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E-JCRT Correspondence

Rehabilitation of large maxillary defect

with twopiece maxillary obturators
ABSTRACT Kanchan
The insertion and removal of an obturator in large maxillary defects with or without trismus is difficult. Fabrication of a twopiece P. Dholam,
obturator in such cases overcomes this problem. This article describes rehabilitation of large maxillary defects with two piece maxillary
KarthikM.
Sadashiva,
obturator of three types. All these obturators have a maxillary plate and a bulb component, which are approximated together by
PravinP.
various techniques namely, silicone cover, embedded magnets, and press studs. Prosthetic rehabilitation of large maxillary defects
Bhirangi
with twopiece obturators offers the possibility of adequate oral rehabilitation by fabricating light weight prosthesis, which is easy
to use. The bulb covers the undercut areas of the defect enhancing the facial contour and retention. It facilitates easy examination Department of Dental
of underlying tissues, recreation of the anatomic barrier between the oral and nasal cavities and restoration of the function and and Prosthetic Surgery,
esthetics. Thus, it adds to the quality of life. Tata Memorial
Hospital, Mumbai,
Maharashtra, India
KEY WORDS: Maxillary defects, maxillectomy, obturator, rehabilitation, retention, two piece prosthesis For correspondence:
Dr.Karthik M.
Sadashiva,
INTRODUCTION MATERIALS AND METHODS Department of Dental
and Prosthetic Surgery,
Tata Memorial
Prosthetic obturation is a privileged treatment Twopiece obturator with a silicon bulb Hospital, Mumbai,
modality along with microvascular free tissue This twopiece obturator comprises of maxillary Maharashtra, India.
transfer techniques following maxillectomy. The plate with a bulb and silicone cap [Figure 1a and b]. Email:karthikms21@
optimal reconstruction of maxillectomy defects An impression of the maxillary defect is made gmail.com
depend on patient characteristics such as age, in irreversible hydrocolloid and a master cast is
medical history, tumor stage, and defect size, and obtained.
on the surgeons technical expertise.[13] As we
assess the advantages of prosthetic rehabilitation The silicone cap is first fabricated. On the master
over surgical reconstruction, the fact remains that cast the hollow portion of the defect is waxed.
dental rehabilitation is not accomplished in surgical Approximately 5mm thick extending on to
reconstruction in most cases.[4] Fabrication of an the palate(2mm) on the medial side of the
obturator prosthesis offers the possibility of dental defect[Figure1c]. This 2mm border functions
rehabilitation and is cost effective. It also facilitates as a vertical stop and facilitates insertion and
examination of the surgical site for early detection removal of the silicone cap. Processing of the
of recurrence.[5] silicone cap is done(i.e.flasking, dewaxing and
packing) with heat temperature vulcanizing
A onepiece maxillary obturator is used for acquired silicone(molloplastB, Regneri GmbH and Co. KG,
defects. Insertion and removal of the obturator is a WGermany)[Figure1d and e]. Keeping this silicon
significant problem in patients with limited mouth cap in the intraoral defect[Figure1f], a pickup
opening. Clinical management of this problem can impression is made with irreversible hydrocolloid
be achieved by surgery, the use of dynamic opening using maxillary stock tray[Figure1g]. Heat cure
devices and modification of obturators.[6] A twopiece acrylic obturator with teeth is then fabricated Access this article online

maxillary obturator is indicated in patients with on this master cast with silicon bulb[Figure1h]. Website: www.cancerjournal.net

trismus and in large maxillary defects. It has a bulb Fabrication of the obturator with a hollow bulb is DOI: 10.4103/0973-1482.140801

component and a maxillary plate which can be with done with routine prosthodontic procedures. Full PMID: ***

or without artificial teeth. This article describes arch wire bending[as shown in Figure1i] is the Quick Response Code:

rehabilitation of a large maxillary defect with two source of retention.

piece maxillary obturators, which are assembled by
different mechanisms of adherence.(a) Obturator The silicone cover separates the oral cavity from
with a silicon bulb,(b) obturator with embedded sinonasal cavities to reestablish function through
magnets,(c) obturator with press studs. adequate closure of the defect. It helps primarily in
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Dholam, etal.: Two piece maxillary obturators

a b c

d e f

g h i
Figure 1: Two piece obturator with a silicone bulb (a) Maxillary obturator and silicone bulb cap assembled together, (b) Intraoral view of the
obturator in the oral cavity, (c) Waxing of the defect: 5 mm thick modelling wax lines the defect with 2 mm border extending the palatal surface
of the medial wall, (d) Processing of the silicone bulb, (e) Silicone bulb cap obtained after the processing, (f) Silicone bulb cap lining the intraoral
maxillary defect, (g) Pick-up impression of the silicone cap, (h) Master cast obtained with the silicone cap, (i) Maxillary obturator and silicone bulb cap

