SECTION EDITORS

I. KENNETH ADISMAN
MAXILLOFACIAL PROSTHETICS LOUIS J. BOUCHER

TEMPOROMANDIBULAR JOINT DENTAL IMPLANTS

Obturator prosthesis design for acquired maxillary
defects
Ronald P. Desjardins, D.M.D., M.S.D.*
Mayo Clinic and Mayo Foundation, Rochester, Minn.

Maxillary defects are created by surgical treat- prosthesis design that challenge the prosthodontist's
ment of benign or malignant neoplasms and by ability to attain the basic prosthodontic objectives.
trauma. Except for patients with small oro-antral The achievement of these objectives will b e
and oronasal defects, which may be amenable to influenced greatly by the size and location of the
surgical closure, patients with these defects are acquired defect and the quantity and integrity of the
rehabilitated by prosthodontic means. remaining structures. The preoperative prostho-
t
Prosthodontic management of palatal defects has dontic evaluation of patients who are to undergo
been employed for many years (Fig. 1)? Ambroise maxillary resection is very important (Fig. 2). Close
Parr probably was the first to use artificial means to cooperation between the surgeon and the prostho-
close a palatal defect-as early as the 1500's. The dontist can result in a defect that is more amenable
early obturators were used to close congenital rather to obturation. For example, patients in whom a
than acquired defects. The early objectives of treat- portion of the maxilla can be left intact on the defect
ment were artificial closure of the defect and side wiU be rehabilitated more successfully than
adequate retention of the artificial closure. The patients who have the classic hemimaxillectomy.
ingenious designs of tlle early pioneers accomplished Sometimes the premaxilla can be left in patients who
these objectives. As time progressed newer and better have posterior maxillary lesions (Fig. 3, A), and the
concepts of obturation evolved." ~" tuberosity often can remain in patients who have
All prosthodontists are aware of the basic objec- anterior maxillary lesions (Fig. 3, B). These
tives of prosthodontic therapy. A comfortable, remaining structures will enable the prosthodontist
cosmetically acceptable prosthesis that restores the to accomplish his objectives in the edentulous and
impaired physiologic activities of speech, deglutition, the dentulous patient. In addition the integrity of the
and mastication is a basic objective of prosthodontic remaining teeth and the alveolar bone should not be
care. The most important objective of prosthodontic compromised. For example, there must be adequate
care, emphasized by DeVan, 3 is preservation of the alveolar bone on the surgical side of the remaining
remaining teeth and tissue. teeth if they are to be retained (Fig. 3, B).
These basic objectives also must be applied in the Prosthesis design relative to all phases of prostho-
patient requiring maxillofacial rehabilitation. Ideal- dontics has been discussed by many authors? 2a The
ly tile patient with the acquired maxillary defect need for support, retention, and stability in
should be provided with an obturator prosthesis that designing any prosthesis should be understood if the
is comfortable, restores adequate speech, deglutition, objectives of prosthodontic care are to be attained.
and mastication, and is acceptable cosmetically. If For the patient with an acquired maxillary defect it
there is any patient in whom compromised is often necessary to modify, and sometimes violate,
remaining structures must be preserved, it is the some of the basic principles of prosthesis design
maxillofacial patient. because of the basic nature of the defect. The
A maxillary defect creates increased problems in remaining structures are most often unilateral, thus
encouraging movement of the prosthesis with asso-
ciated stress directed to these remaining structures.
Presented at the meeting of the Academy of Denture Prosthetics,
This stress can increase bone resorption and may
San Antonio, Texas.
*Assistant Professor of Dentistry, Mayo Medical School, Roches- jeopardize the remaining support for an obturator
ter, Minn. prosthesis. The frequent location of unilateral

424 APRIL 1978 VOLUME39 NUMBER 4 0022.3913/78/0439-0424S01.20/0 9 1978 The C. V. Mosby Go.
OBTURATOR PROSTHESIS DESIGN

Key~ Fauchard~wingedobturotor

Fig. 1. An early prosthesis used to obturate a congenital

defect. The !key was used to open the wings, which
engaged the 'palatal shelves for retention. (Redrawn from
Aramany, M. A.: A history of prosthetic management of f -

cleft palate: Pard to Suersen. Cleft Palate J 8:415, 1971.)

,J

W Fig. 3. Conservative surgical management creates a more

acceptable prosthodontic foundation. A, The premaxillary
segment remains. B, The tuberosity and associated molar
remain. Note adequate bone support of teeth adjacent to
defect.

