obturators - cleft palate.ppt

xcvbnm

1. GOOD MORNING

2. Obturators – Prosthetic
Management Of Cleft Palate
Presented by :
R. Priya Darshini
2 nd MDS

3. CONTENTS
•Introduction
•Definition
•Historical review
•Types of deformities
•Classification of cleft palate
•Indications of obturators
•Functions of obturators
•Prosthetic management
•Conclusion
•References

4. INTRODUCTION
•Common intra oral defects
•Acquired
•Congenital
OBTURATOR

5. DEFINITION
•The name obturator is derived from the latin word
“obturare” which means close or to shut off.
•A prosthesis used to close a congenital or a acquired tissue
opening, primarily of hard palate and or contigious
alveolar structures. ( GPT -8)

6. Lynch, Pierre Fauchard and his role in development of obturators, BDJ, vol 199, 2005
Gregory, evolution of obturator framework, J Prosthet Dent, 2003, 89, 608-610
History
Ambroise Pare (1541) : ‘OBTURATUER’
•Prosthesis – ‘COUVERCLE’ (OR COVER LID)
•First person to close a defect..
•A dry sponge was attached to the upper surface of the disc.
When the sponge becomes moist by the secretion and it
expands and hold the prosthesis in place.
•Used turnbuckle type of mechanism to hold the prosthesis in
place

7. Pierre Fuchard (1728) :
•Father of scientific dentistry.
•Palatal obturators
•Wings in the shape of propellers which can be folded
together while being inserted and spread out after
insertion with a special key.
•The retaining feature is in the form of a butterfly wings
which are made to open by a key after the closed wings
have been inserted through the palatal perforation.
Lynch, Pierre Fauchard and his role in development of obturators, BDJ, vol 199, 2005
Gregory, evolution of obturator framework, J Prosthet Dent, 2003, 89, 608-610

8. •Snell (1828) : Credited with the earliest fabrication of a
speech-aid prosthesis for such patients.
•Suersen (1867 ) : Rigid fixed obturator using a wire –
loop posterior extension shaped by use of gutta percha.
•William Morton (1869) : Has been known to treat
palatal defect patients with a gold plate to which the
patients missing teeth are soldered.
•Kingsley (1880) : Described artificial appliances for the
restoration of congenital and acquired defects of the
palate, nose or orbits.
Desjardins; Prosthodontic management of the cleft-palate patient J Prosthet Dent. June, 1975,
655-666, vol 33

9. Types Of Maxillofacial Deformities
•CONGENITAL
–Cleft palate
–Cleft lip
–Facial cleft
–Missing ear
–prognathism
•ACQUIRED
–Accidents
–Surgery
–Pathology
•DEVELOPMENTAL
–Prognathism
–Retrognathism
Chalian; Maxillofacial Prosthetics, pg - 5-6

10. Classification Of Cleft Lip And Palate
According to Veau :
•Type 1 : Defect of red portion of the lip (vermilion )
•Type 2 : Clefts which include vermilion and a portion of the lip
musculature upto the nostril on affected side but not including the
floor of the nostril.
•Type 3 : Unilateral complete clefts involving the full thickness of
the lip typically accompanied by a marked deformity of the nose.
•Type 4 : Bilateral clefts of the lip either partial, complete or in
combination.
Chalian; Maxillofacial Prosthetics, pg – 358-359

11. CLASS I CLASS II CLASS III CLASS IV
NORMAL
VEAU’S CLASSIFICATION

12. Classification Of Cleft Lip And Palate
Chalian; Maxillofacial Prosthetics, pg – 358-359

13. Chalian; Maxillofacial Prosthetics, pg – 358-359

14. Kernahan’s striped ‘Y’ Smith’s
Liu, Cleft Palate-Craniofacial Journal, September 2007, Vol. 44 No. 5

15. Indications For Use Of Obturator
An obturator may be used
•To act as a framework over which tissues may be shaped by the
surgeon.
•To serve as a temporary prosthesis during the period of surgical
correction
•To restore a patient's cosmetic appearance rapidly for social contacts
•When surgical primary closure is contra-indicated

16. •When the size and extent of the deformity contraindicates
surgery
•When the local avascular condition of the tissues
contraindicates surgery
•When the patient is susceptible to recurrence of the original
lesion which produced the deformity