achieving retention by covering the undercuts on the defect
side. It also supports the facial tissues and provides more
comfort and stability.
Two piece obturator with embedded magnets
A magnet retained two piece maxillary obturator facilitates
easy insertion and approximation of the prosthesis due to
the magnetic forces.[7,8] This obturator too has a silicon bulb
and a maxillary plate.[Figure2]. After obtaining the master
cast of the maxillary defect, the silicone bulb is fabricated in
MolloplastB(Regneri GmbH and Co. KG, WGermany) with a
lining of heat polymerizing acrylic resin of 3mm thickness, on
the palatal surface of the bulb. 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.
only the terminal surfaces of the magnet plates extend to the
outer surface of the acrylic lid. By doing so, the magnets were
completely isolated from the oral environment with the bulb
and plate of the obturator in place.
Two piece obturator with press studs
A twopiece maxillary obturator is fabricated having a silicon
bulb attached with the help of acrylic pressstuds on the
maxillary plate[Figure3]. The silicone bulb covering the defect
is processed on the master cast with selfcuring silicone(Soft
Oryl, Teledyne Getz, USA). Three depressions are made on the
palatal surface of the bulb. The maxillary plate is fabricated
with corresponding elevations to approximate the depressions
on the bulb. The twopiece prosthesis with a large flexible and
resilient silicone bulb can be inserted comfortably by the patient
followed by the acrylic plate being oriented in place using the
acrylic pressstuds. This makes it an economical option.[9]

A closed field, permanent, rare earth neodymiumironboron, DISCUSSION

commercially available magnet(Ambika Corporation,
NewDelhi, India) having 4.5mm length and 1.3mm 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.
The magnetic assembly is attached to the heatcured acrylic
plates of the obturator with autopolymerizing resin so that
In large maxillary defects, the obturator bulb extends vertically
to engage the surgical defect and horizontally to the lateral
aspect of the orbital floor. This increases the size and weight
of the prosthesis. This causes soreness and discomfort for the
patient as the remaining structures are subjected to continuous
stresses. Flexible or resilient material liners such as silicones
permit engagement of bony undercuts providing more comfort
and stability without compromising retention.[10]
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Dholam, etal.: Two piece maxillary obturators
Figure 2: Two piece obturator with embedded magnets
Silicone material is nontoxic, noncarcinogenic, resilient,
hygienic, easy to handle and well tolerated by intraoral tissues.
However, it has limitations, such as the increased weight
of the prosthesis when used in a bulk form as it cannot be
hollowed out. It is expensive with additional costs incurred
due to the laboratory procedures for twostage processing.[11]
The disadvantage of room temperature vulcanizing silicone
material such as relative deformation during mastication and
susceptibility to monilial infection can be easily eliminated or
reduced by using heat temperature vulcanizing silicone, which
chemically bonds to the heat cured acrylic plate.[12]
In case of the two piece obturator with silicone bulb, the
large defect results in a heavier prosthesis, to the extent that
the force of gravity prevails over the capacity of retention of
the substructures and residual elements. In order to reduce the
weight of the prosthesis, the bulb portion of the obturator was
hollowed after it was processed with acrylic resin. The silicon
is used in a thickness of 5mm around the acrylic bulb as it is
adapted well to the tissues in the defect area in comparison
to acrylic. The patient benefits from the reduced weight of
the obturator, which also offered a harmonic resonance box
which enhances the patients phonation. Ahollow maxillary
obturator fabricated in acrylic resin may reduce the weight of
the prosthesis by up to 33%, depending upon the size of the
maxillary defect.[11] Hence in the other two cases where the bulk
of the silicon bulb was more for the ease of use of the patient in
cases like poor manual dexterity and trismus, additional modes
of retention between the silicon and acrylic portions were
required such as magnets and acrylic pressstuds respectively.[12]
Although magnets were not popular in the past, a closed field
magnetic system is generally preferred by a prosthodontist.[13]
Complete encasement of the magnetic assembly inside the
bulb of the obturator eliminates the cytotoxic effects of
corrosion products released from magnets to minimize the
effect on local tissues. It also provides greater retention while
reducing the magnetic field effect compared to open field
magnetic systems.
Figure 3: Two piece obturator with press studs
CONCLUSION
In patients with maxillary defects, surgical procedures cannot
provide satisfactory cosmetic and functional rehabilitation.
These are compromised people who require physical as well
as psychological rehabilitation through a multidisciplinary
approach. The twopiece obturator prosthesis provides good
comfort to the patients in terms of placement and removal
of the obturator in large maxillary defect. The obturator bulb
covered the undercuts on the defect side and separated the
oral cavity from sinonasal cavities to reestablish functionality
through adequate closure of the defect to prevent the passage
of air, liquid and food. It also supported the facial tissues and
provided more comfort and stability without compromising
retention. To achieve complete patient satisfaction, informing
and instructing patients about obturator use, routine
psychological care, and institution of speech therapy should be
done. This article describes different techniques of fabrication
of twopiece maxillary obturator prostheses.
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Cite this article as: Dholam KP, Sadashiva KM, Bhirangi PP.
Rehabilitation of large maxillary defect with two-piece maxillary obturators.
J Can Res Ther 2015;11:664.
Source of Support: Nil, Conflict of Interest: None declared.