Residual maxilla support

In the residual maxilla the primary areas available
for support are the residual teeth, the alveolar ridge,
Fig. 2. Adenocystic carcinoma (cylindroma) originating and tile residual hard palate.
in minor salivary glands necessitates maxillary resection.
Teeth. Garious involvement of the remaining
Note the clinical extension of lesion beyond the midline
and into soft palate. teeth should be resolved, and the periodontal status
of these teeth should be made optimal (Fig. 4, A).
Fixed splinting (Fig. 4, B) of some or all of the teeth
remaining structures suggests that the obturator in the remaining segment may be necessary if there is
portion of ttle prosthesis, in addition to the residual doubt about their ability to support a large prosthe-
structures, must contribute significantly to the sis.
support, retention, and stability of the prosthesis to Resistance to movement of a prosthesis toward the
satisfy the basic prosthodontic objectives. tissue is emphasized in removable partial denture
design (Fig. 5). The need for occlusal rests, cingulum
SUPPORT rests, or ineisal rests is understandable. The n u m b e r
Support is the resistance to movement of a pros- a n d location of these rests is determined by the
thesis toward the tissue. T h e support available from number, position, and health of the remaining teeth
the residual maxilla and from within the defect both as well as by the size and location of the defect. T h e
must be considered. placement of ocelusal rests should be sufficiently

TIIE J O U R N A L OF PROSTIIETIC DENTISTRY 42.5,

 DESJARDINS

Fig. 5. The" internal surface of an 0bturator prosthesis.

Note occlusal rests, retentive clasps, guiding planes, and
extension of the obturator to provide support and reten-
tion within the defect.

ity, the arch form is improved and the support for

the prosthesis is increased considerably (Fig. 3).
9Residual hard palate. The residual hard palate is,
with few exceptions, an important structure for
support of an obturator prosthesis (Fig. 6). The
broad, flat palate is more conducive to support than
Fig. 4. A, presurgical complete mouth radiographs. Note the high, tapering palate. Large palatal tori should
the lesion (cylindroma) in the right maxilla, the perio- be removed because the prosthesis will require relief,
dontal involvement in maxillary left quadrant, and the and this will decrease the support. T h e posterior
extensive occlusal wear on left side. B, the postoperative extension of the prosthesis depends on the slope of
clinical status indicates that the maxillary left second
molar was removed, periodontal treatment was com- the soft palate as well as on the extent of the defect
pleted, and the remaining teeth in the maxillary left posteriorly. Removal of the hard palate, even in part,
quadrant were splinted to better distribute stresses of an alters the function of the muscular aponeurosis of the
obturator prosthesis. soft palate and often permits a more posterior
extension of the prosthesis than might ordinarily be
extensive to minimize the movement of the pros- permissible.
thesis toward the tissue. Occlusal rests stiould be
located as close to the defect as possible and adjacent Within-the-defect support
to edentulous areas. They should be well-rounded so Positive support within the defect to prevent
as to permit some prosthesis movement without rotation of the prosthesis into it must be considered.
placing excessive torque on the teeth. This support can be achieved by contact of the
Alveolar ridge. The residual alveolar ridge is prosthesis with any anatomic structure that provides
important for support in both the edentulous and a firm base (Figs. 4, B, and 6). The exact structure
the dentulous patient (Fig. 6). Its importance depends on the size and extension of the defect. In
increases as the n u m b e r of remaining teeth decreases. most acquired maxillary defects the floor of the
All of the factors that are important in appraising orbit, the bony structures of the pterygoid plate, and
the support for a complete denture are even more the anterior surface of the temporal bone near the
important to support in the acquired maxillary infratemporal fossa are considered for positive
defect. The size and shape of the residual alveolar support. The nasal septum m a y be used if the defect
ridge are the more obvious factors to consider. The extends beyond the midline.
large, broad ridge or the ridge with a square or ovoid Floor of the orbit. Although the floor of the orbit
tendency are usually better support than the small, might be considered a broad base on which to rest an
narrow ridge with a tapering contour. In patients obturator prosthesis, the use of the floor for support
with a retained premaxillary segment or a tuberos- should be minimal. It cannot be used for support if

