 The word “Obturator” is derived from

the Latin word ‘obturare’ which means

to close or shut off.

 Most common of all intra oral defects

are in the maxilla, in the form of an
opening into the antrum & the
nasopharaynx.
 Definition
 According to the glossary of prosthodontic
terms, obturator is a prosthesis used to
close a congenital or acquired opening

 An obturator is a disc or plate, natural or

artificial which closes an opening or defect
of the maxilla as a result of cleft palate or
partial or total removal of the maxilla for a
tumour mass (Chalian et al 1971)
 Review of literature
 Ambroise Pare (1541)
described the first
obturator.
 It consisted of a simple
disk attached to a
sponge. The sponge was
inserted into the defect
and, by absorbing
moisture from
secretions; it would swell
and draw the disc tightly
over the defect.
 Review of literature
 Pierre Fouchard,
described more advanced
prostheses in his 18th
Century writings.
 These prostheses were
supported by wings that
could be positioned by the
patient from the oral side
and made use of the floor
of the nose for retention.
 He also used ligatures
affixed to natural teeth for
retention of the obturator
 Review of literature

 Bourdet (1757) suggested that silk

ligatures attached to natural teeth could
be used to support a less bulky sheet of
metal to obturate the defect in a less
destructive manner.
 Review of literature
 Delabarre (1820) pointed
out the inadequacy of
weak silk ligatures for
retention
 He introduced a new
concept of wire connecting
the obturator with
laterally placed metal
bands that were clamped
on the teeth
 He is also credited with the
design and fabrication of
the first artificial velum.
 Review of literature

 Snell (1823) first utilized a cast for the

construction of a gold plate obturator, to
which rubber flaps were attached with a
gold hinge.

 He is also credited with the earliest

fabrication of speech aid prosthesis
 Review of literature
 Ballif (1826) used
two spiral springs
which were
supported on the
mandible to fasten
his obturator.

 This was quite

similar to
Fouchard’s design
 Review of literature
 Schange (1842) recommended
that Delabarre’s obturator
should be provided with his
own solid retainers that he used
for orthodontic purpose.
 He also constructed artificial
soft palate, metal plates
movable on a hinge which were
pressed against the remaining
portion of the soft palate by a
spring, so that the plates
followed their movements
 Review of literature
 Charles Stearns (1855) also constructed an
artificial velum
 Gustav Passavants (1863) reported that a
shelf like soft tissue projection extended
anteriorly from the posterior pharyngeal wall
during phonation called Passavants ridge.
This bulging forward of the superior
constrictor musculature tended to reduce the
defect as a compensatory mechanism. It also
served as a Posterior - inferior landmark for
the determination of obturator extension in
the oronasopharynx
 Review of literature
 Suersen (1867)
proposed the fixed
obturator concept.
 He suggested that a
valve seal could be
obtained by filling the
defect by a prosthesis
around which the
residual soft tissues
could operate to obtain
closure.
 Review of literature

 Claude Martin (1875) described the use of

surgical obturator prosthesis
 Review of literature

 Schiltsky (1881) tried

reducing the weight of
the obturator by
forming a hollow
lump from vulcanized
soft rubber and
fastened it to a
movable strut.
 Review of literature
 Ludwig Warnekros
(1896) developed a
rigid obturator. He
used the Suersen’s
lump but formed it
significantly narrower
and therewith gave it
the form it still
maintains today
 Review of literature
 Schalit & Froschels (1928) developed the
MEAT-obturator. It was composed of a
palatal plate with a lump vertically and
stiffly attached to it. He achieved its speech
improving action by closing the
nasopharyngeal opening.

 Strain (1953) described a device to attach

the distal extension velar portion to the
denture of a cleft palate patient
 Review of literature

 Andrew Ackerman (1955) published in an

article, the use of various prosthesis, which
included maxillary hollow obturators.

 Steadman (1956) described the use of an

acrylic resin prosthesis lined with gutta
percha to hold a skin graft within a
maxillectomy defect
 Review of literature

 Nidiffer & Shipman (1957) were earliest to

describe the closed hollow obturator. They
described a technique using a removable
plaster core

 Brown (1968) discussed the peripheral

considerations in improving obturator
retention
 Review of literature
 Rahn et al (1970) in his text book on
maxillofacial prosthetics narrated in detail
the principles and concepts for the
prosthodontic rehabilitation of both
acquired and congenital maxillary defects

 Chalian (1971) in his text book on

maxillofacial prosthetics described the
principles, treatment planning and routine
treatment for the prosthetic rehabilitation of
maxillary acquired defects and cleft palate
defects
 Review of literature
 Malson (1972) reported 2 cases of
compensating obturator which allowed
movements of the tissues of the soft palate
and their growth and development

 Sharry (1974) in his text book on complete

dentures described in detail, the fabrication
of obturators for edentulous patients He
described the method for achieving
peripheral seal during impression
procedures
 Review of literature

 Eley et al (1974) described the use of a

precision attachment for prosthetic
treatment of cleft palate

 Desjardins (1975) described in detail the

complete prosthodontic management of
the cleft palate patient in various phases.
These phases are the early phase, the
adjunctive phase and the adult phase
 Review of literature
 Matalon et al (1976) used sugar to
fabricate the hollow bulb

 Aramany (1978) described in detail the

prosthetic reconstruction following
resection of the hard and soft palate. He
also gave the basic principles in designing
obturators for partially edentulous
patients. He put forward a new system of
classification of acquired maxillary defects
and the design principles for the removable
cast framework
 Review of literature
 Parel et al (1978) described a technique for
the fabrication of single visit hollow
obturators for edentulous patients using
sugar to fabricate the hollow bulb

 Oral et al (1979) described the construction

of a buccal flange obturator. He also
evaluated that the speech intelligibility with
this obturator proved superior to the hollow
obturator in simplicity, speed of fabrication,
reduced weight, retention and hygiene
 Review of literature
 Laney Williams (1979) in a text book about
maxillofacial prosthetics narrated typical
problems encountered during prosthetic
rehabilitation in maxillary defect patients
and approaches to treatment in such
conditions

 Mac Entee (1979) described obturators on

overdentures
 Review of literature
 Schneider (1979) used ice to fabricate the
hollow bulb

 Taylor et al (1983) discussed and described

in detail about the fabrication, advantages
and disadvantages of meatus obturator

 Worley et al (1983) discussed a method for

controlling the thickness of hollow bulb
obturators
 Review of literature
 Coffey (1984) advised obturation of
maxillary defects with inflatable balloons.

