformations such as cleft palate
 Short hard or soft palateShort hard or soft palate
 Deep nasopharynxDeep nasopharynx
 Acquired neurological deficitsAcquired neurological deficits
 Surgical resection of Neoplastic diseaseSurgical resection of Neoplastic disease

 Palatal insufficiencyPalatal insufficiency andand palatal incompetencepalatal incompetence are oftenare often
used to define palatopharyngeal deficitsused to define palatopharyngeal deficits
 Palatal insufficiency: patients with inadequate length ofPalatal insufficiency: patients with inadequate length of
soft palate affect palatopharyngeal closure butsoft palate affect palatopharyngeal closure but
movement of remaining tissue is under normal limitsmovement of remaining tissue is under normal limits
 Deficiency is secondary to structural limitation. ExampleDeficiency is secondary to structural limitation. Example
patients with congenital developmental deficiency andpatients with congenital developmental deficiency and
acquired soft palate defectsacquired soft palate defects

 Palatal incompetence: refers to patients withPalatal incompetence: refers to patients with
essentially normal palatopharyngeal structure, butessentially normal palatopharyngeal structure, but
intact mechanism is unable to effectintact mechanism is unable to effect
palatopharyngeal closure.palatopharyngeal closure.
 Example : patients with neurological disease suchExample : patients with neurological disease such
as bulbar poliomyelitis, myasthenia gravis, oras bulbar poliomyelitis, myasthenia gravis, or
neurological deficiency secondary toneurological deficiency secondary to
cerebrovascular accidentcerebrovascular accident

Palatopharyngeal deficits
Palatopharyngeal insufficiency
- Speech aid appliance used
Palatopharyngeal incompetence
- Palatal lift appliance used

Normal PalatopharyngealNormal Palatopharyngeal
Function For SpeechFunction For Speech
 When impairment of the palatopharyngeal port isWhen impairment of the palatopharyngeal port is
present, speech is typically characterized by excessivepresent, speech is typically characterized by excessive
nasal resonance (hypernasality), inappropriate audiblenasal resonance (hypernasality), inappropriate audible
nasal air emission, and a decrease in intraoral airnasal air emission, and a decrease in intraoral air
pressure during the production of oral speech sounds.pressure during the production of oral speech sounds.
Speech may be only partially intelligibleSpeech may be only partially intelligible
 Velopharyngeal incompetence is the functional inabilityVelopharyngeal incompetence is the functional inability
of the soft palate to effect complete seal with theof the soft palate to effect complete seal with the
posterior and / or lateral pharyngeal wallsposterior and / or lateral pharyngeal walls

Clinical Features ofClinical Features of
velopharyngeal incompetencevelopharyngeal incompetence
 Escape of air resulting in nasal speech that may beEscape of air resulting in nasal speech that may be
unintelligible.unintelligible.
 Middle ear infections like otitis media due to obstructionMiddle ear infections like otitis media due to obstruction
of eustachian tube.of eustachian tube.
 Nasal regurgitationNasal regurgitation
 Psychological problemsPsychological problems
 Social discriminationSocial discrimination

Indications for prosthodonticIndications for prosthodontic
carecare
For un-operated patientsFor un-operated patients
 A wide cleft with a deficient soft palateA wide cleft with a deficient soft palate
 A wide cleft of the Hard PalateA wide cleft of the Hard Palate
 Neuromuscular deficit of the soft palate and pharynxNeuromuscular deficit of the soft palate and pharynx
 Delayed surgeryDelayed surgery
 Expansion prosthesis to improve spatial relationsExpansion prosthesis to improve spatial relations
 Combined prosthesis and orthodontic applianceCombined prosthesis and orthodontic appliance
In operated patientsIn operated patients
 Incompetent palatopharyngeal mechanismIncompetent palatopharyngeal mechanism
 Surgical FailuresSurgical Failures

ContraindicationsContraindications
 Feasibility of surgical repairFeasibility of surgical repair
 Mental RetardationMental Retardation
 Uncooperative patient and parentsUncooperative patient and parents
 Uncontrolled dental cariesUncontrolled dental caries
 Lack of a trained prosthodontistLack of a trained prosthodontist
Objectives in prosthodontic speech applianceObjectives in prosthodontic speech appliance
constructions:constructions:
 Restoring socially acceptable speechRestoring socially acceptable speech
 Restoration of the masticating apparatusRestoration of the masticating apparatus
 Esthetic facial and dental harmonyEsthetic facial and dental harmony
 Psychologic adjustment of the patient to the conditionPsychologic adjustment of the patient to the condition

Diagnosis of palatopharyngealDiagnosis of palatopharyngeal
incompetenceincompetence
 Oral assessmentOral assessment
 Speech assessmentSpeech assessment
 Videofluorographic assessmentVideofluorographic assessment
 VideonasoendoscopyVideonasoendoscopy

Speech BulbSpeech Bulb

Palatal Lift

Palatal LiftPalatal Lift

Meatal obturator prosthesis
 First described by
Schalit (1946) later
advocated by Sharry
(1958)