426 APRIL 1978 VOLUME 39 NUMBER 4

OBTURATOR PROSTHESIS DESIGN

there has been an orbital exenteration. If the orbital

floor has been removed b u t the orbital contents
remain the prosthesis should not contact the orbital
structures, because they will move with movement of
the prosthesis. If tile patient has a large defect,
especially in vertical relationships, it often is not
possible to fabricate a large enough obturator that
still would be able to be inserted through the oral
opening. Consideration should be given to a two-
piec e sectional prosthesis and to the additional
weight which increases the problems of fabrication
and of insertion and removal. And lastly, the excep-
tionally large vertical prosthesis may alter the nasal
resonance if too m u c h of the resonating chamber is Fig. 6. An edentulous patient after maxillary resection.
obturated, thus affectihg speech quality. The alveolar and palatal size and shape as well as defect
Use of the orbital floor often is not possible or size and location are critical relative to support, retention,
practical. Although the floor has a broad area for and stability of an obturator prosthesis.
support, it .hsually is not needed because positive
support within the defect should be achieved mainly provide adequate prosthesis retention. Both direct
to prevent rotation of the prosthesis into the defect. retention and indirect retention are important.
The patient should use the contralateral side for
mastication.
Residual maxilla retention
Pterygoi d plate or temporal bone. T h e most O b t u r a t o r prosthesis design differs for the dentu-
commonly Used region for support of an obturator lous and the edentulous patient (Figs. 4, B, and 6).
prosthesis within the defect itself is tile remaining The structures in the remaining maxilla amenable
bony structures in the posterolateral aspect of the to providing obturator retention ai'e limited to the
defect. Depending on the extent of surgery this remaining natural teeth and the alveolar ridge.
structure is most often the pterygoid plate, but it Teeth. T h e teeth are the greatest asset for
could be the anterior surface of the temporal bone if providing retention of the obturator prosthesis.
the pterygoid plate h a s been removed. Positive However, the amount of stress generated by move-
contact of the prosthesis with this bony structure can ment of the obturator prosthesis may be very great.
be relatively extensive and is usually adequate to The number, position, and periodontal status of the
tripod the support for an obturator prosthesis so that remaining teeth are the most critical factors in
rotation of the .prosthesis into the defect is mini- evaluating the amount of stress that remaining teeth
mized. Not only the final prosthesis but also all the may be able to absorb. Fixed splinting of some or all
trial bases must contact this structure if the of the remaining teeth m a y be indicated to provide
completed occlusion is to be acceptable. dissipation of the stresses directed to primary abut-
T h e nasal septum. In defects that extend across ment teeth (Fig. 4, B).
the midline the nasal septum becomes ax/ailable for In removable partial denture design the use of
support. T h e nasal septum is a poor support for an intracoronal or extracoronal direct retainers must be
extensive prosthesis because it is partly cartilage, has considered. When the remaining teeth are located
very little bearing area, and is covered with nasal unilaterally, the intracoronal retainer might provide
epithelium. Tile nasal septum should not be used some benefit in minimizing the amount of vertical
routinely, but in defects that are excessively large it movement of the obturator prosthesis within the
provides additional resistance to rotation of the defect. If the defect is small and the remaining teeth
obturator into the defect if used with positive stable, intracoronal retainers might be considered. If
support in the posterolateral area of the defect. tile defect is large and some or all of the remaining
teeth are weak, extracoronal retainers should be
RETENTION used.
Retention is the resistance to vertical displacement For extracoronal retainers (Fig. 5), removable
of the prosthesis. Consideration must be given to partial denture design must be modified to
structures within the residual maxilla as well as to accommodate an obturator prosthesis. Due to the
those within the defect that must be relied on to unilateral location of the teeth, with all retentive

THE JOURNAL OF PROSTitETIC DENTISTRY 427

 DESJARDINS

be effective as stress breakers they should be no

larger than 19 gauge. The specific location of the
retentive clasps will be dictated by the location and
relative stability of the remaining teethl Considera-
tion should be given to placing retentive clasps 9as
near to and as far from the defect as possible, with at
least one and preferably more retentive clasps
between these extreme positions. Relatively weak
teeth should not be clasped unless they can be
splinted permanently to other more stable teeth.
The effectiveness of an indirect retainer depends
on its distance from the fulcrum line. The patient
with a retained premaxilla or tuberosity on the
Fig. 7~ The internal surface of a prosthesis for a patient defect side will have the foundation for a more
with the premaxilla intact. Note the improved indii'ect effective indirect as Well as direct retainer because of
retention when the premaxillary segment remains. the bilateral distribution of retentive arms (Fig. 7).
In patients with remaining natural teeth distributed
areas located on one side, rotation of ttle prosthesis unilaterally the arch form becomes important rela-
out c~fthe defect and of the clasps out of theretentive tive to the placemen.t of an effective indirect retainer.
undei'cuts may. occur. Location of these retentive A square arch form is more favorable to tile place-
undercuts must be counteracted by guiding planes or ment of an indirect retainer farther from the fulcrum
by the pala!al placement of some retentive Clasps. lihe than a tapering or an ovoid arch form. The
The relative effectiveness of any guiding plane number and position of the remaining teeth could
depends on its relationship to the path of the negate any positive advantage of a square arch
insertion and removal of the prosthesis. If the fol'm.
remaining teeth are not parallel with the walls of the Alveolar ridge. The total absence of teeth in the
defect, and if the palatal surfaces of the teeth are not remaining maxillary segmerit presents a more diffi-
long enough, adequate guiding plane s cannot be cult problem when one attempts to secure acceptable
provided to resist vertical displacement of the obtu- retention for an obturator prosthesis (Fig. 6)- The
rator and disengagement of the retentive clasp arms. retentive capabilities of the edentulous residual
To be effective, a guiding planewill provide some maxillary segment musk be evaluated by the same
stress to the abutment teeth, and its distribution is factors that contribute to acceptable retention of a
important to the long-term preservation of the conventional complete denture, i.e., Utilization of the
teeth. phys!eal properties of adhesion, cohesion, atmo-
The use of palatal, retentive_ clasps in conjunction spheric pi'essure, and interracial surface tension.
with buccal retentive cla!ps also can be considered. Certain anatomic configurations are more favorable
However, the relative effectiveness of palatal clasps is than others in developing these retentive proper-
determined by tile inclination of the teeth.in relation ties.
to the defect and the length of the palatal surface of Ridge size and shape influence retention. A large
the abutment teeth. Although buccal and palatal ridge With a broad ridge crest is more retentive than
retentive tips should not be used on the same tooth is a small or tapering ridge crest. The palatal contour
because of minimized bracing on insertion and influences the ability to increase or decrease the
removal, the number and position of the remaining interfacial surface tension. The broad , flat palate i s
teeth may' necessitate their u s e . more retenti~,,e than the high, tapering palate. The
The retentive clasps, whether they are buccal only arch form a n d its ability to provide indirect reten-
or buccal and palatal, should provide for stress- tion, even in the edentulous state, cannot be over-
breaking activity to decrease some of the torquing looked. The square arch form is more conducive tc
force generated by the size and location of the retention than tile tapering or ovoid arch form. The
obturator. Cast clasps should be of a length, thick- edentulous patient can benefit more than the dentu-
ness, shape, and taper that can permit some stress- lous patient if the premaxillary segment or the
breaking effect. Wire clasps can be considered, but to tuberosity can be retained on the defect side. These