17. Functions of an obturator
•To keep the wound or defective area clean, and it can
enhance the healing of traumatic or post surgical defects.
•To reshape and reconstruct the palatal contour and soft
palate.
•Improves or in some instances makes speech possible.
•In important area of esthetics the obturator can be used to
correct lip an cheek position.
Chalian; Maxillofacial Prosthetics, pg - 133

18. Functions of obturator
• It can benefit the morale of patients with maxillary
defects.
•When deglutition and mastication are impaired, it can be
used to improve functions.
•It reduces the flow of exudates into the mouth.
•The obturator can be used as a stent to hold dressing or
packs post surgically.
Chalian; Maxillofacial Prosthetics, Pg - 133

19. Indications for prosthesis
Robert Millard (1971) director of speech and hearing services at the
Ip Lancaster cleft palate clinic
•Unoperated palates :
–Wide cleft and deficient soft palate
–Wide cleft of hard palate
–Neuromuscular deficiency of soft palate and pharynx
–Delayed surgery
–Expansion prosthesis to improve spatial relations
•Operated palates :
–An incompetent palatopharyngeal mechanism
–Surgical failures
Chalian; Maxillofacial Prosthetics, pg – 370-372
Desjardins; Prosthodontic management of the cleft-palate patient J Prosthet Dent. June, 1975,
655-666, vol 33

20. Contraindications For Prosthesis
Robert Millard (1971)
•Surgical repair feasible
•When surgical closure of cleft will produce anatomic and
functional repair.
•Mentally retarded patient
•Uncooperative patient
•Rampant caries – requires unusual care and frequent
examinations.
Chalian; Maxillofacial Prosthetics, pg – 374
Desjardins; Prosthodontic management of the cleft-palate patient J Prosthet Dent. June, 1975,
655-666, vol 33

21. Obturators For Congenital Defects Of Palate
3 types of obturators :
1)A simple base plate – to close the opening of hard palate &
helps to correct swallowing, feeding and speech.
2)Obturator with tail –
–consisting of a speech appliance or a speech aid prosthesis - to
restore soft and hard palate defects &
–A velopharyngeal extension – to correct speech.
3)An overlay or superimposed denture
Chalian; Maxillofacial Prosthetics, pg - 133

22. Maxillary Orthopaedics
Mc Neil and others provided general guidelines for maxillary
orthopedic appliances and presurgical treatment.
• Factors that influence the results obtained :
Configuration and extent of the cleft
Growth potential of the patient
Parental cooperation and
Appliance design.
Chalian; Maxillofacial Prosthetics, pg – 404

23. Type Of Appliance
Passive or holding type
Active or expansion type
•Generally if any degree of collapse is manifested an expansion
appliance is placed.
•If the collapse appears in the anterior region, a fan type of split
holding appliance is used.
•In case of arch collapse, surgical closure of the lip is delayed
until the expansion appliance has achieved an ideal arch
configuration.
Chalian; Maxillofacial Prosthetics, pg – 405

24. •Cases presenting initially with an ideal arch alignment or a
wide cleft configuration are operated as soon as the
holding appliance is placed.
•In either situation , the cleft lip is surgically closed
between 1 and 10 months.
•Primary purpose of the appliance prior to lip closure is not
to proliferate or initiate growth, but to guide the maxillary
segments into proper spatial position with each other and
with the mandibular arch
Chalian; Maxillofacial Prosthetics, pg – 406

25. Passive Palatal Appliance
•Used when anterior cleft width is narrow, and lip can be repaired without
significant tension on surgical site.
 
•Maintains posterior arch width while allowing lip to close cleft.
 
•First post-surgical week – appliance not removed.
•Worn continuously for the next few months – removed only for cleaning.
 
•After two months – anterior acrylic removed – to make room for the
moving premaxilla.
 
Daniel Ravel , pediatric dental health.

26. Passive Palatal Appliance – bilateral cleft
•Maintains the lateral width of the maxillary segments after lip
closure.
  
•Problem: need to modify the appliance as the child grows.
 
•Dramatic changes can be seen by four months, accomplished by
maintenance of the arch width by appliance.
 
•The premaxillary segment is re-oriented in response to pressure
from the newly-established band of the continuous lip.
 
