OBTURATOR

Contents
 Introduction
 Objectives, Indications and Functions of Obturator
 History
 Classification of maxillary defects
 Effects and Treatment options for maxillary defects
 Types of Obturators - Surgical obturator
Interim obturator
Definitive obturator
 Design considerations for definitive obturator
 Complications with obturators
 Management of soft palate defects
 Palatal lift prosthesis
 Additional design schemes
 Recent advances
 Summary

Introduction
Maxillofacial prosthetics: “the branch of prosthodontics concerned with the restoration and/or
replacement of stomatognathic and craniofacial structures with prostheses that may or may not
be removed on a regular or elective basis” – GPT 9
Maxillofacial prosthesis: “any prosthesis used to replace part or all of any stomatognathic and/or
craniofacial structures” – GPT 9
Various maxillofacial defects cause facial disfigurement affecting quality of life of the patient.
Among all intraoral defects, maxillary defects must be the most common one that can appear in
the form of communication between oral cavity and maxillary sinus or nasopharynx.
The size of the defect may vary from small to large, which may include parts of hard and soft
palate, alveolar bone, floor of nasal cavity, and maxillary sinus and may extend up to floor of
orbit and zygomatic complex.
In general, such defects can be prosthodontically rehabilitated by prosthesis called obturator.

Obturator
From the latin word Obturare – which means “Close up”
Definition: “a maxillofacial prosthesis used to close, cover, or maintain the integrity of the oral
and nasal compartments” – GPT 9
These defects could be resulting from a congenital, acquired, or developmental disease process,
such as cancer, cleft palate, osteoradionecrosis of the palate. The prosthesis facilitates speech and
deglutition by replacing those tissues lost because of the disease process and can, as a result,
reduce nasal regurgitation and hypernasal speech, improve articulation, deglutition, and
mastication.

Objectives in treating patient with an Obturator:

1. To restore the function: Speech, respiration, chewing, and deglutition.
2. To restore the form: Facial appearance.
3. Separation between oral and nasal cavities.
4. To provide support for the orbital contents to prevent ophthalmic complications such as
enophthalmus and diplopia.

Indications of Obturator:
1. To obturate the defect temporarily during the period of surgical correction.
2. To act as a scaffold over which tissues can be shaped by surgeons.
3. To restore patient’s facial form, thereby improving aesthetics and self-image.
4. In the case of large defects, where primary closure is not possible.
5. When the patient’s age and general condition contraindicate reconstruction surgery.
6. In large size defect where results of reconstructive surgery will be unpredictable.
7. When blood supply to the site is affected as in the case of radiation therapy, which will lead to
compromised blood supply.
8. In the case of extensive and aggressive pathological lesion, which have higher chances of
recurrence.

Functions of Obturator:
1. It serves as levin tube for feeding purpose.
2. Helps to keep the wound or defective area clean.
3. It can enhance the healing of traumatic or postsurgical defects.
4. It re-establishes the palatal contour and/or soft palate, which can be helpful to restore speech
of the patient
5. In important area of esthetics, the obturator can be used to correct lip and cheek positions.
6. It can benefit the morale of patient with maxillary defects.
7. It improves mastication and deglutition.
8. It prevents the flow of exudates into the mouth.
9. The obturator can be used as stent to the dressings or packs post surgically in maxillary
resections.

History of Obturators:
The literature reveals the use of artificial material by Ambroise Pare in 1500’s, to obturate the
palatal defect using a Sponge and even used a turnbuckle type mechanism to hold the prosthesis
in place.
Pierre Fauchard (1728) described two types of palatal obturators, which used wings as part of
the design. These obturators could be inserted into the mouth and opened to close the defect
using a key system.
William Morton (1869) used a gold plate to treat palatal defect.
Claude Martin (1875) started using a surgical obturator for maxillary defects.
Fry (1927) described the importance of taking impressions before surgery
Steadman (1927) used gutta percha to hold a skin graft in position for surgical correction of
maxillectomy.