428 APRIL 1978 VOLUME39 NUMBER 4

O B T U R A T O R PROSTHESIS DESIGN

residual structures permit a better Utilization of the

indirect retention principle.

Within-the-defect retention
Retention of an obturator prosthesis cannot be
totally and adequately provided by the residual
maxillary structures in either the edentulous or the
dentulous patient unless the defect is exceptionally
small. Large defects that ~ipproach the extent of the
hemimaxillecto~ny must Contribute intrinsically to
the retention of the obturator prosthesis if the
objectives of prosthesis design and prosthodontic
care are to be achieved. If tile obturator extension
itself could minimize the vertical displacement of the Fig. 8. An obturator prosthesis for an edentulous patient.
prosthesis, less stress would be generated tO the Note the maximal extension of the denture base as well as
residual max!ll~iry structures. There are five intrinsic the extensions over the palatal shelves, into the anterior
nasal aperture, and into the nasopharynx.
areas within and around the defect that can provide
retention tot~the obturator itself: the residual soft pharyngeal musculature and blockage of the eusta-
palate, the residual hard palate, tile anterior nasal chian tube must be avoided. There must be positive
aperture, the lateral scar band, and the height of the contact of the pharyngeal extension with the
lateral w a l l . superior surface of the soft palate if the extension is
Residual sol't palate. The residual soft palate to be effective for both border seal and retention. If
pro~,ides a posterior palatal seal which will minimize the slope or tautness of tlae remaining palate only
the passage Of food and liquids above the obturator permits contact in the region adjacent to the defect,
prosthesis (Figs. 4, B, and 6). Extension of the further extension is of minimal value.
obturator prosthesis onto the nasopharyngeal side of Residual hard palate. Depending on the location
the soft palate will help in this purpose and will also of the line of palatal resection, there will be varied
provide retention. Total surgical removal of the Soft degrees of undercut 9 this line into the nasal or
palate should be avoided because it creates a clinical paranasal cavity (Figs. 4, B, and 6). Although use of
situation similar to a congenital 9 palate, in the undercut need not be Considered in all obturator
which the severity of the defect is increased because a prostheses, engagement of the medial wall of the
significant portion of the maxilla also has been defect can increase retention, which is an advantage
removed. In most patients with soft palate lesions the in the edentulous patient and the patient w i t h
maxilla need not be extensively sacrificed, and most relative weakness of the remaining teeth.
patients with disease that necessitates an extensive The engagement of the medial undercut depends
maxillectomy do not require removal of all the soft on the path of the insertion and removal of the
palate. Any palatal rim remaining, no matter how prosthesis. There is a greater accommodation of a
small, can be of great value. hard denture base in the edentulous patient because
The amount of extension onto the superior surface of the ability to rotate the prosthesis into position
of the soft palate is limited by the. extent Of the (Fig 8). However, obturator extension along this
defect, the lateral and posterior pharyngeal walls, margin and into the undercut is best provided by a
and the relativd slope and tautness of the remaining soft denture base material. The objective of pros-
soft palate (Fig. 5). Ideally, the larger the extension thesis extension is to provide resistance to vertical
the more effective it should be relative to both border and horizontal displacement. The extension should
seal and retention. The relative size and position Of not contact the septum or the turbinates.
the nasopharyngeal opening and its relationship to 9 Anterior nasal aperture. The anterior nasal aper-
the path Of insertion and removal of the prosthesis ture can be entered unilaterally or bilaterally, de-
limit its extension. Rotation of the pharyngeal exten~ pending on tile extent of the defect to or beyond tlae
sion into the defect may be necessary rather than a midline and upon the presence or absence of the
direct vertical path of insertion and removal. Over- nasal septum (Fig. 9). If the anterior nares can be
extension and the associated impingement of the entered from the defect the bone support for this

TIlE JOURNALOF PROSTHETICDENTISTRY 429

 DESJARDINS

seldom prominent anterior to the premolar region.