•The anterior portions of the lateral maxillary segments will
eventually need to be freed of their acrylic cover – to allow for
further molding.
 
Daniel Ravel , pediatric dental health.

27. Jackscrew devices
•Consist of acrylic pieces that fit over the alveolar
segments.
•Acrylic pieces – manipulated by single or multiple
jackscrews to adjust the position of the alveolar segments.
•Allow the manipulation of the palatal segments to the
desired locations and the screws also keep the tongue out
of the cleft.
•Do not allow the rotation of the alveolar segments into
desired locations, as seen with the molding plates.
RIZWAAN, Journal Of Clinical And Diagnostic Research. 2010 December;(4):3632-3638

28. Requirements For Speech Appliance
•Oral and facial balance, masticatory function, & speech
•Preservation of remaining tissues
•Not displace the soft tissue
•Not interfere
•More retention and support – crowning and splinting
•Minimal weight
•Easy repair
•Velar and pharyngeal sections of the prosthesis should never
be displaced.
•Superior convex, inferior concave
Chalian; Maxillofacial Prosthetics, pg – 374

29. Prosthetic Speech Appliances For Children
•3 types of speech aids
–An obturator with palatal – velar – pharyngeal
portion
–Baseplate type to obturate palate and helps
speech
–Anterior prosthesis – contours upper lip and
improves anterior occlusion
Chalian; Maxillofacial Prosthetics, pg – 408

30. Obturator With Palatal – Velar – Pharyngeal Portion
•Used to promote increased muscular activity so that the
coordinated movement of the soft palate and posterior
pharyngeal wall will achieve velopharyngeal closure
during speech.
•Pharyngeal bulb is undersized to promote activity of the
muscles involved in velopharyngeal closure.
Chalian; Maxillofacial Prosthetics, pg – 408

31. Rationale For Pharyngeal Bulb
•Approach should not be mechanical
•Provide close adaptation
•Allow complete closure during speech and
swallowing and yet present an opening for
breathing at the margins at rest
•Tissues not displaced
•Muscle movement should not be interfered
Chalian; Maxillofacial Prosthetics, pg – 409

32. Base Plate Obturator
•Perforation exists in hard palate and
surgeon desires growth of the child before
surgical closure
•Soft palate - surgically repaired and
functionally well - a speech bulb is not
indicated.
Chalian; Maxillofacial Prosthetics, pg – 411

33. Anterior Prosthesis
•Mandibular prognathism – sudden growth of
mandible without comparable growth of
maxilla
•Anterior prosthesis – restore function to
mandibular dentition and creates a pleasing
profile.
•It will also rebuild the needed arch form and
supply tooth replacements for normal
articulation and mastication
Chalian; Maxillofacial Prosthetics, pg – 411

34. Prosthesis For Adults
•Prosthesis categorised into
1.Snap on type
2.Non snap – on type.
Chalian; Maxillofacial Prosthetics, pg – 414

35. Snap – On Prosthesis With No Speech Bulb
Chalian; Maxillofacial Prosthetics, pg – 414

36. Removable Partial Prosthesis With No Speech Bulb
Chalian; Maxillofacial Prosthetics, pg – 414

37. Complete Superimposed Denture With No Speech Bulb
Chalian; Maxillofacial Prosthetics, pg – 415

38. Snap – On Prosthesis With Speech Bulb
Chalian; Maxillofacial Prosthetics, pg – 416

39. Complete Super Imposed Denture With Bulb
Chalian; Maxillofacial Prosthetics, pg – 417

40. Unconventional Speech Aid Prosthesis
Chalian; Maxillofacial Prosthetics, pg – 419

41. Indications for overlay dentures :
•Patients who had premaxillary resection early in life resulting in maxillary
contraction leaving foreshortened occlusal relationship in consequence of
the lack of vertical, lateral and anteroposterior growth
•Patients with floating premaxillae in abnormal relationships so that
maxillae are contracted
•Patients with lip collapse and tightness in whom the super imposed
prosthesis supports and plumps the lip for more harmonious facial contour
•Postoperative cleft palate patients with few or minimal number of
abutment teeth exhibiting collapsed occlusal relationships due to inhibition
of maxillary growth as compared to mandibular development

