Enhanced retention of a maxillofacial

prosthetic obturator using precision

attachments: Two case reports

Sema Murat1
Ayhan Gurbuz1
Abulfaz Isayev1
Bahadir Dokmez1
Unsun Cetin1

Abstract
The majority of maxillary defects can be rehabilitated with conventional simple obturator pros-
thesis. However, inadequate retention, stability and support may be associated with the use of an
obturator. Precision attachments have been used to retain obturators for some time. The use of pre-
cision attachments in a dentate maxillectomy patient can yield significant functional improvement
while maintaining the obturator’s aesthetic advantages. This clinical report describes the prosthetic
rehabilitation of two maxillary defects with an obturator retained using extracoronal resilient preci-
sion attachments. (Eur J Dent 2012;6:212-217)

Key words: Obturator; retention; precision attachment

This case report was presented at the 14th Congress of the Balkan Stomatological Society (BaSS),
Varna, BULGARIA, May 2009.

Introduction
Surgical and prosthetic rehabilitation can offer the nasal side of the flap causing unpleasant odors
functional and aesthetic improvements to post- and local infections.2 Obturators can be used for
maxillectomy patients. Despite advances in surgi- either temporary or permanent rehabilitation.3-5
cal procedures, surgical reconstruction of maxil- Fabrication of an obturator prosthesis offers the
lectomy defects is not always possible because possibility of immediate and adequate dental re-
of the general health condition of the patient.1 In habilitation. Moreover, the prosthesis can be easily
addition, the ability to monitor the defect for recur- removed to examine the surgical site so that tumor
rence is lost and mucous tends to accumulate on recurrence may be detected in a timely manner.
The primary goal of prosthetic obturation is
closure of the maxillectomy defect and separation
1
Department of Prosthodontics, Faculty of Dentistry,
Ankara University, Ankara, TURKIYE of the oral cavity from the sino-nasal cavities in or-
der to prevent hyper-nasal speech and liquid leak-
Corresponding author: Dr. Sema Murat
Ankara Universitesi, Dishekimligi Fakultesi, Protetik
age into the nasal cavity.6-9 The prosthesis should
Dis Tedavisi AD. Besevler Ankara, TURKIYE also improve mastication, swallowing, articulation
Tel: + 90 312 2965555 and speech intelligibility, restore facial contours
Fax: + 90 312 2123954
and reduces drooling.5,10-13 Failure of prosthetic
Email: semamurat47@yahoo.com.tr
treatment is often related to the retentive proper-

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 Murat, Gurbuz, Isayev, Dokmez, Cetin

ties of the prosthesis. Retention is affected by a noma of the maxillary sinus that was treated by a
variety of factors, including the level of direct/in- unilateral maxillectomy followed by post-surgical
direct retention promoted by the remaining teeth; radiation therapy. As a result of surgery and radio-
defect size; available tissue surrounding the cav- therapy, the patient had experienced fibrosis and
ity; and muscular control.14 Stability and esthetics scar contraction, and after 4 years of successful
also contribute to treatment success in terms of treatment with a conventional obturator prosthe-
improvements in the patient’s social life.15,16 sis, he presented with an ill-fitting obturator that
The majority of maxillary defects can be re- was no longer retentive. Extra-oral examination
habilitated with a conventional simple obturator revealed a collapsed midface and diplopia. Intra-
prosthesis that uses various clasps as retention oral examination showed resectioning of the hard
components.17-19 In many cases, however, a con- palate, alveolar bone, teeth and soft tissue that
ventional obturator prosthesis is unable to provide did not exceed the midline. The patient had 4 vi-
adequate retention, stability and support. In such able maxillary teeth (left central incisor, left lat-
cases, precision attachments may be very useful. eral incisor, left canine and left first premolar) and
The use of multiple attachments has been de- mild periodontal disease. The defect was classi-
scribed as providing increased stability and reten- fied according to Aramany as a Class I Curved Arch
tion of the prosthesis, as well as improved water Form.17
and air tightness.20 The use of attachments as an The obturator framework was designed ac-
adjunct to maxillary obturators is indicated for (a) cording to Kennedy Class I RPD design principles,
improved aesthetics and (b) improved retention in including tooth support, placement of direct re-
comparison to conventional clasping on incisors as tainer adjacent to the defect extension base, and
terminal abutments adjacent to a large defect.7,20 indirect retention.11,21 The obturator was retained
These two clinical reports describe the pros- using extracoronal resilient attachments so that
thetic rehabilitation of maxillary defects using an retentive buccal clasps were not required.
obturator with extracoronal resilient attachments All remaining teeth were splinted using a
used in place of retentive buccal clasps. 4-unit metal-ceramic fixed partial denture (FDP)
to distribute the anticipated obturator stresses.
FIRST CASE REPORT Resilient extra-coronal ball attachments (Servo
A 65-year-old man was referred by his head and Dental, Hagen Halden, Germany) were placed at
neck surgeon to the Department of Prosthodon- the left central incisor and left first premolar for
tics at the Ankara University, Faculty of Dentistry direct retention (Figure 1). Rest seats were pre-
in Ankara, Turkey for an evaluation for prosthetic pared to direct the forces along the long axes of
treatment. The patient’s major complaints were the abutments and reduce wear on the attach-
lack of retention and instability of the prosthesis, ment.5,20 A primary impression was made using
impaired speech and mastication, and liquid leak- irreversible impression material (Soft Hydrogum,
age into the oral cavity. Five years earlier, the pa- Zhermack, Rovigo, Italy) and poured in Type III
tient had been diagnosed with epidermoid carci- dental stone (Dentstone; Pankaj Industries, Mum-
bai, India). A custom-made tray was constructed
from auto-polymerizing acrylic resin according
to a predetermined outline on the stone model,
a secondary impression was made from polyvinyl
siloxane (Xantopren M mucosa; Heraeus Kulzer,
Hanau, Germany) in order to develop a definitive
cast on which the obturator framework would be
designed (Figure 2). The definite cast was then ex-
amined in order to re-evaluate the obturator path
of insertion, after which the obturator framework
was waxed on the refractory cast. The framework
pattern was cast in base-metal alloy, finished and
Figure 1. Intraoral view of patient.
polished (Figure 3), and evaluated intraorally. Oc-