Because of its lack of bone support the lateral s e a r
band also tends to stretch with continued use. This
stretching may necessitate sequential additions to
the.prosthesis which may be limited by cosmetic
requirements and prosthesis size and weight. Poste-
rolaterally, the extension and contour should not
interfere with the movement of the ascending ramus
or the eoronoid process in function.
Height of lateral wail. In addition to the physical
engagement of the four-structures mentioned the
lateral wall of the defect can be utilized for indirect
retention. There is a fulcrum line around which the
Fig. 9. Communication of the anterior nares with the obturator prosthesis rotates (Fig. 10); geometrically,
maxillary defect.
it is known that a point sweeping along a given
radius undergoes vertical displacement. At a given
portion of the nose has been lost, and its relative horizontal flexure the longer radius undergoes less
position is variable. vertical displacement than a shorter radius. Thus a
Afiterior extension from the medial portion of the high lateral wall of an obturator will undergo less
obturaior prosthesis provides some resistance to vertical displacement with a given defect wall flexure
vertical dislblacement of the anterior portion of the than will a shorter prosthesis lateral wall. This
prosthesis (Fig. 8). Because this extension competes principle becomes more important when the line of
for insertion and removal with the extension over the rotation approaches the medial wall of the defect,
soft pal~ite it often must be limited. If the bone and it is of greatest importance in the edentulous
support has been lost the Overlying soft tissue can be patient when the prosthesis often rotates around the
distended easily .for insertion a n d removal. The line of palatal resection.
effectiveness of increased retention, however, will be
minimized because the soft tissue tends to stretch STABILITY
with continued use of the prosthesis. Stability is the resistance to prosthesis displace-
Lateral scar band. For adequate surgical closure ment by functional forces. Many of the anatomic
most large maxillary resections are lined with a split- structures and design principles that have been
thickness skin graft (Figs. 4, B, 6, and 9) along the discussed for support and retention of an obturator
anterior, lateral, and posterolateral walls of the prosthesis also directly provide stability of a prosthe~
defect. A scar band results after surgical resection at sis. Because function tends t o move an obturator
about the level of the mucobuccal fold. If the skin prosthesis, the principles of obturator design that
graft has not been placed to line the defect there is a minimize rotation around the horizontal plane ahd
tendency for excessive cicatrization and collapse of minimize movement within the horizontal plane
the defect and problems in prosthodontic rehabilita- itself must be considered.
tion. Patients with a split-thickness graft tend to Rotation of the prosthesis around the horizontal
have a slight contraction at the area where the skin plane is that rotation seen around the fulcrum line.
joins the buccal mucosa. This contraction is not Many aspects of obturator design are important to
excessive; it is localized to the area of junction with both retention and stability.
the buccal mucosa; and it probably is contraction of Movement of tile prosthesis within the horizontal
the traumatized buccal mucosa itself. T h e skin plane can be anteroposterior, mediolateral, rota-
superior to the junction tends to stretch, creating an tional, or a combination of any or all of these
area above the Scar band that can be engaged by the directions. As with retention and support specific
obturator prosthesis; this minimizes vertical dis- areas of the residual maxilla, as well as the defect
placement of the prosthesis. itself, must be considered in minimizing the extent of
T h e extent of engagement of the lateral scar band these potential movements..
depends on the character of the defect (Figs. 4, 13, 6, Residual maxilla stability. If natural teeth remain,
and 9). The lateral scar band usually is more the bracing components of the prosthesis framework
prominent laterally and posterolaterally and is can be used to minimize movement in all t h r e e

430 APRIL 1978 VOLUME 39 NUMBER 4

ORTUP~TOR PROSTHESIS DESIGN

I L%.~(
{~~'''~ ".