Classification of Maxillary defects:

Mohammed Aramany’s classification (1978):
He divided the defects into six categories based on the relationship of the defect to the remaining
teeth and the frequency of occurrence.
Class I
In this, resection performed along the midline of the maxilla and the teeth are maintained on one
side of the arch. This is the most common type of maxillary defect.

Class II
In this type, the defect is unilateral retaining the anterior teeth on contralateral side.
Class III
The palatal defect occurs in the central portion of the hard palate and may involve a part of soft
palate. In such cases, the majority of the teeth can be saved and designing of such prosthesis is
less complicated.

Class IV
Such defects cross the midline and involve both sides of maxilla. The design of such prosthesis is
more complex.

Class V
In such cases, the bilateral defect lies behind the remaining abutment teeth. Such defects require
splinting of remaining abutment teeth.
Class VI
It is a rare type of defect that lies anterior to the remaining teeth. This type of defect is more
common because of trauma or congenital defects and less commonly due to planned surgical
intervention.

Devin J. Okay et al classification (2001): *Additional classification*

They divided palatomaxillary defects into 3 major classes and 2 sub classes
Class Ia
Defects that involved the hard palate but not the tooth bearing alveolus

Class Ib
Defects that involved maxillary alveolus and dentition posterior to canines or the premaxilla.
Class II
Defects that involved maxillary alveolus along with dentition unilaterally or the anterior half of
palatal surface

Class III
Defects that involved maxillary alveolus along with dentition bilaterally or total surface of
palate.

Subclass f
Defects that involve inferior orbital rim
Subclass z
Defects that involve body of zygoma

Effect of Maxillary defects:

The maxillary defects may lead to anatomical and functional deformity of the maxillofacial
region affecting the esthetics of the patient. As far as the function is concerned, it can produce
difficulty in speech, mastication, and deglutition.
Loss of partition between oral and nasal cavity will lead to passage of fluid into nasal cavity.

Treatment options for maxillary defects:

The defect involving maxilla can be rehabilitated either by surgical correction with plastic
surgery or by obturator prosthesis.
The rehabilitation team involves oral and maxillofacial surgeon, plastic and reconstructive
surgeon, maxillofacial prosthodontist, oral pathologist, maxillofacial radiologist, and
psychiatrist.
The treatment with plastic surgery will provide better results as far as esthetic and function are
concerned. However, in many cases, plastic surgery may be contraindicated because of advanced
age of the patient, poor general health, very large defect, high cost involved and poor blood
supply because of radiation therapy.
In such cases, prosthetic rehabilitation is the best solution to treat the patient.

- The prosthodontic management is also easier and technically less demanding, when
compare to surgical correction.
Prosthodontist-Surgeon approach:
The prosthodontist will prepare surgical stents and immediate prosthesis, which will aid in
recovery of the patient. During joint consultation, the prosthodontist and surgeon should discuss
about the tentative line of resection and type of prosthesis to be used.
When insertion of stent or prosthesis has been planned at the time of surgery, the trained
prosthodontist should be present at the time of operation. Intraoperatively, the maxillofacial
prosthodontist may modify the prefabricated prosthesis using cold cure acrylic resin and other
materials.
Postoperatively, the surgeon will evaluate the healing of surgical wound and depending on that
will advise for the time for fabrication of the prosthesis. During postoperative healing, the wound
should not be disturbed which may affect the healing adversely. On the other hand, fabrication of
some stabilizing prosthesis may help in rapid healing.

Types of Obturators
The postsurgical treatment plan for the patient requiring prosthodontic rehabilitation can be
divided into three phases. Depending on time between surgery and insertion of prosthesis, three
types of obturators are used for rehabilitation of the patient.
1. Surgical obturator
2. Interim obturator
3. Definitive obturator
The feeding plate is also a type of obturator which is used to close defect created by cleft palate.
Its use is followed by surgical intervention to close the congenital defect.
The velopharyngeal prosthesis is a type of obturator, which extends to cover the defect of soft
palate. It rehabilitates patient’s speech and will prevent regurgitation during swallowing.