 Moore et al (1985) compared rigid and

flexible obturation for surgical cleft of the
soft palate and concluded that for speech
and fit, the rigid obturator is the best,
flexible obturator comes next, and semi
flexible as the worst
 Review of literature

 Khan (1989) described soft palate

obturator prosthesis made with visible light
cured resin

 Schmaman et al (1992) described the foam

impression technique for maxillary defects
 Functions of obturator
(Lang & Bruce, 1967; Chalian et al, 1971)

1. It can be used for feeding purpose.

2. It can be used to keep the wound or defective

area clean, thus enhance the healing of
traumatic or post surgical defects.

3. It could be used as a stent to hold dressings or

packs post surgically. It reduces the possibility
of post operative haemorrhage.

4. It can help to reshape and reconstruct the

palatal contour and/or soft palate.
 Functions of obturator
(Lang & Bruce, 1967; Chalian et al, 1971)

5. It improves speech or in some instances, makes

speech possible.

6. It helps in reducing the flow of exudate, saliva and

fluids from the mouth into the nasopharaynx.

7. In the important area of esthetics, the obturator can

be used to correct lip & cheek contour

8. It benefits the morale of the patient with maxillary

defects

9. When deglutition & mastication are impaired, it can

be used to improve function
 Objectives of maxillary obturators

1. Restoration of esthetics & cosmetic

appearance of the patient
2. Restoration of function

3. Protection of tissues

4. Therapeutic or healing effect

5. Psychologic therapy
 Indications of use of an Obturator
(Nidiffer & Shipmon, 1957)

1. To act as a framework over which tissues

may be shaped by the surgeon

2. To serve as a temporary prosthesis during

the period of surgical correction

3. When surgical primary closure is

contraindicated

4. When the patient’s age contraindicates

surgery
 Indications of use of an Obturator
(Nidiffer & Shipmon, 1957)

5. When the size & extent of the deformity

contraindicates surgery

6. When the local avascular condition of the

tissues contraindicates surgery

7. When the patient is susceptible to the

recurrence of the original lesion which
produced the deformity
Ideal qualities for maxillary obturators
1. It should help the patient to carry out
natural functions, like phonation, deglutition
and mastication.

2. It should exhibit life like appearance to aid

function.

3. The design of the prosthesis should be such

that it is easily and swiftly placed and held in
position both comfortably and securely.
Ideal qualities for maxillary obturators

4. The prosthesis should be durable for a

reasonable period of time, retain its finish
and polish

5. It should be easy to clean so as to maintain

hygiene
Classification of obturators
According to the origin of the discrepancy

1. For congenital defect

a) To close and opening of the hard palate a
simple base plate type helps to correct the
swallowing, feeding and speech.
b) An obturator with a tail, consisting of a
speech appliance or a speech aid prosthesis
which restores soft and hard palate defects
and a velopharyngeal extensions which
corrects the speech.
c) An overlay denture or a super imposed
denture.
According to the origin of the discrepancy

2. For acquired defect

a) The immediate temporary obturator or
surgical obturator

b) The temporary obturator or treatment

obturator or transitional obturator

c) The permanent obturator or definitive

obturator
According to the location of the defect

1. Lateral or buccal obturators

2. Alveolar obturators

3. Hard palate obturators

4. Soft palate obturators

5. Pharyngeal obturators
According to the type of obturator attachment
to the basic maxillary prosthesis

1. Fixed

2. Hinged

3. Meatus

4. Detachable
According to the physiologic movement of
the oral, nasal and pharyngeal tissues
adjacent the obturator

1. Static obturator

2. Functional obturator
Mohamed Aramany (1978) classification

1. Class I

2. Class II

3. Class III

4. Class IV

5. Class V

6. Class VI

7. Class VII
 Preoperative Considerations for
maxillectomy patients
According to Desjardins (1977), preoperatively
the prosthodontist is concerned with four
objectives

1. Psychological support of the patient

2. Preoperative dental management

3. Preoperative impressions

4. Suggestions for the surgeon

 Preoperative Dental Management
Prior to tumor surgery, every attempt should be
made to treat existing dental disease
1. The risk of emergency dental problems
during the post surgery healing period will be
reduced, allowing a more complication-free
recovery

2. Early treatment of dental disease will increase

the likelihood that the remaining teeth will
serve as adequate abutments for the
prostheses.
 Presurgical impressions

 Presurgical impressions of both arches should

be made as the resultant casts serve as a record
of the presurgical state and may be referred to
when designing and fabricating the obturator
prosthesis subsequent to surgery.

 It is recommended that two casts be made

before surgery. One is kept as a permanent
presurgical record while the other may be used
to fabricate the surgical obturator and the
postsurgical obturator.
 Presurgical impressions

 Presurgical impressions of the maxillary

arch should capture the full vestibular
depth. The overextended soft tissue
reflections of the vestibular area of the
impressions will allow maximum extension
of the surgical obturator into the defect area
and will offer the greatest possible support
for the surgical dressing.
 Suggestions for the surgeon
I. Removal of any exposed inferior turbinate,
regardless of oncologic necessity

1. Maintaining the inferior turbinate will preclude

extending the medial wall of the obturator bulb
into the nasal cavity. Height of this medial wall
a) Counters rotation of the prosthesis during
function.

b) Allows liquids that reflux into the cavity at

the medial periphery of the bulb to be
redirected back into the oropharynx instead
of running forward and out the nares.
 Suggestions for the surgeon

2. Facilitates superior prosthetic extension and

retention

3. Prohibits the potential for subsequent inferior

turbinate edema and descent into the oral
cavity

4. Functional movement of the obturator

prosthesis against the turbinate is likely to
cause bleeding.
 Suggestions for the surgeon