Vertical \ ~
displacement\ ._.....~.,
too,uss~p . /

I I' " ::. i..."-:.".<.~:: .....,. ~_~-'--'.--.,,~_~ ~

i
, - ~:!....:..!~!~i ~! .~

Given horizontal
flexure
Fig. 10. A geometric representation emphasizes the importan.ce of the lateral wall height in
design of an obturator prosthesis. With a given horizontal flexure, the longer radius undergoes
less vertical displacement than does the shorter radius. (Redrawn from Brown, K. E.:
Peripheral consideration in improving obturator retention. J PRosrntr DENT20:176, 1968.)
directions (Figs. 5 and 7). It is advantageous to provide retention and stability to a prosthesis (Fig.
provide maximal bracing and to extend this bracing 11, A). The retention developed by adequate pros-
interproximally when possible to minimize rota- thesis design can be easily interrupted during func-
tional as well as anteroposterior movement of the tion, thus rendering the prosthesis unstable. The
prosthesis. most important aspect of stability is occlusion (Fig.
In edentulous patients maximal extension of the 11, B). An unstable prosthesis results if the occlusal
prosthesis commensurate with good complete den- relationship does not maintain intimate prosthesis
ture design is imperative (Fig. 8). Maximal extension contact with the supporting and retentive structures
into the mucobuccal fold, and especially the disto- of a residual maxilla and its defect during occlusal
buccal extension as the buccal flange approaches the function.
hamular notch, is important in minimizing move- Maximal distribution of the occlusal force in
ment within the horizontal plane. centric and eccentric jaw positions is imperative to
Within-the-defect stability. As with support and minimize the movement of the prosthesis and the
retention the defect itself must be considered to resultant forces to individual structures. The patient
enhance the stability of an obturator prosthesis (Figs. with an acquired maxillary defect should not masti-
4,/3, and 6). Maximal extension of the prosthesis in cate over the defect. Although some support is
all lateral directions must be provided. Impingement provided within the defect it is usually minimal
on the mandible in function, however, must be when compared with that provided by the residual
avoided. Special emphasis must be placed on maxilla. The partially edentulous patient is not
maximal contact with the medial line of resection, likely to have a problem with unilateral mastication,
the anterior and lateral walls of the defect, the and existing occlusal relationships may dictate many
pterygoid plates, and the residual soft palate. aspects of the occlusal scheme. For example, steep
Contact of the obturator portion of the prosthesis vertical overlap of the anterior teeth will prevent
with these structures minimizes anteroposterior, occlusal balance in the eccentric position. The eden-
mediolateral, and rotational movement of the pros- tulous patient, however, can expect a less stable
thesis. prosthesis during mastication (Fig. 11, C), and a
Occlusion. All of the anatomic factors mentioned balanced occlusal scheme should be provided.
for both the dentulous and the edentulous patient Occlusal balance remains a prime concern relative to

THE JOURNAL OF PROSTHETIC DENTISTRY 431

 DESJARDINS

The prosthesis must contact the medial line of

resection and may engage the residual bony palate
from the anterior mucobuccal fold to the soft palate
(Fig. 12, A and B). A soft liner may be incorporated
to aid retention along tile residual palatal shelf. An
extension may be provided into the anterior nasal
aperture, and the medial surface of the o b t u r a t o r
should be continuous with the extension into the
nasopharynx. 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
tile obturator should not be high enough to obstruct
nasal breathing, particularly in patients who have
had the turbinates rescctcd. Contact with the nasal
scptum may be necessary for support i n defects
which pass the midline. This contact should be made
with a soft material, and superior extension should
be minimal for adequate nasal breathing. The
medial surface should not be as high as the lateral
surface, and tile 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 of the prosthesis
provide the support for the facial muscles (Fig. 12, C
and D). The anterior contour influences the facial
appearance, and it should approximate facial
symmetry when possible. The anterior and lateral
surfaces are continuous with the extension into or
about the anterior nasal aperture anteriorly; they
extend along and above the anterior and lateral scar
band as it progresses posterolateraily until it contacts
tile pterygoid plate or the anterior surface of the
temporal bone. Inferior and lateral extension should
not restrict mandibular movement. Contact with the
support in the distobuccal region of the defect should
be as extensive as possible. The anterior and lateral
surfaces should extend superiorly as much as possible
to enhance retention by minimizing vertical
displacement upon rotation from the fulcrum line.
Fig. 11. A, An obturator prosthesis depicts complete The anterior and lateral surfaces also should be
obturation of the defect. B, The occlusal scheme with the higher than the medial surface and undergo a
obturator prosthesis in place. The remaining natural teeth gradual decline in height posteriorly in order to
should control eccentric movements. C, The balanced encourage mucous drainage medially and posteri-
occlusion of obturator prosthesis in an edentulous
patient. orly.
Tile pharyngeal portion of the obturator pros-
the parafunctional occlusal contacts used at times thesis is continuous with both the lateral and medial
other than during mastication. surfaces (Fig. 12, E and F). Laterally, the pharyngeal
portion begins at the pterygoid plate and contacts
O B T U R A T O R SIZE A N D EXTENSION the lateral pharyngeal wall during function but
In reviewing tile anatomic regions that should be passes below the eustachian tube. The pharyngeal
contacted for support, retention, and stability, the portion should contact tile superior surface of the
design of an obturator prosthesis becomes simplified. soft palate and may achieve functional contact with

432 APRIL 1978 VOLUME 39 NUMBER 4

OBTURATOR PROSTHESIS DESIGN

Fig. 12, A and B. A, The medial wall of maxillary defect. B, The medial surface of an
obturator prosthesis.