42. Obturator for soft palate
•Velum – covering or veil
•Soft palate – complex neuromuscular
aponeurosis
Taylor; Clinical Maxillofacial Prosthetics

43. Depending On Degree And Type Of
Palatopharyngeal Closure :
•Palatopharyngeal Insufficiency:
–Some Or All Of The Anatomic Structure Is Absent
•Palatopharyngeal Incompetence:
–Soft Palate – Adequate Dimensions But Lacks
Movement
•Palatopharyngeal Inadequecy : Incompetence -
Insufficiency - Reduction Of Pharyngeal Wall
Function
Taylor; Clinical Maxillofacial Prosthetics

44. Adisman (1971) – 3 general types of prosthesis
1.The fixed or immobile prosthesis which remains stationary
permitting the palatal and pharyngeal musculature to
contract and function against its lateral and posterior
surfaces.
2.The hinge or movable prosthesis popular in the
nineteenth century which attempted to imitate the soft palate
but was too complicated and difficult to make and maintain
3.The meatus type extended into the nasal cavity instead of
the pharynx with an airway provided by perforation of the
nasal extension. This type is indicated for unrepaired hard
and soft palate clefts

45. Pharyngeal obturator
•Speech aid / speech bulb prosthesis
•Separation between oropharynx and
nasopharynx
•Fixed structure against which pharyngeal
muscles can function to effect
palatopharyngeal closure
Taylor; Clinical Maxillofacial Prosthetics

46. Taylor; Clinical Maxillofacial Prosthetics

47. Objective of pharyngeal
obturator
•To prevent food and fluid leakage into nose
and improve speech
Taylor; Clinical Maxillofacial Prosthetics

48. Meatus obturator
•Closes posterior nasal choanae through
vertical extension from the distal aspect of
the maxillary prosthesis
•Entire soft palate is lost in edentulous
patient
Taylor; Clinical Maxillofacial Prosthetics

49. Taylor; Clinical Maxillofacial Prosthetics

50. Hinged Pharyngeal Obturator
•Not indicated.
•Mechanics in fabrication
•Lack of advantage over fixed horizontal
obturator
Taylor; Clinical Maxillofacial Prosthetics

51. Palatal Lift Prosthesis
•Gibbons and Bloomer in 1958
•Positioning device
•Speech disorders – palatopharyngeal incompetence
•Neurodegenerative disorders, multiple sclerosis,
amyotrophic lateral sclerosis (ALS), tumors, traumatic
head injury
•Innervations – IX, X, XI, VII
•Stimulates soft palate into improved function – Beery
et al
Taylor; Clinical Maxillofacial Prosthetics

52. Palatopharyngeal function
•Levator veli palatini and superior constrictor
•Levators veli palatini contracts soft palate moves superior
and posterior – contact posterior pharyngeal wall.
•Level of anterior tubercle of atlas
•Posterior pharyngeal wall function – Passavants pad or
ridge
•Superior constrictor in lateral pharyngeal wall move
medially to contact and press into lateral portion of
elevated soft palate
Taylor; Clinical Maxillofacial Prosthetics

53. •Normal speech – full closure of
nasopharyngeal sphincter except m, n and
ng
•Normal swallowing
Taylor; Clinical Maxillofacial Prosthetics

54. Conclusion
•It is not mere survival from disease alone but a return to It is not mere survival from disease alone but a return to
normal functioning life is a goal normal functioning life is a goal
•When nature has provided insufficient tissue for
successful surgical closure, the prosthesis becomes the
method of choice.
• Many cleft patients with deficient maxillary development
find that the speech appliance combined with an anterior
denture enables them for the first time in their lives to
speak intelligently, to eat normally and to have an
esthetically acceptable appearance

55. References
•Lynch, Pierre Fauchard and his role in development of
obturators, BDJ, vol 199, 2005
•Gregory, evolution of obturator framework, J Prosthet
Dent, 2003, 89, 608-610
•Desjardins; Prosthodontic management of the cleft-palate
patient J Prosthet Dent. June, 1975, 655-666, vol 33
•RIZWAAN, Journal Of Clinical And Diagnostic
Research. 2010 December;(4):3632-3638
•Daniel Ravel , pediatric dental health.

56. •Chalian; Maxillofacial Prosthetics
•Taylor; Clinical Maxillofacial Prosthetics

57. Thank You