II. Resect the entire velum if more

than two-thirds of the anterior soft
palatal tissue has been resected

III. Resect the entire velum if the

resection of lateral lesions extends
to the uvula.
 Suggestions for the surgeon

IV. Transalveolar
resections in dentate
patients should be
as distant as
possible from the
nearest tooth to be
retained
 Suggestions for the surgeon
V. The premaxillary anatomy should be
preserved to provide greater prosthetic
support and stability.
1. Tripoding effect can be achieved (i.e. a
class II design),
2. The increased surface area also enhances
retention.
3. Less collapse of facial form and less
postoperative contracture.
4. Attachments of muscles of facial
expression are also preserved
 Suggestions for the surgeon
VI. Replace exposed respiratory mucosa with a
split thickness skin graft
1. Keratinized tissue provides a better prosthetic
bearing area than respiratory mucosa.
2. Promotes the development of a cicatricial band
at the juncture between the skin graft and
the mucosa.
3. The superior aspect of this band can
subsequently be engaged to improve
obturator retention.
 Suggestions for the surgeon
VII. Reflect margin of palatal mucosa superiorly

Reflect a maintained
margin of palatal
mucosa superiorly
across the exposed
palatal bony surface to
prevent respiratory
mucosal granulation at
the juncture of oral
cavity and nasal or
perinasal surfaces
 Suggestions for the surgeon

VIII. Grafting the sinus walls

The sinus walls are covered with

respiratory mucosa, which must be denuded
and covered with a split-thickness skin graft.
Grafting the sinus walls stops formation of
polypoid tissue and mucus generation within
the sinus and allows the walls become load-
bearing areas.
 Prosthetic
Rehabilitation of
Acquired Hard Palate
Defects
Prosthetic Rehabilitation of Acquired
Hard Palate Defects
1. Immediate surgical obturator (maxillary
surgical prosthesis, immediate temporary
obturator)

2. Transitional (Transitional Obturator,

Postsurgical Obturator, Interim
Obturator)

3. Definitive obturator
 Immediate surgical obturator

The maxillary obturator used primarily in

conjunction with a surgical procedure to resect
the maxillae and adjacent structures totally or in
parts is called an immediate temporary obturator.

The prosthesis is a base plate type of construction

without a definite extension into the defect.

Fabricated on casts obtained from pre-operative

impressions and is inserted at the time of
operation.
 Immediate surgical obturator

After initial healing and removal of the pack i.e. 7

to 10 days (Beumer et al, 1979) the immediate
obturator is usually discarded and replaced by
a transitional prosthesis having a definite
bulbous extension and occasionally anterior
artificial teeth.

Objective of these two obturators is to restore &

maintain oral functions at reasonable levels
during the postoperative period until healing is
substantially completed.
 Advantages of Immediate surgical
obturator
1. The surgical obturator, provides an anatomically
accurate, stable, clean scaffold upon which to
support the surgical dressing that, in turn
supports the facial flap and keeps pressure on
the skin graft placed over the denuded internal
surface of the facial flap

2. It provides a barrier between the surgical

dressing and the oral cavity

3. Reduces oral contamination of the wound during

the immediate post surgical period and may thus
reduce the incidence of oral infection.
 Advantages of Immediate surgical
obturator
4. Allow patients to perform deglutition thus the
nasogastric tube can be removed at an early date

5. Enable the patients to speak normally by

reproducing normal palatal contours & by
covering the defect.

6. Minimize the initial feelings of loss that occur

when patients realize the extent of their surgical
defects.

7. The prosthesis may reduce the period of

hospitalization. (Nakamoto, 1971)
Principles of design of a surgical obturator
(Beumer et al, 1979)

1. It should terminate short of skin graft- mucosal

junction

2. Normal palatal & alveolar contours should be

reproduced to facilitate postoperative speech &
deglutition.

3. Posterior occlusion should not be established on

the defect side until the surgical wound is well
organized.
Principles of design of a surgical obturator
(Beumer et al, 1979)

4. It should be simple, lightweight & inexpensive

5. The obturator for dentate patients should be

perforated at interproximal extensions to allow
for it to be wired to remaining teeth

6. In some patients, existing complete denture or

RPD may be adapted for use as a surgical
obturator
 Materials used for immediate surgical
obturator
1. Sponges (James & Raines, 1955)

2. Gutta-percha (Steadman, 1957; Hammond,

1966)

3. Inflatable bulbs, (King,1978)

4. Acrylic Resin – most preferred material

 Fabrication of Surgical Obturator in
Edentulous Patients

 An alginate impression is made & cast poured.

 If any tumor bulk is present on the alveolus or

hard palate, this area of the cast is reduced to
normal contour.

 The prosthesis should have border extensions

identical to a complete denture.
 Fabrication of Surgical Obturator in
Edentulous Patients

 It is fabricated with heat cure or

autopolymerising resin.

 Heat Cured plate is not necessary because the

prosthesis will be used for less than 10 days.

 Most commonly fabricated in clear resin to

facilitate visualization of the underlying tissues at
the time of placement and during the initial
healing period.
 Retention of Surgical Obturator

 A palatal bone screw

 Circumzygomatic wires

 Sutures into the surrounding

mucosa
 Palatal bone screw
1. The palatal bone screw is placed through a
midpalate hole predrilled through the acrylic
resin baseplate in the midpalate at the anterior
peak of the palatal vault.

2. This position will allow placement of the screw

into the Vomer.

3. The hole should be drilled from the palate to the

intaglio surface and angled posteriorly.

4. A 13 to 1 6 mm self-tapping screw should be used

to ensure enough length to pass through the
denture and achieve adequate bone retention.
 Palatal bone screw
5. One midpalatal screw is adequate, but if the
vomer is resected, two screws placed at
conflicting angles through the denture in the
lateral hard palate (at the junction of the
alveolus and the palatal vault) will secure the
prosthesis.

5. A small plug of tissue conditioner or

polyvinylsiloxane over the head of the screw will
keep the screw attached to the denture in the
event the patient dislodges the denture during
the postoperative period

6. The palatal bone screw offers the most stability

of the three options
 Circumzygomatic wire retention

1. Wires are passed over the zygomatic arch and

threaded through two bilateral holes placed
in the premolar area of the baseplate flange.