Fig. 12, C and D. C, The lateral wall of a maxillary defect. Note the scar band at the
junction of the mucosa and skin graft. D, The la'teral surface of an obturator prosthesis.

the posterior pharyngeal wall if the path of insertion After placement of the teeth the palatal contour
and removal will permit the extension. Prosthesis should be symmetric with the portion of the pros-
extension over tile soft palate of the nondefect side thesis that covers the remaining maxillary segment.
should be continuous with the medial surface of the Because excessive prosthesis weight causes retention
obturator and is limited by the path of insertion and problems most obturator prostheses should be made
removal. The height of the pharyngeal portion of the hollow. Although there are many acceptable
prosthesis is limited laterally by the eustachian tube techniques for fabricating hollow prostheses, the
and should have less height medially than laterally palatal region is often the lid for the hollow portion,
and less height than tile remainder of the obturator and special care must be taken to assure reasonable
in order to encourage mucous drainage posteriorly. symmetry.
T h e contour of the inferior surface of tile pros- The superior surface of the prosthesis is sometimes
thesis is influenced by tooth position and palatal modified to improve the quality of speech (Fig. 12,
contour (Fig. 12, G). The mediolateral and antero- 1t). Although speech quality, especially resonance,
posterior positions of the teeth are determined by the varies considerably among patients, the ~,ariation is
remaining structures. The principles of complete related more to the extent of the defect than to the
denture fabrication should be followed in deter- obturator itself. Patients who have extensive defects
mining tooth position. If good surgical technique which can not be obturated adequately despite
and early prosthodontic rehabilitation have been modification of the superior surface of the prosthesis
provided the occlusal scheme need not be compro- may not demonstrate a normal quality of speei:h.
mised. The inferior surface contour distal t o t h e teeth The prosthodontist does not have much oppor-
must not impinge on the functioning mandible. tunity to vary the superior surface significantly. The

THE JOURNALOF PROSTttETICDENTISTRY 433

 DESJARDINS

Fig. 12, E and F. E, The pharyngeal wall of a maxillary defect. Note the opening into the
nasopharynx. F, The pharyngeal surface of an obturator prosthesis.

Fig. 12, G and H. G, The inferior surface of obturator prosthesis. H, The superior surface
of an obturator prosthesis. Note the posterior and medial slope of the superior surface.

heights of the anterior and lateral walls are deter- character and position of the remaining structures.
mined by esthetics and retention. "/'he height of the The defect, in conjunction with the remaining struc-
medial wall and the pharyngeal extension are deter- tures, must be used to provide support, retention,
mined by anatomicqimitation and by the mechan- and stability of an obturator prosthesis.
ical principles used to encourage drainage. Connec- If basic prosthodontic principles are applied the
tion of these superior extensions of other surfaces size and extension of the obturator will be deter-
determines the superior surface. Most patients will mined, a n d the extensive variation so commonly
demonstrate acceptable speech; prosthodontic prin- seen in obturators will be minimized. Acceptable
ciples should not be compromised in an attempt to prosthodontic care for the patient with tile acquired
provide better resonance. maxillary defect should include cautious prosthesis
design combined with routine maintenance care to
SUMMARY provide comfort, function, cosmetics, and minimal
Fabrication of obturator prostheses does not change to the compromised remaining structures.
require a special ability to fabricate a prosthesis
extension into a defect or an arbitrary extension of a REFERENCES
prosthesis into a defect. Fabrication of an obturator 1. Aramany, M. A.: A laistory of prosthetic management of
cleft palate: Part to Suersen. Cleft Palate j 8:415, 1971.
prosthesis depends on tile application of basic pros-
2. Chalian, V. A., Drane, J. B., and Standish, S. M.: Maxillo-
thodontic principles that are used in the treatment of facial Prosthetics. Baltimore, 1971, The Williams & Wilkins
patients without maxillary defects. S o m e principles Company.
must be modified because of tile defect and the 3. DeVan, M. /k|.: "/'he nature of the partial denture founda-