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Maxillofacial prosthetic obturator

clusal relationship were secured and mounted in a SECOND CASE REPORT

semi-adjustable articulator. Teeth position and oc- A 36-year-old man was referred to the Depart-
clusion were checked, and the necessary correc- ment of Prosthodontics at the Ankara University,
tions were made before processing the dentures. Faculty of Dentistry in Ankara, Turkey for prosthet-
A closed, hollow-bulb obturator prosthesis was ic rehabilitation. His primary concerns were poor
processed from heat-polymerizing acrylic resin facial appearance, impaired speech and regurgita-
using conventional laboratory procedures. (Luci- tion of food into the nasal cavity. The patient had
tone 199; Dentsply, Austenal, New York) (Figure 4) undergone a bilateral partial maxillectomy fol-
and delivered (Figure 5). The obturator portion of lowing the diagnosis of squamous cell carcinoma
the prosthesis was smoothed to reduce the pos- of the maxillary sinus. Treatment did not include
sibility of trauma to the mucosa and thus improve chemotherapy or radiotherapy. Clinical examina-
tolerance of the prosthesis. tion revealed a maxillofacial defect extending from
The patient was provided with oral hygiene the premaxilla to the right first molar, left canine
instruction, and follow-up evaluations were per- and hard palate. The defect was classified accord-
formed at 3 and 6 months. At the 1-year recall ing to Aramany as a Class VI Curved Arch Form.17
visit, the patient reported that the obturator pros- The patient’s post-surgery maxillary dentition con-
thesis was comfortable and easy to maintain. sisted of 6 maxillary teeth (left canine, left second

Figure 2. Final impression. Figure 3. The obturator framework on master modal.

Figure 4. Processed prosthesis. Figure 5. Frontal view of the prosthesis in occlusion.

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premolar, left first molar, left second molar and low obturator was designed and delivered to the
right first and second molars) (Figure 6). At the patient (Figure 8-9). Treatment was completed
request of the patient, the obturator framework to the aesthetic and functional satisfaction of the
was designed with attachments instead of buccal patient, who has been using his prosthesis for 2
clasps. The treatment objectives included separa- years with no complaints. The plastic segment of
tion of the nasal and oral cavities, restoration of the prosthesis has been changed twice during this
the mid-facial contour and improved speech func- time due to deformation of the plastic segment.
tions through the provision of a full complement of
maxillary anterior teeth. DISCUSSION
The right first molar, left canine and left sec- The conventional removable obturator frame-
ond premolar adjacent to the defect area were re- work design uses various clasps as retention com-
stored using metal-ceramic restorations. ponents.14,17,18 Increasing retention often requires
Direct retention was provided by resilient extra- deepening the dental undercut or increasing the
coronal attachments attached to the mesial sur- supra bulge.22,23 Clasps have a low capacity for re-
faces of the right first molar and left first premo- tention, and plastic deformation caused by cycles
lar, and the palatinal surfaces were milled. Double of insertion/removal may also lead to a rapid loss
Akers clasps on the framework were attached to in retention that results in air and liquid leakag-
the right first molar and second molar abutments es as well as discomfort.24 In some cases, preci-
to provide additional retention. Multiple rests were sion attachments may be very useful. Although
placed on the restorations to improve stability and additional laboratory procedures and resulting
provide added support for the prosthesis (Figure increases in costs associated with attachments
7). Clinical and laboratory procedures were per- represent a disadvantage,25 nylon attachments
formed as in the case described above a non-hol- are fairly economical, easily replaced, and reduce

Figure 6. Intraoral conditions prior to prosthetic treatment. Figure 7. The obturator framework on master modal.

Figure 8. Processed prosthesis. Figure 9. Final appearance with prosthesis in place.

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Maxillofacial prosthetic obturator

receptacle wear. For the cases described here, jected to receive implant surgery due to financial,
resilient extracoronal ball attachments repre- social and psychological reasons.
sented an easy alternative that involved chang-
ing the mechanism’s retentive nylon caps (female Acknowledgement
component).26,27 Authors thank Deborah Semel for her editorial
The residual maxillary form (ie, amount and assistance.
contour of the remaining palatal shelf, height of
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