Surgical obturator
It is a plate type appliance, preferably created with clear acrylic prepared from the preoperative
impression cast.
It is inserted at the time of resection of maxilla in the operating room.
Advantages:
1. Surgical obturator restores patient’s oral functions, speech, mastication and deglutition
soon after surgery.
2. It will help the patient psychologically; along with the positive impact with replacement
of anterior teeth.
3. Reduces chances of bleeding post operatively.
4. Maintains the skin graft in position by helping in packing.
5. Prevents oral contamination and reduce chance of infection.
6. Restores palatal contour and covers the defect.
Features:
1. Simple, lightweight and inexpensive.
2. Prepared from clear acrylic.
3. On defect side it should terminate short of graft-mucosal junction.
4. Posterior teeth should not be replaced on the defect side until surgical wound is well
organized.
 5. If any posterior teeth at defect side have to be restored, it is kept out of occlusion.
6. Replacement of anterior teeth is preferred, as it has psychological benefits.
7. On the defect side, it should have a wire loop to carry gutta-percha or impression
compound.
Retention of surgical obturator:
For dentate patients- in case of small defects, the prosthesis can be retained by using clasps on
remaining teeth. In case of larger defects, wiring to the teeth is required.
For edentulous patients
 Suturing into the surrounding mucosa-suture into the vestibule.
 Palatal bone screw or implants-at the anterior peak of palatal vault angled posteriorly.
 Circumzygomatic wiring-wires are passed over the zygomatic arch and threaded through
two bilateral holes placed in the premolar area of the baseplate flange.
 Use of existing dentures-by relining them to adapt to the tissues.

Interim obturator
This obturator is prepared after initial healing of the surgical wound.
Features:
1. Fabricated from postsurgical impression cast.
2. On the oral side, the prosthesis will have contour of palate and alveolar ridge and usually
without teeth.
3. On the defect side, the prosthesis will have a bulb, projecting into the defect.
4. The bulb part is to be lined with soft relining material, which is to be changed at regular
intervals.
5. Patient must be reviewed every two weeks as soft tissues show rapid changes, which
requires frequent adjustments in the prosthesis.
*mention impression taking procedures if necessary*
*impression compounds in small increments, using gauze to protect the defect site, about limited
mouth opening if present, primary and secondary impressions, stock tray and custom tray, inject
 impression material into surgical cavity, block out defect undercuts before final impression in
cast*.

Definitive obturator
Definitive prosthesis is to be fabricated after complete healing of the surgical wound and when
the patient’s physical and emotional conditions permit procedures to be undertaken for prosthesis
fabrication.
Factors to be considered while making definitive prosthesis:
1. Size and location of the defect
2. Healing of surgical wound
3. Prognosis of tumor recurrence
4. Effectiveness of present obturator
Usually fabricated 6 months after surgery. But the tissue remodeling at the wound site can
continue for 1 year after surgery.

Design features for definitive obturator

In case of edentulous patients, the designing will be similar to a complete denture with a bulb
depending upon the size of the defect.
In case of partially dentate patients, the designing will be similar to a cast partial denture.
According to Aramany’s classification, the design features can be as follows:
Class I
 Support from remaining natural teeth, palate and any other structures.
 Rests on most anterior abutments and mesio-occlusal surfaces of most posterior
abutments.
 Guide planes and indirect retainers required
Class II
 Support from palate, aided by a square or ovoid palatal form.
 Double rests, guide planes and indirect retainer required.
 Retention from cast circumferential or I bar clasp and posterior retainer.

Class III
 Support from remaining natural teeth via widely separated and bilaterally located rests.
 Guide planes are usually short and indirect retention is not required.
 Retention from cast retainers (Circumferential, I bar or T bar).

Class IV
 Support from rests located centrally on all abutment teeth along with engagement of the
defect.
 Retention in this case is problematic. A mixture of buccal retention on the premolar
region and palatal retention on the molar side is used.
 Reduced posterior occlusion to be given.
Class V
 Labial stabilization and splinting especially of terminal abutments.
 Rests on the most posterior abutments.
 Stabilization and bracing is provided by broad palatal coverage and contact with palatal
surface of remaining teeth.
 Indirect retention is by rests located as far forward from the fulcrum line.
 Retention by I bar retainer or swing lock.