2. This technique is the most invasive and has

greatest morbidity when removing the wires
in the clinical setting.

3. It is not commonly used

 Suture retention
1. In a previously irradiated patient, one might
elect to use the suture technique to avoid placing
a bone screw in the irradiated palate.

2. Sutures placed at the periphery of the prosthesis

may be secured into the soft tissues at the height
of the vestibule against the bone of the remaining
maxillary alveolus.

3. The surgical side will be secured along the

internal surface of the cheek.

4. Individual 2-0 silk sutures can be passed through

six to eight predrilled holes in the lateral and
anterior border of the acrylic resin baseplate.
 Suture retention
5. Each suture is secured with a knot against the
denture flange and tagged with a hemostat. The
baseplate is then taken to the oral cavity and
each suture passed through the soft tissue and
tied.

6. It is not necessary to suture across the soft palate

for adequate retention as soft palate sutures are
difficult to remove when the patient is in the
clinic.

7. There will be slight prosthesis movement with

this technique, but the packing will be secured
and the prosthesis will not dislodge.
 Use of the existing maxillary denture
as surgical obturator
It is advisable not to use the existing complete
denture as a surgical obturator
 Once an attempt has been made to use the
existing denture, the patient will expect it to be
used throughout the entire prosthetic period.
 Maintaining a comfortable occlusion while
constantly reducing and relining the flanges of
unstable obturator prosthesis is almost
impossible.
 Despite the denture reline, achieving appropriate
occlusion when securing the obturator with a
bone screw, wires, or sutures is very unlikely.
Patients will need to discontinue use of the
mandibular denture during the surgical obturator
phase due to these occlusal discrepancies.
 Use of the existing maxillary denture
as surgical obturator
 As facial contracture occurs, the anterolateral
border of the denture will require significant
reduction. the contracture is so great that the
anterior teeth will extended beyond the obturator
prosthesis periphery.
 The teeth on the surgical side often require facial
reduction and ultimately removal from the
baseplate due to overextension. If the teeth are not
reduced, the lip is too protruded and unseats the
prosthesis. If the teeth are repositioned, they will
likely be in a negative horizontal overlap with the
lower teeth.
Surgical obturator in dentulous patients
Two basic approaches:

1. One can fabricate the obturator according to the

most conservative line of resection, which will
still allow the obturator to be used for larger
resections with the understanding that surgical
dressing may be needed to fill the space between
the obturator and the final line of resection.

This method allows the surgeon to utilize the

obturator regardless of the size of the defect and
does not require the surgeon (or the
prosthodontist) to perform intraoperative
adjustments to the obturator
Surgical obturator in dentulous patients
2. The other option is to design and fabricate the
surgical obturator for the most extreme surgical
resection thereby making it fit best in the worst
case situation.

With this approach the surgeon must be willing

and able to modify the obturator to
accommodate teeth that are not resected but
have been removed from the cast during
obturator fabrication. The prosthodontist has to
be available at the time of surgery to perform
the modifications
Surgical obturator in dentulous patients

Fabrication :

The teeth in the area of

resection are removed and
the surrounding alveolar
process in the planned
defect area is reduced
approximately 2 mm.

Substantial inter dental and

soft tissue undercuts are
blocked out and the cast is
duplicated
Surgical obturator in dentulous patients
The surgical obturator is then waxed
and processed on the duplicate
cast.

Surgical obturator can be made

directly on the cast with
autopolymerising resin also.

Clasp retention is usually inadequate

and hence provisions should be
made for screw or wiring type of
retention as decided by the
surgeon
 Transitional Obturator
 The interim obturator is placed when the surgical
dressing that was supported by the surgical
obturator is removed from the superior recesses
of the maxillectomy defect.

 The temporary obturator has a false palate, false

ridge, teeth and a closed bulb which is hollow

 The interim obturator serves the patient for four

to six months while the maxillectomy defect heals
and matures.

 Natural teeth selected for abutment are clasped

with stainless steel or wrought metal wire
retainers to enhance retention and stability.
Fabrication of Transitional Obturator

1. Modifications of existing immediate

surgical obturator

2. Arbitrary scraping of Presurgical casts

3. Taking a new impression at the time of

removal of immediate surgical
obturator, pack & sutures
 Modifications of existing immediate
surgical obturator
 The baseplate used for the
surgical obturator can be
border moulded, relined and
modified to serve as the interim
prosthesis.

 Optimal border seal and

extension is needed in the
remaining hard palate. After
this is accomplished and the
base is stable, the periphery of
the surgical defect is impressed

 Tissue conditioner material is added incrementally along

the borders of the defect & border moulded. The clinician
should continue this procedure around the entire periphery
until tile defect is sealed
 Modifications of existing immediate
surgical obturator
 The impression of the surgical side requires that
the patient perform exaggerated head movements
turning right to left with the head level and then
again with the neck flexed and extended. The
mouth should be opened and closed, and the
mandible moved laterally. The patient should also
be asked to swallow

 After the tissue conditioner impression, the entire

tray and impression can be used as a wax pattern.
It can be flasked, completely removed from the
stone mold, and the mold packed in
autopolymerising or heat processed resin. The
prosthesis may be hollowed further to decrease
weight.
 Modifications of existing immediate
surgical obturator
 Patients should be
advised that
adjustments are needed
if pain or bleeding
occurs or if prosthesis
does not fit.

 During follow up if the

tissue conditioner
becomes hard, then it is
scraped with a bur and
a new layer is applied.
 Modifications of existing immediate
surgical obturator

 The temporary obturator is usually worn 3 to 6

months, depending on the disease prognosis,
progress of the patient and the patient's ability to
manipulate the prosthesis

 A definitive prosthesis is not indicated until the

surgical is healed and dimensionally stable and
the patient is prepared physically and
emotionally for the restorative care that may be
necessary
 Modifications of existing immediate
surgical obturator
 Adjustment are frequently necessary to
accommodate the healing tissues and to retain
an effective seal. These modifications are
usually accomplished through one of
two means.

a. Addition of soft prosthodontic liner to

existing prostheses.

b. Addition of PMMA to existing prostheses.