MeatalMeatal
obturatorobturator

Palatal augmentation prosthesisPalatal augmentation prosthesis
 When surgical resection involving the tongue and / orWhen surgical resection involving the tongue and / or
floor of mouth limits the mobility, it affects both speechfloor of mouth limits the mobility, it affects both speech
and deglutitionand deglutition
 With tongue mobility limitation, the contour of the palateWith tongue mobility limitation, the contour of the palate
can be augmented by a prosthesis to modify the spacecan be augmented by a prosthesis to modify the space
of Dondersof Donders
 To allow food manipulation to be more easily transmittedTo allow food manipulation to be more easily transmitted
posteriorly Into the oropharynxposteriorly Into the oropharynx
 Prosthesis movement potential as lowProsthesis movement potential as low
 Diagnostic resin prosthesis is given, followed by castDiagnostic resin prosthesis is given, followed by cast
metal prosthesismetal prosthesis

Procedures for Building anProcedures for Building an
Intraoral Prosthesis to AssistIntraoral Prosthesis to Assist
Speech or SwallowingSpeech or Swallowing

Preliminary Dental Work-upPreliminary Dental Work-up
 Oral HygieneOral Hygiene must be satisfactory or else, prosthesis willmust be satisfactory or else, prosthesis will
increase risk for…increase risk for…

DecayDecay

InflammationInflammation

Fungal infectionFungal infection
 Radiographs are needed to…Radiographs are needed to…

Check for adequate bone support for retentionCheck for adequate bone support for retention
• Important for good stability and supportImportant for good stability and support

Check for decayCheck for decay

 Examine Preliminary ImpressionsExamine Preliminary Impressions
 Determine strategies forDetermine strategies for fitfit && retentionretention::

1. Select teeth for retention1. Select teeth for retention

2. Changing or shaping tooth as needed2. Changing or shaping tooth as needed

3. Adding material to tooth structure, molar bands,3. Adding material to tooth structure, molar bands,
crowns, or resincrowns, or resin

Preliminary Dental WorkPreliminary Dental Work
 Crowns: if tooth has large restoration(s) and integrity isCrowns: if tooth has large restoration(s) and integrity is
compromisedcompromised

common in older patientscommon in older patients
 Resin: if tooth is small, misshapen, conical, orResin: if tooth is small, misshapen, conical, or
underdevelopedunderdeveloped

resin added to healthy tooth to provide a “notch”resin added to healthy tooth to provide a “notch”
/anchor for wire/anchor for wire

common in younger patientscommon in younger patients

Designing the Prosthesis:Designing the Prosthesis:
 Use oral examination of bite to:Use oral examination of bite to:

Place clasps where they do not interfere with dentalPlace clasps where they do not interfere with dental
bitebite
 Use an acrylic (plastic) or metal baseUse an acrylic (plastic) or metal base

Acrylic: for young patients who:Acrylic: for young patients who:
• may need several prosthesismay need several prosthesis
• have less certain prognosis for successhave less certain prognosis for success
• may train out of prosthesismay train out of prosthesis

Prosthesis Design continued...Prosthesis Design continued...
 Use metal base: with older patientsUse metal base: with older patients

Benefit: more stable and durableBenefit: more stable and durable

Initial Prosthesis:Initial Prosthesis:
 There is no soft palate portion yet (inactive)There is no soft palate portion yet (inactive)
 Try in mouthTry in mouth

Adjust acrylic for intimate fitAdjust acrylic for intimate fit

Inspect visuallyInspect visually

Pressure indicator paste will identify wherePressure indicator paste will identify where
adjustments are neededadjustments are needed

Initial Prosthesis continued...Initial Prosthesis continued...
 If patient is young, has cognitive impairment, orIf patient is young, has cognitive impairment, or
strong gag reflex:strong gag reflex:

take it slowly, ensure patient comfort firsttake it slowly, ensure patient comfort first

wear for 1-2 weeks prior to adding lift or bulbwear for 1-2 weeks prior to adding lift or bulb
portionportion
 Educate patient:Educate patient:

oral hygiene and eatingoral hygiene and eating

wearing timewearing time

increased salivaincreased saliva

taking it in and outtaking it in and out

Additions and ModificationsAdditions and Modifications
 Prior to adding: oral exam, check for ulcerations, andPrior to adding: oral exam, check for ulcerations, and
make adjustmentsmake adjustments
 Acrylic base: add wire loop and small amount ofAcrylic base: add wire loop and small amount of
acrylicacrylic

depending on patient cooperation and tolerance,depending on patient cooperation and tolerance,
use thermo-plastic wax to build “tail”use thermo-plastic wax to build “tail”
 Metal base: already has wire loop built inMetal base: already has wire loop built in

add wax for lift or bulbadd wax for lift or bulb
 After adding wax, convert to acrylic, polish, andAfter adding wax, convert to acrylic, polish, and
deliverdeliver

