Brief discussion for Obturators used in Maxillofacial Rehabilitation

Brief discussion for Obturators used in Maxillofacial Rehabilitation

1. OBTURATORS (PROSTHODONTIC REHABILITATION FOR MAXILLOFACIAL DEFECT) Presented by: Ko Ko Aung (House Surgeon – GP IX)

2. CONTENTS Introduction Definition History & Background Materials used for Obturators Maxillofacial defects Functions Types of Obturators General principle of design Other considerations Conclusion Reference

3. Introduction The most common of intra oral defects are in the form of cleft or opening in the palate. These defects may be acquired or congenital. Acquired is due to injuries or surgical excision of tumor Congenital is due to malformation. This condition require restoration with fixed or removable prosthesis to replace missing teeth, to stabilize and align the arch segment, restore the occlusal function and to provide facial support and help in speech All this is usually aided with the help of an obturator.

4. Definition An obturator is a dis or plate, natural/artificial which closes an opening or defect of the maxilla as a result of a cleft palate or partial or total removal of maxilla for a tumour mass. (Chalian, 1971) Only 60% of patients with maxillary defect received further maxillofacial prosthodontic treatment (Shwe Hlaing, 2015). OBTURATORS (latin: obturare, to seal/ to shut off)

5. History & Background Early 20th century, prosthetic restorations first made from dentists and plastic surgeons Even so, until 1953, prosthetic reconstruction of head and neck neglected by medical and dental profession 1953 - American Academy of Maxillofacial Prosthetics founded Due to the continuous advancement, today, almost all patient with oral or facial defects are referred to dentists for construction of maxillofacial prosthesis

6. History & Background Ambroise Paré , French surgeon (1517-1590); the first person who described the use of prostheses to close a defect. In 1728, Pierre Fauchard designed obturators with foldable, wing-shaped propellers that spread out using a special key. Wiliam Morton (1869): known to treat defect with a gold plate and missing teeth are soldered Claude Martin (1875) single obturator in the maxillary defects Ambroise Paré (1517 – 1590) Pierre Fauchard (1679 – 1761 )

7. Primitive generation - ivory, stone, wood, gold, bronze, gum, cotton, to obturate the defect After First World War - gelatin glycerin compound (Hennig) Today - Acrylic Resin, Acrylic-co-polymers, Polyvinyl Chloride & Co- polymer, Polyurethane Elastomers, Silicone Elastomers Recent Advances - Silicone block Co polymers, Polyphosphoazenes, Foaming Silicones, Siphenylenes Future, bionic eye, nose, ear, which consists of microchips, transducers, polymer, semiconductors, electronic array and radio transmitter Materials used for Obturators

8. Cleft palate Cleft lip Acquired Congenitial Maxillary Defects Total Maxillectomy Partial Maxillectomy Congenital defects: Develop during intrauterine life (embryonic life) between 6th & 9th weeks of embryo Acquired defects: It is the destruction to some degree of an originally normal maxillofacial structure Types of Maxillary Defects

9. Classification of Maxillofacial Prosthesis

10. Multi-disciplinary approach oral surgeon maxillofacial prosthodontist radiotherapist oncologist speech therapist psychiatrist vocational rehabilitation counselor Close cooperation between maxillofacial prosthodontist and other team members especially oral surgeon is important The liaison between the maxillofacial surgeon and the prosthodontist produces a very useful supporting area for a retentive and stable prosthesis

11. Basic Objectives of Obturators It should be comfortable. Should restore adequate speech, deglutition, and mastication Should be acceptable cosmetically. To achieve all these objectives, the obturator should have adequate support, retention and stability.

12. Functions of Obturators 1. It can be used to keep the wound or defective area clean, and it can enhance the healing of traumatic or post surgical defects. 2. It can help to reshape or reconstruct the defect. 3. It also improves or in some instances makes speech possible. 4. In important area of esthetics the obturator can be used to correct lip an cheek position. 5. It can benefit the morale of patients with maxillary defects. 6. When deglutition and mastication are impaired, it can be used to improve functions. 7. It reduces the flow of exudates into the mouth, 8. The obturator can be used as a stent to hold dressing or packs post surgically.

13. Classification of Obturators According to Aramany M.A: he has proposed that partially edentulous maxillectomy dental arches be classified into six groups Class I Resesction in this group is performed along the midline of the maxilla,teeth are maintained on one side of the arch. Class II Defect is unilateral, retaining the anterior teeth on thecontra lateral side Class III Palatal defect occurring on the central portion of the hard palate and may involve part of the soft palate. Dentition is preserved.