 Modifications of existing immediate
surgical obturator
 Addition of soft prosthodontic liner to existing
prostheses

(1) Advantages:
(a) Consumes the least amount of time
(b) Minimizes cost in that there is no dental laboratory
expense

(2) Disadvantages:
(a) Porosity of the soft liner accumulates microbes
(b) The soft liner can tear
(c) The soft liner cannot be as highly polished as
PMMA
(d) The bulk of a soft liner increases the prosthetic
weight
 Modifications of existing immediate
surgical obturator
 Addition of PMMA to existing prostheses
(1) Advantages:
(a) It is dense and can be highly polished
(b) It can readily be cleansed
(c) The obturator bulb can be hollowed and the
PMMA can be appreciably thinned to decrease
prosthetic weight

(2) Disadvantages:
(a) Requires dental laboratory expertise and generates
expense
(b) Necessitates two clinical appointments
(c) Necessitates a period of time during which the
patient is without the prosthesis
 Modifications of existing immediate
surgical obturator
 According to Beumer(1979) modifications should
be avoided & a new prosthesis should be
constructed because
– Periodic addition of interim lining material increases
the bulk and weight of the prosthesis This temporary
material may become rough & unhygienic

– If teeth are included in the resection, then the addition

of anterior denture teeth to the obturator can be of
great psychological benefit to the patient

– If retention & stability are inadequate then occlusal

contacts on the defect side may result in their
improvement.
Arbitrary scraping of Presurgical casts
 Presurgical casts can be taken and arbitrarily scraped
depending upon the amount of resection that has been
done.

 Then an acrylic plate is made over this cast

 Now since the peripheries of the resected area are

arbitrarily formed, they are coated with incremental
layers of tissue conditioner so as to extend to exact depths

 As mentioned above, the impression is flasked and

converted to acrylic resin

 The procedure is most effective when the anticipated

defect is relatively small or when the surgical margin is
easily predicted
 Taking a new impression
 An impression is made of the remaining palate,
alveolar ridge, teeth and border structures of the
defect in irreversible hydrocolloid material.

 On the cast produced from the impression an

acrylic resin base is fabricated with an extension
to obturate the surgical defect. It is necessary to
engage only enough of the defect to seal its
borders at rest and during function.

 Overextension merely adds to the weight, bulk

and difficulty of manipulation.
 Definitive obturator
 When surgical interventions are finished and
healing has progressed for four to six months
following the cessation of all therapy, the interim
obturator can be replaced with a definitive
obturator.

 The timing will vary depending on (Zarb, 1967;

Chalian et al., 1971; Beumer III et al., 1979).
– The size of the defect,
– The progress of healing
– The prognosis for tumor control,
– The effectiveness of the present obturator, and
– The presence or absence of teeth.
 Definitive obturator

 The defect must be engaged more aggressively for

edentulous patients to maximize support,
retention & stability. Therefore the recovery
period is extended for these patients.

 Changes associated with healing and remodeling

will continue to occur in the border areas of the
defect for at least 1 year. Dimensional changes are
primarily related to the peripheral soft tissues
rather than to bony support areas
Definitive obturator Treatment concepts:
(Beumer 1979)

1. Movement of the obturator prostheses

2. Tissue changes

3. Covering prosthesis

4. Teeth

5. Weight

6. Extension into the defect

 Definitive obturator Treatment
concepts: (Beumer 1979)
1. Movement of the obturator prostheses
The obturator may be displaced superiorly with
the stress of mastication and will tend to drop
without occlusal contact

2. Tissue changes
Dimensional changes will continue to occur for
at least a year secondary to scar contracture and
secondary organization of the wound. So the
obturator portion of the prosthesis should be
made in acrylic resin in order that it may be
rebased to compensate for these changes
 Definitive obturator Treatment
concepts: (Beumer 1979)
3. Covering prosthesis
Obturators of the hard palate are just covering
prosthesis serving primarily to re-establish the
oral-nasal partition.

4. Teeth
Presence of teeth or even root stumps enhances
the prosthetic prognosis by assisting in the
retention, stability & support of the prosthesis

5. Weight
The prosthesis should be as light as possible so
that the teeth and supporting tissues are not
stressed unnecessarily. Hence it is made hollow.
 Definitive obturator Treatment
concepts: (Beumer 1979)
6. Extension into the defect
It depends upon the requirement of retention, stability
and support. If these can be achieved from the remaining
maxillary structures then the extension into the defect
need not be extensive

It also depends upon the configuration of the defect and

the character of the lining mucosa. Extension of the
prosthesis superiorly along the nasal septum offers little
mechanical advantage and also the ciliated pseudo
stratified columnar epithelium lining it cannot tolerate
any stresses. In contrast, extension superiorly into the
lateral margin of the defect will enhance retention,
stability & support. Stresses are also well tolerated by
the skin graft and the oral mucosa lining the cheek
surface of the defect
Prosthodontic principles in obturator
design

1. Retention

2. Stability

3. Support
 Retention ( Beumer et al, 1979)

Retention is the resistance to vertical displacement

of the prosthesis

It is derived from
1. Residual maxillary retention
• Teeth
• Alveolar ridge
2. Within the defect retention
• Residual soft palate
• Residual hard palate
• Anterior nasal aperture
• Lateral scar band
• Height of lateral wall
 Teeth
 Number, position, and periodontal status of the remaining
teeth are the most critical factors
 When the remaining teeth are located unilaterally, the
intracoronal retainer might provide some benefit
minimizing the amount, of vertical movement of the
prostheses within the defect.
 If the defect is small and the remaining teeth stable
intracoronal retainers might be considered.
 If the defect is large and some or all of the remaining teeth
are weak, extracoronal retainers should be used
 If the remaining teeth are not parallel with the walls of the
defect, and if the palatal surfaces of the teeth are not
adequate, guiding planes may be provided to resist
vertical displacement of the obturator and disengagement
of the retentive clasp arms
 Alveolar ridge
 Factors contributing to acceptable retention of a
conventional complete denture, i.e. utilization of physical
properties of adhesion, cohesion, atmospheric pressure
and interfacial surface tension.