434 APRIL 1978 VOLUME 39 NUMBER 4

 OBTURATOR PROSTHESISDESIGN

tion: Suggestions for its preservation. J PROSTHET DENT the basic sciences and the clinical sciences to develop a
2:210, 1952. scientific basis for obturator prosthesis design for acquired
4. Henderson, D., and Steffel, V. L.: Principles of removable maxillary defects. The variables intrinsic to the ablation of
partial denture. In McCracken's Partial Denture Construc- maxillary neoplasms defy stereotyped or standardized
tion: Principles and Techniques, ed 3. St. Louis, 1969, The impression procedures and design of maxillary obturator
C. V. Mosby Company, pp 83-94. prostheses. Dr. Desjardins has reduced a complicated
5. Applegate, O. C.: The correctable ,~vaximpression. In Essen- subject to its fundamental components and offered a
tials of Removable Partial Denture Prosthesis, ed 2. Phil- practical and clinically valid scientific procedure for the
adelphia, 1959, W. B. Saunders Company, pp 230-256. design of maxillary obturator prosthesis.
6. Frechette, A. R.: The influence of partial denture design on Presurgical consultation with the surgeon is desirable
distribution of force to abutment teeth. J PROSTHETDENT but not always practiced. A surgeon who is prosthetically
6:195, 1956. oriented can provide favorable anatomical landmarks
7. Kaires, A. K.: Effect of partial denture design on bilateral which would aid the prosthodontist and benefit the
force distribution. J PROS'TriErDENT 6:373, 1956. patient in prosthetic rehabilitation. In the real world of
8. Kaires, A. K.: Effect of partial denture design on unilateral resective tumor surgery the majority of surgeons operate
force distribution. J PROSTHETDENT 6:526, 1956. with little or no consideration for providing the prostho-
9. Kaires, A. K.: Partial denture design and its relation to force dontist with a favorable foundation for prosthetic ther-
distribution and masticatory performance. J PROSTHETDENT apy.
6:672, 1956. It should be emphasized that the defect of a partially
10. Blatterfein, L.: Systematic method of designing upper edentulous maxilla m a y need only coverage and sealing,
partial denture bases. J Am Dent Assoc 't6:510, 1953. without maximal superior penetration. T h e completely
11. Schuyler, .C. It.: The partial denture as a means of stabi- edentulous maxilla, however, requires maximal penetra-
lizing abutment teeth, j Am Dent Assoc 28:1121, 1941. tion and intimate contact of the obturator extension of the
12. Lazarus, A. H.: Partial denture design. J PROSIHET DENT prosthesis to the surrounding surfaces of the defect for
1:438, 1951. retention, stability, and support.
13. Perry, C.: IA philosophy of partial denture design. J PROS- Dr. Desjardins' statement regarding the placement of
TIlET DENT 6:775, i956. retentive clasps "as near to and as far from the defect as
14. Loos, A.: The bio-physiological principles in the construe. possible" is an excellent principle of design. However, the
tion of partial dentures. Br Dent J 88:61, 1950. stress-breaking capacity of cast clasps, regardless of their
15. Kelly, E. K.: The physiologic approach to partial denture length, thickness, shape and taper, is doubtful. Sure'eying
design. J PROSTHETDENT 3:699, 1953. the defect cavity in addition to the remaining teeth on the
16. Schmidt, A. It.: Planning and designing removable partial mastercast is a d v l s a b l e - t o eliminate those undercut areas
dentures, j PROSrHETDENT 3:783, 1953. in the defect that are undesirable and incompatible with
17. Steffel, V. L.: Planning removable partial dentures. J a favorable path of insertion of the partially edentulous
PROSTIIET DEN~r 12:524, 1962. obturator prosthesis and to select the undercuts in the
18. Hammond, j.: Dental care of edentulous patients after defect which will aid the retention of the prosthesis.
resection of maxilla. Br Dent J 120:591, 1966. The importance of occlusion should b e stressed in the
19. Sharry, J. J.: Extensions of partial denture treatment. Dent support of maxillary obturator prostheses. T h e occlusal
Clin North Am, Nov. 1962, pp 821-835. plane of the artificial teeth for the prosthesis with the jaw
20. Kelly, E. K.: Partial denture design applicable to the defect should be favored. T h e mandibular dentition
maxillofacial patient. J PROSTllETDENT 15:168, 1965. should be restored as ideally as possible to minimize or
21. Adisman, I. K.: Removable partial dentures for jaw defects 9eliminate occlusal imbalances for the maxillary prosthesis
of the maxilla and mandible. Dent Clin North Am, Nov. restoring a maxillary defect. T h e stability of the maxillary
1962, pp 849-870. prosthesis would be enhanced if the forces of occlusion in
22. Brown, K. E.: Peripheral consideration in improving obtu- mastication would direct the prosthesis upward, inward,
rator retention. J PROS'FIlETDENT 20:176, 1968. and posteriorly i n b i l a t e r a l simultaneous'posterior teeth
23. Brown, K. E.: Clinical considerations improving obturator contact.
treatment. J PROSrHETDENT 24:461, 1970. Adequate mucous drainage is a frequent annoyance,
particularly in the well-fitting maxillary obturator pros-
Reprint requests to:
thesis. Providing a groove or trench on the superior surface
SEcTiON OF PUI]LICATION$
of tile obturator extension inclined downward towards the
I~ AYO CLINIC
nasopharynx would aid in the passage of mucous and nasal
ROCUESTER, F,IiNN. 55901
fluids posteriorly. Sometimes an auxiliary escape channel
may be indicated to prevent the accumulation of nasal
mucous secretions.
DISCUSSION Dr. Desjardins has presented an excellent paper about a
I. Kenneth Adisman, D.D.S.* difficult and complex phase of prosthodontics. I am
pleased to have the opportunity to add these remarks to an
Dr. Ronald Desjardins is to be c o m m e n d e d for his
outstanding presentation.
comprehensive and analytical paper in which he combines
LK.A.
100 CENTRAL PARK SOUTII
*New York; N. Y. NEW YORK, N. Y. 10019

TIlE JOURNALOF PROSTtIETIC DENTISTRY 435