14. Classification of Obturators Class IV Defect crosses the midline and involves both sides of the maxilla. Few teeth remain which lie in the straight line. Class V surgical defect in this case is bilateral and lies posterior to the remaining abutment teeth. Class VI it is rare to have maxillary defect anterior to the remaining abutment teeth. This occurs mostly in trauma or congenital defects rather than in planned surgical intervention.

15. TYPES OF OBTURATORS 1) Based on phase of treatment :- Surgical obturators (immediate surgical obturators & delayed surgical obturators) Interim obturators Definitive obturators 2) Based on the material used :- Metal obturators Resin obturators Silicone obturators 3) Based on area of restoration :- Palatal obturator Meatal obturators

16. Obturators on basis of phase of treatment:- A temporary prothesis used to restore the continuity of the hard palate immediately after surgery or traumatic loss of a portion or all of the hard palate and/or contiguous alveolar structures. ( i.e.,gingival tissue, teeth) GPT9 i. (1). Immediate surgical obturator :- It is inserted at the time of surgery. (2). Delayed surgical obturator :- It is inserted 7-10 days after surgery. It is of two types :- SURGICAL OBTURATORS

17. INTERIM OBTURATOR A prothesis that is made several weeks or months following surgical resection of a portion of one or both maxillae. It frequently includes replacement of teeth in defect area. This prosthesis when used, replaces the surgical obturator that is placed immediately following the resection & may be subsequently replaced with a definitive obturator.-GPT

18. DEFINITIVE OBTURATOR A prosthesis that artificially replaces part or all of the maxilla & the associated teeth lost due to surgery or trauma.-GPT

19. Obturators on basis of material used:- i. Silicone Obturator Resin Obturator Metal Obturator

20. Obturator on basis of area of restoration:- PALATAL OBTURATOR Closes or occludes opening caused by cleft or fistula Used to facilitate separation of oral & nasal cavities for speech, feeding, & swallowing & hypernasality

21. MEATAL OBTURATOR It is special type of obturator that extends up to nasal meatus. It establishes closure with nasal structures at a level posterior & superior to posterior border of hard palate. The closure is established against the conchae & roof of nasal cavity. It separates oral & nasal cavities. Indicated in patients with extensive soft palate defects.

22. PALATAL LIFT PROSTHESIS It is a special type of obturator, which is a definitive prosthesis with a posterior extension. It is helpful in restoring palato-pharyngeal incompetence where soft tissue musculature is compromised. e.g. myasthenia gravis, bulbar poliomylitis & cerebral palsy. It is clubbed with obturator if needed.

23. DESIGN OF PROSTHESIS • Must apply the basic principles of support, retention and stability so as to minimize the stress generated to the structures of the mouth. • The location of the fulcrum line, retentive undercuts and potential for indirect retention will be important factors in determining the prognosis. • In general, the prosthesis will have a fulcrum line near the defect area. • If natural teeth or implants are present to provide retention and support for the prosthesis, the fulcrum line will pass between the most posterior occlusal rests on each side of the arch. • Retentive clasps placed into undercuts adjacent to the defect will resist the downward displacement of the prosthesis due to the effects of gravity. • Occlusal rests on the opposite side of the fulcrum line from the defect will act as indirectretainers. Long guide planes on the natural teeth will also assist in prevention of rotationaldislodgment of the prosthesis.

24. Other Considerations Location and size of the defect Importance of the abutment tooth adjacent to the defect Usefulness of the lateral scar band, which flexes to allow insertion of the prosthesis but tends to resist its displacement Use of the surveyor for the purpose of locating and preserving useful undercuts or eliminating undesirable undercuts.

25. CONCLUSIONS 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 patien

26. REFERENCES Review article maxillofacial prosthetics part-1: a review. Dr. Aakarshan Dayal Gupta, Dr. Aviral Verma, Dr. Tanay Dubey and Dr. Saloni Thakur Harsh Mahajan, Kshitij Gupta (2012;) Maxillofacial Prosthetic Materials: A Literature Review Journal of Orofacial Research, p#87-90 Hatem Algarni etal (2022). Classification of maxillectomy in edentulous arch defects. algorithm, concept, and proposal classifications: A review Dr. Shirish Pawar and Dr. Pratiksha Somwanshi Classification of maxillofacial defects: a review article

27. REFERENCES Maxillofacial Prosthetics by Chalian. Oral and maxillofacial rehabilitation by Buemer. Mohamed A. Aramany - Basic principles of obtuarator design for partially edentulous patients. Part II: Design principles. JPD 40:656, 1978.

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