 Ridge size and shape influence retention to a certain

extent. A large ridge with a broad ridge crest is more
retentive than is a small or tapering ridge crest.

 The palatal contour influences the ability to increase or

decrease the interfacial surface tension. A broad flat palate
is more retentive than the high tapering palate.

 A square arch form is more retentive than the tapering or

ovoid arch form.
 Residual soft palate

 It provides a posterior palatal seal, which

minimizes the passage of foods and
liquids above the obturator prosthesis &
provides retention.
 Residual hard palate

 Depending upon the location of the line of

palatal resection there will be varied degrees of
undercuts along this line into the nasal or
paranasal cavity.

 The prosthesis should thus be extended to

provide resistance to vertical and horizontal
displacement. However the extension should
not contact the septum or the turbinates.
 Anterior nasal aperture

 It may be extended unilaterally or

bilaterally, depending upon the extent of
the defect to or beyond the midline & upon
the presence or absence of the nasal septum
 Lateral scar band

 A scar band results after surgical resection at

about the level of the mucobuccal fold. As the scar
band organizes, it contracts in the manner of a
purse string thus creating an undercut superiorly
and a concavity inferiorly.

 The scar band is flexible and permits the

prosthesis to be inserted but will tend to resist
dislodging forces. (Brown, 1968)
 Height of lateral wall

 It provides indirect retention.

 A high lateral wall of an obturator will

undergo less vertical displacement with a
given defect wall than will a shorter
prosthesis lateral wall
 Stability
(Desjardins, 1978; Beumer et a!., 1979)

 Stability is the resistance to prosthesis

displacement by functional forces.

 Movement of the prosthesis within the

horizontal plane can be anteroposterior,
mediolateral, rotational, or a combination
of any or all of these directions.
 Stability
(Desjardins, 1978; Beumer et a!., 1979)

1. Residual maxilla stability

2. Stability within the defect

3. Occlusion

4. Obturator size and extension

 Residual maxilla stability

 If sound natural teeth remain, the bracing

components of the prosthesis framework can
be used to minimize movement in all three
directions.

 In edentulous patients, maximal extension of

the prosthesis is imperative in minimizing
movement within the horizontal plane.
 Stability within the defect
 Maximal extension of the prosthesis in all
lateral directions must be provided.

 Special emphasis must he placed on maximal

contact with the medial line of resection, the
anterior and lateral walls of the defect, the
pterygoid plates, and the residual soft palate.

 Contact of the obturator portion of the

prosthesis with these structures minimizes
anteroposterior, mediolateral and rotational
movement of the prostheses
 Occlusion
 The most important aspect of stability is
occlusion.

 Maximal distribution of occlusal force in

centric and eccentric jaw positions is
imperative to minimize the movement of the
prostheses and forces on individual
structures.

 Stress created by lateral forces (Aramany,

1978) is minimized by the
– correct selection of an occlusal scheme,
– elimination of premature occlusal contacts,
and
– wide distribution of stabilizing
components.
 Occlusion
 Acrylic resin teeth with a reduced occlusal contact area
may be indicated.

 Altering the cusp angle of posterior teeth may influence the

stability of the prosthesis

 It may be necessary to accept an occlusion that is not

bilaterally balanced in eccentric occluding positions for an
edentulous maxilla or mandible.

 In edentulous patients, non-anatomic posterior teeth are

preferred. The teeth are set in centric relation and adjusted
to eliminate lateral deflective occlusal contact

(Academy of Denture Prosthetics, 1989)

 Obturator size and extension

 The obturator must contact the medial line of resection

and may engage the residual bony palate from the
anterior mucobuccal fold to the soft palate.

 An extension may be provided into the anterior nasal

aperture.

 The height of the medial surface may be limited by the

turbinates, which should not be in contact with the
prosthesis. The medial surface of the obturator should not
be high enough to obstruct nasal breathing.

 Contact with the nasal septum may be necessary for

support in defects which pass the midline.
 Obturator size and extension

 The medial surface should not be as high as the

lateral surface, and the anterior aspect should be
higher than the posterior aspect in order to
encourage mucous drainage in a medial and
posterior direction into the nasopharynx.

 The anterior and lateral surfaces should extend

superiorly as much as possible to enhance
retention by minimizing vertical displacement.
The anterior and lateral surfaces of the
prosthesis provide the support for the facial
muscles
 Support
(Beumer III et al, 1979; Jacob & Yen, 1991)

Support is the resistance to movement

of a prosthesis towards the tissue.
 Support
(Beumer III et al, 1979; Jacob & Yen, 1991)

1. Residual maxilla
– Teeth
– Alveolar ridge
– Residual hard palate

2. Within the defect

3. Tissue changes
 Teeth

Only sound teeth should be selected to

provide support
 Alveolar ridge
 The height and contour of the residual alveolar
ridge and the depth of the sulci are important for
support

 The large, broad ridge or the ridge with a square

or ovoid tendency usually provides better support
than the small narrow ridge with a tapering
contour.

 In patients with a retained pre-maxillary segment

or a tuberosity, support for the prosthesis is
increased considerably
 Residual hard palate

 The residual hard palate is an important

structure for support of an obturator
prosthesis.

 The broad, flat palate is more conducive

to support than the tapering palate.
 Within the defect
 This support can be achieved by contact of the
prosthesis with any anatomic structure that
provides a firm base.

 In the acquired maxillary defects, following are

considered for positive support.
– the floor the orbit,
– the bony structures of the pterygoid plate
– the anterior surface of the temporal bone
– the nasal septum - if the defect extends beyond
the midline
 Tissue changes
 Dimensional changes will continue to occur for
at least a year secondary to scar contracture
and further organization of the wound. The
prosthesis may be rebased to compensate for
these changes.

 Also the occlusion and base adaptation must be

re-evaluated frequently and corrected by
selective grinding of the occlusion or refitting
the base of the prosthesis.