Adding/ModificationsAdding/Modifications
continued...continued...
 After adding wax for bulb, continue to shape / defineAfter adding wax for bulb, continue to shape / define
for optimal speechfor optimal speech

convert to acrylic, polish, and deliverconvert to acrylic, polish, and deliver
 Add or subtract to lift or bulb at any time using waxAdd or subtract to lift or bulb at any time using wax

Palatal Drop FormationPalatal Drop Formation
 Similar to process for building lift/bulbSimilar to process for building lift/bulb

Lower palatal vault or create a posteriorLower palatal vault or create a posterior
“ramp” to increase tongue contact“ramp” to increase tongue contact
 Add / modify based on:Add / modify based on:

auditory perceptual judgments of speechauditory perceptual judgments of speech
soundssounds
• stronger lingual stops, fricatives, affricatesstronger lingual stops, fricatives, affricates

tongue contact during swallowtongue contact during swallow
• improved bolus controlimproved bolus control
• no leaks / pocketingno leaks / pocketing

Adequacy of ProsthesisAdequacy of Prosthesis
 Visual exam of prosthesis in mouthVisual exam of prosthesis in mouth
 Auditory-perceptual judgments of speechAuditory-perceptual judgments of speech
 Nasendoscopy of speech with prosthesisNasendoscopy of speech with prosthesis
in placein place
 Patient report:Patient report:

comfort & stabilitycomfort & stability

speech & swallow improvementsspeech & swallow improvements

Modifying ProsthesisModifying Prosthesis
 Add to velar / pharyngeal area withAdd to velar / pharyngeal area with
temporary waxtemporary wax

How much at each visit is dependent uponHow much at each visit is dependent upon
patient tolerancepatient tolerance
 Goal is to provide optimal speechGoal is to provide optimal speech

audio-perceptual judgmentsaudio-perceptual judgments
• initially: excessive closure or hyponasality?initially: excessive closure or hyponasality?

nasendoscopy viewnasendoscopy view

““Training Out” of the ProsthesisTraining Out” of the Prosthesis
 Once optimal closure is achieved, wear forOnce optimal closure is achieved, wear for
approximately six monthsapproximately six months
 Systematic reduction programSystematic reduction program

1-2 month intervals1-2 month intervals

reduce 1-2 mm each timereduce 1-2 mm each time
 Speech bulb: lateral reductionsSpeech bulb: lateral reductions
 Palatal lift: top, sides, back reductionsPalatal lift: top, sides, back reductions

““Training Out” of the ProsthesisTraining Out” of the Prosthesis
 Continue reductions as long as the speakerContinue reductions as long as the speaker
can compensate by producing acceptablecan compensate by producing acceptable
speechspeech
 total reduction:total reduction:

nonsurgical approach to VP managementnonsurgical approach to VP management
 partial reduction:partial reduction:

more permanent closure of VP mechanismmore permanent closure of VP mechanism
requiredrequired
• pharyngeal flap? more permanent prosthesis?pharyngeal flap? more permanent prosthesis?

ReferencesReferences
 Maxillofacial rehabilitation. Beumer, Curtis &Maxillofacial rehabilitation. Beumer, Curtis &
FritellFritell
 McCraken’s removable denture prosthodonticsMcCraken’s removable denture prosthodontics
1111thth
eded
 Maxillofacial prosthetics. ChalianMaxillofacial prosthetics. Chalian
 Diagnosis and treatment planning. LaneyDiagnosis and treatment planning. Laney
 GPT - 8GPT - 8

 Sandeep Kumar, Veena Hegde. Prosthodontics inSandeep Kumar, Veena Hegde. Prosthodontics in
Velopharyngeal Incompetence. JIPS, (under publication)Velopharyngeal Incompetence. JIPS, (under publication)
 Armany MA. Basic principles of obturator design forArmany MA. Basic principles of obturator design for
partially edentulous patients. Part I: Classification. Jpartially edentulous patients. Part I: Classification. J
Prosthet Dent 1978;40:554-557Prosthet Dent 1978;40:554-557
 Armany MA. Basic principles of obturator design forArmany MA. Basic principles of obturator design for
partially edentulous patients. Part II: Design principles. Jpartially edentulous patients. Part II: Design principles. J
Prosthet Dent 1978;40:656-662Prosthet Dent 1978;40:656-662

 Wright MS. Design for maximal attention of obturatorWright MS. Design for maximal attention of obturator
prosthesis for hemimaxillectomy patients. J Prosthetprosthesis for hemimaxillectomy patients. J Prosthet
Dent 1982;47:88-91Dent 1982;47:88-91
 Kelly KE. Partial denture design applicable to theKelly KE. Partial denture design applicable to the
maxillofacial patient. J Prosthet Dent 15:168-75maxillofacial patient. J Prosthet Dent 15:168-75
 Lauciello RK.. Flexible temporary obturators for patientsLauciello RK.. Flexible temporary obturators for patients
with severely limited jaw opening. J Prosthet Dentwith severely limited jaw opening. J Prosthet Dent
1983;49:523-261983;49:523-26

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