Palatal ObturatorsScott Culpepper, DDSKings County Hospital

PALATAL OBTURATOR: A PROSTHESIS THAT OCCLUDES AN OPENING SUCH AS AN ORONASAL FISTULA.

Surgical resection, as in SCCa Used in cleft lip and palate cases Traumatic injury to the palate

Functiono Used in speecho Prevent nasal regurgitation that occurs

during feedingo Often used as a therapy for cleft lip and

palate, or for treatment of resected neoplasms.

o Includes any missing teeth to provide occlusion and esthetics

o In some cases, a palatal obturator can be gradually downsized, so that tissues can gradually strengthen over time and compensate for the decreasing size of the obturator.

o They can be simple or complex, and reflect a whole area of practice.

o May involveo Dentists, Oral Surgeonso Plastic surgeonso Oral & Maxillofacial Prosthodontistso Speech therapistso Oncologists

TYPESo Palatal plate (most common)

LATHAM DEVICEPlaced by plastic surgeons, for babies with

complete clefts of lip and palate.Surgical placement, designed to bring two

pieces of cleft palate together and to make lip repair easier

NASAL ALVEOLAR TYPE

PLANNING Ideally, obturator is planned prior to

surgery, or consistent with planned closure of cleft lip and palate.

Depends of extent of surgery, and subsequent surgeries Eventual closure of fistula? Additional resection of carcinoma?

Modification Obturator: very short term, used for immediate blockage and seal of fistula. May be made chairside.

Interim Obturator: used when no further surgical procedures are planned. Great part of surgical treatment planning.

Preoperative impressions, bite registrations and tooth set-up.

Placed and relined in the OR, for immediate use post-operatively.

Requires constant revision as tissues heal.

TWO CASES

CASE #1: INTERIM Male pt, complaining of existing obturator

that does not fit. Ca treatments, still ongoing, tissues are

continuously changing and Ca is probably out of control at this point.

Pt. did not receive radiation b/c proximity to brain, surgical resections have also stopped at this point.

How do you get retention?

WHAT WOULD HELP An oral and maxillofacial prosthodontist Presurgical treatment planning, there

appeared to have been some in this case Prosthesis would ultimately have 2 parts

that lock together: extraoral+intraoral Retentively engaging all involved tissues

makes a heavy prosthesis, and seems uncomfortable for pt.

Is there another way?

SECOND CASE: THIRD TYPE OF OBTURATOR

Definitive Obturator Used when surgical rehabilitation is not

possible. Long-term use after tissues have fully healed

and matured. May also be implant supported

CASE SELECTION This was an appropriate case

Isolated defect No further surgery planned Mature and healthy tissues Not a far stretch from conventional dental

prosthesis Retention is mostly gained from the fistula

or defect itself, rather than by conventional means

PREPARE YOUR PATIENTS Etiquette: If you’re conversing w/a patient, make

sure they have old obturator in, so they can answer you….. Get all concerns, complaints, questions up front.

Sell implants: Conventional prosthesis may not have enough retention. Understand that from the start.

Prepare the patient: Estimated number of appts. Some discomfort, irritation while working to record the

tissues of the fistula. Gagging, sneezing.

PRELIMINARY IMPRESSIONS Stock tray w/adhesive, lots of alginate Additional alginate to add to fistula Record opposing dentition if any Mark Midline, lab may not be able to

tell Order custom tray

CUSTOM TRAY Border molding Master impression, can also be multi-

phase This is the hardest for the patient Order an occlusal rim on a record base

where fistula tissues have been blocked out

You need to try in rims several times, no need to engage fistula every time during this phase

OCCLUSAL RIMS Make the record base so you can try it

in repeatedly w/o trauma. Establish VDO, check phonetics,

occlusal plane, etc. Tooth selection, wax try-in etc.

DELIVERY Need time. Most adjustment is in area of fistula. Go easy with try-ins, often the patient

is better at placing it than we are. Final polish. Implant retention is always an option,

even after delivery.