(Academy of Denture Prosthetics, 1989)

General considerations of bulb design
(Chalian et al, 1971; Beumer III et al, 1979)

 A bulb is not necessary with a central palatal

defect of small to average size where healthy
ridges exist.
 It is not necessary in the surgical or immediate
temporary obturator.
 It should be hollow to aid speech resonance, &
to reduce the weight on the unsupported side.
 It should provide facial aesthetics and act as a
foundation for a combination of extraoral
prostheses in communication with the intraoral
extension.
General considerations of bulb design
(Chalian et al, 1971; Beumer III et al, 1979)
 It should not cause the eye to move during
mastication
 It should be one piece, if possible, to provide
better colour matching and maximal patient
acceptance.
 It should not be so large as to interfere with
insertion if the mouth opening is restricted
 It should have a complete seal to prevent air
or fluid entry
 It should always be closed superiorly
 Open type obturator
Advantages
 1. Less weight
 2. Is easier to adjust

Disadvantages
 Nasal secretions accumulate leading to odour and
added weight.

 Difficulty in polishing and cleaning the internal

surface, from saliva, mucous crusts, food accumulation
(unhygienic, foul smelling)

 The inability to obtain support from the superior

aspect in the defect area.

Indication
 in patients where the secretions are less (post
radiation),
 Closed type obturator
Advantages
1. No accumulation of nasal secretions in the bulb
2. Derives support from the superior aspect of the defect

Disadvantages
1. Heavier in weight
2. difficult to adjust
3. Some seepage of saliva always occurs through the
acrylic over a period of time leading to its
accumulation inside the hollow bulb, thus increasing
weight
4. Opening of the bulb to remove fluids is associated with
characteristic unpleasant odour.

Indication
1. In Patients where secretions are normal,
 Advantages of a hollow bulb obturator
(Nidiffer & Shipmon, 1957; Brown, 1970; Parel & Drane,
1975; Beumer III et al, 1979; Shimodaira et al, 1998)

1. The weight of the obturator is reduced, making it more

comfortable and efficient.
2. The lightness of the obturator improves one of the
fundamental problems of retention and increases
physiological function so that teeth and supporting tissues
are not stressed unnecessarily.
3. The decrease, in pressure to the surrounding tissues aids
in deglutition and encourages the regeneration of tissue.
4. The light weight of the hollow bulb obturator reduces the
self-consciousness of wearing a denture.
5. The lightness of the obturator does not cause excessive
atrophy and physiological changes in muscle balance
Technique for fabrication of hollow bulb

1. Acrylic Resin bulb

a. Two piece hollow obturator
b. One piece hollow obturator

2. Silicone bulb

3. Combination
 Two piece hollow obturator
 The master cast with the waxed up and polished
trial obturator is dipped in slurry of gypsum for
five minutes.
 Modeling clay is put into the open defect area.
Plaster, sugar, salt, pumice, etc can also be used
instead of clay.
 The false palate and ridge are shaped and
contoured, leaving an approximately 2 mm
thickness for the wax pattern on the reshaped
palate and ridge.
 Create a recess or step around the palatal
opening of the obturator part to a depth of 1.5
mm to 2 mm. The modeling clay is covered with
tinfoil as a separating medium
 Two piece hollow obturator
 wax pattern for the lid is carved and finished.
 The wax lid is separated, and the tinfoil and
modeling clay from the defect part are discarded.
 Then the wax pattern of the obturator is
processed in heat cure acrylic resin
 The margin of the lid is undercut or perforated
for retention and then sealed over the main base
in its proper position with self cure resin.
 The prosthesis is then finished & polished.
 The same procedure can also be accomplished
with self cure resin.
 Techniques of fabricating one piece
hollow obturator
 Plaster (Nidiffer, Shipman, 1957; Buckner, 1974)
 Asbestos (Worley 1983)
 Clay (Elliot, 1983; Palmer, 1985)
 Self cure resin (Chalian,1972; Guelde,1980)
 Polyurethane foam (Tanaka, 1977)
 Plastic toys (Beder, 1978)
 Sugar (Matalon, 1976; Parel, 1978)
 Ice (Schneider, 1978)
 Pumice (Minsley, 1976)
 Light cure acrylic resin (Benington, 1989)
Technique 1 : Using acrylic resin shim
- (Chalian, 1972)

The defect area is entirely filled with wax,

contoured and finished. The trial obturator on the
master cast is flasked and the wax boiled out
Technique 1 : Using acrylic resin shim
- (Chalian, 1972)

undercut areas in the defect are blocked out

 Technique 1 : Using acrylic resin shim
- (Chalian, 1972)

The entire defect area is relieved with one thickness

of base plate wax with three stops in the lower half
of the flask.
One thickness of base plate wax is also placed in top
half of the flask over the teeth and palate area
Technique 1 : Using acrylic resin shim
- (Chalian, 1972)

Autopolymerising acrylic resin is mixed. A layer of

resin 2 mm thick is then contoured in the defect
side over the wax relief.
Another layer of resin is contoured over the wax in
the top half of the flask.
Technique 1 : Using acrylic resin shim
- (Chalian, 1972)

The flask is then closed and allowed to set for a

minimum of 15 minutes.
Technique 1 : Using acrylic resin shim
- (Chalian, 1972)

After curing, the flask is opened and the wax is flushed off
the shim with a stream of boiling water.
The excess of acrylic is then removed from the shim and
placed back into the defect using the three stops for correct
positioning for final processing with heat cure resin
Technique 1 : Using acrylic resin shim
- (Chalian, 1972)

The heat cure acrylic resin is mixed and packed in

the flask with the shim in place.
It is Cured, deflasked, & polished
Thus in the final processed obturator with the
exception of the three stops, all other areas of the
bulb will be covered with heat cured resin
Technique 2 - Using Asbestos (Worley 1983)

waxing, flasking and wax elimination done

Technique 2 - Using Asbestos (Worley 1983)

Major undercuts and areas where extra acrylic

resin may be needed are blocked out with wax.
 Technique 2 - Using Asbestos (Worley 1983)

The entire defect area is relieved with one thickness

of base plate wax with three stops in the lower half
of the flask.
One thickness of base plate wax is also placed in top
half of the flask over the teeth and palate area
Technique 2 - Using Asbestos (Worley 1983)