Class VI
 Support from rests located on the distal surface of anterior abutments
 Greater stability from providing additional rests
 Guide planes on the proximal surfaces adjacent to the defect
 Retention from cast retainers
Complications with obturator prosthesis
Leakage into nasal cavity – prosthesis has to be disclosed with a tissue conditioning material.
Hyper nasal speech – Add a pharyngeal bulb to the posterior medial aspect of the prosthesis,
obturating the nasopharynx.

Management of soft palate defects

Abnormalities are grouped based on anatomy and physiology of involved structures,
1. Palatopharyngeal insufficiency – when some or all of anatomic structure of soft palate is
absent.
2. Palatopharyngeal incompetence – soft palate is of normal dimension but lacks movement
because of disease/trauma affecting muscular/neurologic capacity.
3. Palatopharyngeal inadequacy – includes incompetence and/or insufficiency but may also
suggest a reduction or absence of pharyngeal wall function.
A pharyngeal obturator prosthesis / speech aid / speech bulb prosthesis, extends beyond the
residual soft palate to create separation between the oropharynx and nasopharynx.

Technical considerations:
 After the oral portion of the obturator is completed, a retentive loop is extended
posteriorly.
 High fusing modelling compound is inserted and the patient is instructed to flex the
neck fully to achieve contact of chin to chest.
 Lateral aspects of obturator are formed by rotation and flexion of the neck to achieve
chin contact with left and right shoulders.
 Patient is asked to swallow water during border molding.
 After border molding is completed, the patient should be able to swallow
comfortably, breathe without difficulties and able to pronounce the letters p, b, n, m
and ng.
 Inferior portion of the obturator is maintained parallel to the horizontal hard palate.
 Meatus obturator

 Indicated when entire soft palate has been lost in an edentulous patient.
 It is designed to close the posterior nasal choanae through a vertical extension from
the distal aspect of maxillary prosthesis.

Palatal lift prosthesis

 It is a special type of obturator, which is a definitive prosthesis with a posterior extension.
 It is helpful in restoring palate-pharyngeal incompetence where the soft palate
musculature is compromised, as seen in cases of myasthenia gravis, bulbar poliomyelitis,
cerebral palsy.
 It can be clubbed with an obturator
Advantages
 Minimized gag response
 Tongue physiology, swallowing, mastication and speech are not compromised
 Access to nasopharynx for the obturator
Contraindications
 If adequate retention is not available for basic prosthesis
 If the palate is not displaceable
 Uncooperative patients
*include management of soft palate defects along if asked as a separate short essay*
Additional design schemes for obturators
1. Swing lock design by Parr and Garnder
2. Hollow bulb obturator by Nidiffer and Shipmon
3. Open and close obturator
4. One-piece hollow obturator – Chalian and Barnett
5. Closed hollow obturator – McAndrew and Glen Minsky
6. Inflatable obturator – Payne and Welton
7. Light cured obturator design by Polyzois
8. Hollow obturator with light activated resin by Wang and Hirsch
9. Fluid resin obturator by Browning
10. Foam obturator by Henry Gold
11. Obturators retained with zygomatic implants by Kreissl et al

Recent advances in fabricating obturator

With development in computer technology, now it is possible to fabricate the maxillary
prosthesis for the patient with greater accuracy. Such methods use modern manufacturing
methods and medical imaging technology. The stereolithography and rapid prototyping can make
customized maxillary prosthesis that can be used as implant and placed in position by a surgical
procedure. In this method, 3D CT data of the patient will be collected in the system. All these
data will be transferred to manufacturing facility. The rapid prototyping manufacturing method
now can prepare model of the patient’s skull and desired prosthesis. Further processing can
provide definitive prosthesis, which will have greater accuracy and better rehabilitation of the
defect.

Summary
The management of the patient with maxillectomy requires a multidisciplinary approach. The
contemporary materials and techniques for obturator prosthesis can provide solution for various
clinical conditions. Depending on the case, the operator should select the best suitable material
and technique for successful rehabilitation and thereby improving quality of life of the patient.