Damp asbestos strips are layered together to form

a shape similar to the size of the waxed defect
area. The asbestos mass is wrapped in a sheet of
wet cellophane and placed into the waxed defect
area.
Technique 2 - Using Asbestos (Worley 1983)

The flask is closed gently and pressed. The asbestos will

conform to the shape of the waxed defect.
Several layers of asbestos may need to be added or removed
to achieve filling of the defect. The final form of the asbestos
is preserved and the wax eliminated.
Technique 2 - Using Asbestos (Worley 1983)

Heat cure resin is mixed and packed with the

asbestos lined with cellophane sheet. Trial
closure is done.
Technique 2 - Using Asbestos (Worley 1983)

 Before final closure of the flask, cellophane is

removed from the asbestos form and replaced
with elastophane.

 two sheets of elastophane are placed between

the flasks to keep the two acrylic resin sections
from curing together. The flask is final closed
and the resin cured

 It is then deflasked & the asbestos packing

removed. The acrylic is then cleaned of
remaining elastophane sheets.
Technique 2 - Using Asbestos (Worley 1983)

Heat cure resin is again mixed and placed at the borders

of the 2 parts of the flasks for final closure.
Technique 2 - Using Asbestos (Worley 1983)
 It is then cured again, The second cure can be
accomplished in two ways,
– Cure in water using a short or long cure.
However, the flask can not be totally
submerged or the hollow extension will fill
with water. Place flask in the water so that
the water line is approximately 1/4 inch
below the half flask section.
– It can also be cured in a dry heat oven at 100
degree celsius for 3 hours.

 After the second cure is completed, the

obturator prosthesis is removed from the flask
& finished in the usual manner
 Technique 3- Dual flasking method
(Mahdy, 1969)

 Two identical flasks are required. Their upper and

lower halves should be interchangeable and they should
fit accurately.
 The trial prosthesis is invested in flask in the usual
manner
Technique 3- Dual flasking method
(Mahdy, 1969)

 Wax elimination
 Technique 3- Dual flasking method
(Mahdy, 1969)

Base plate wax added to both the halves of the

flask and it is trial closed with cellophane sheet
between them.
 Technique 3- Dual flasking method
(Mahdy, 1969)

The 2 halves are then again counterflasked using

coloured plaster.
Wax elimination is done.
packing of the dual flaks is done with cellophane
between the coloured plaster and the acrylic.
 Technique 3- Dual flasking method
(Mahdy, 1969)

After deflasking the 2 original flasks are again

packed with heat cure acrylic resin at the
contacting areas and processed to obtain the
final prosthesis.
 Technique 4 (Mcandrew, 1998)

 In this technique, flasking and dewaxing of the

obturator is done & undercuts are blocked in
the usual manner.
 Technique 4 (Mcandrew, 1998)

 A layer of modeling wax (3 mm thick) is

applied on the cast so that it will be replaced by
heat cured acrylic resin
 Technique 4 (Mcandrew, 1998)

 Only the base flask is then counter flasked and

dewaxed again. It is than packed with heat cure
acrylic resin and processed
 Technique 4 (Mcandrew, 1998)

 When deflasking is done, plaster will remain in the

obturator section.
 A lid is then fabricated with light cure or self cure
acrylic resin
 Plaster is then removed from the obturator portion of
the cast.
 The lid is then sealed to the denture base using light
cure or self cure acrylic resin
 Technique 4 (Mcandrew, 1998)

 This base portion containing the denture base is then

placed over the original counter containing the teeth.

 It is then packed with heat cure acrylic resin and

processed.
Technique 4 (Mcandrew, 1998)

The final closed hollow obturator

 Silicone bulb obturator

– The bulb due to its inherent flexibility shapes

in to position by passing over to the undercut
area

– Undercuts present in the defect can be used

by a closely adapting silicone bulb obturator
over an acrylic resin denture base. This will
serve the purpose of support and retention at
the same time being hollow and rigid over
the denture base.
 Advantages of Silicone bulb obturator
(Shimodaira et al, 1994)

 Better retention

 Less irritation than acrylic resin

 Lightness of weight

 Ease of insertion & removal of

prosthesis.
 Silicone bulb obturator

 A master cast is prepared from the rubber base

impression.
 Place two thickness of base plate wax over the
wall of the defect to form a uniform thickness,
and fill the remaining undercuts with wax.
 Invest the wax pattern boil it out.
 Apply release material and allow to dry.
 Silicone bulb obturator
 Place silastic (medical grade silicone) in the
mould, and close the flask. This material cures
without heat in 24 hours

 Remove cured silicone bulb from the cast, and

place it in a concentrated solution of baking
soda to shake of the acetic acid and to
neutralize it for another 12 hours.

 Make a trial check of the retention and comfort

of the silicone bulb after finishing.
 Silicone bulb obturator

 Cut a groove 2-3 mm away from the edge and 2 mm

deep in the inner side of the bulb.
 It should be just above the level of the height of the
remaining part of the hard palatal bone.
 The groove circumvents the bulb on the whole of inner
surface in this area.
 Silicone bulb obturator

 Partially fill the silicone bulb with plaster to

produce a predetermined height, and process
cold curing acrylic resin in to the grooves
 Silicone bulb obturator
 The insert when forced in
to the bulb will complete
the seal of the bulb.

 This is kept aside after finishing so that the patient can

wear the bulb and insert without wearing the dentures.
It will form a complete palate for the patient when he is
without his denture.

 Likewise another self cure resin insert is prepared.

 To construct a complete upper denture having inserts

for the silicone bulb, make an impression of the silicone
bulb with insert in position. Make a cast & fabricate
the complete denture in the usual manner. The denture
is processed and is later attached to the acrylic resin
insert.
 Silicone bulb obturator
 The advantages of the silicone bulb and acrylic
insert are that
– It allows the patient to wear the bulb and
insert without wearing his dentures

– Allows the patient to masticate with the

denture and insert in place with less
irritation to the surgical site, and

– It is much lighter in weight than an acrylic

resin denture obturator