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CASE REPORT Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 1  |  Page : 35-37
Prosthetic rehabilitation of a completely edentulous patient with palatal insufficiency


Department of Prosthodontics, AB Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore - 575 018, India

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Date of Submission25-Apr-2006
Date of Decision11-Sep-2006
Date of Acceptance28-Sep-2006
 

   Abstract 

This article presents a case report of a completely edentulous patient with palatal insufficiency successfully rehabilitated with closed hollow bulb obturator prosthesis and also describes a simple technique for fabricating a two-piece hollow bulb obturator that allows for control of the bulb's wall thickness and weight of the prosthesis.

Keywords: Cleft palate, hollow bulb obturator, palatal insufficiency, prosthetic rehabilitation

How to cite this article:
Bhat AM. Prosthetic rehabilitation of a completely edentulous patient with palatal insufficiency. Indian J Dent Res 2007;18:35-7

How to cite this URL:
Bhat AM. Prosthetic rehabilitation of a completely edentulous patient with palatal insufficiency. Indian J Dent Res [serial online] 2007 [cited 2014 Apr 24];18:35-7. Available from: http://www.ijdr.in/text.asp?2007/18/1/35/30921

   Introduction Top


Cleft lip or palate is one of the most common congenital anomalies, but prevention of this malformation remains obscure. Treatment is dictated by the severity of the problem. A multidisciplinary approach is essential to achieve optimum results. Definitive prosthodontic treatment is usually one of the final therapies instituted and it must attempt to alleviate any anatomical and functional deficiencies that may remain after the gamut of other treatment is essentially completed.

Velopharyngeal deficits may result from congenital malformations. One such deficit is palatal insufficiency i.e. inadequate length of the hard and/or soft palate to affect velopharyngeal closure, but with movement of the remaining tissues within normal physiological limits that may result in hypernasality and decreased intelligibility of speech.[1]

In many patients, velopharyngeal function can be restored by surgical reconstruction. However, residual palatal deficiencies may remain after surgical treatment, which would necessitate placement of an obturator prosthesis. Also, selected cleft palate patients with gross deficiencies of palatal tissues are best treated prosthodontically, without surgical intervention.

The purpose of this article is to present a case report of a completely edentulous patient with palatal insufficiency rehabilitated prosthodontically with a closed hollow bulb obturator and a description of a simple technique for the fabrication of closed hollow bulb obturator prosthesis.


   Case report Top


A 50-year-old female patient reported with a chief complaint of inability to masticate. Although history, general and extraoral examination did not reveal any abnormality except for a nasal twang in her voice lacking resonance, intraoral examination revealed a completely edentulous state [Figure - 1] with a Veau's class II defect i.e. a defect of soft and hard palate up to the alveolus. [2] The inferior turbinates were visible through the defect [Figure - 2]. Tissue undercuts were present in the palatal region at the site of the defect and in the mandibular lingual region.

Detailed case history revealed that the oronasal communication was present since birth and the defect was not treated surgically.

Considering her socio-economic condition and her functional and esthetic requirements, a closed hollow bulb obturator was planned for the patient.

A gauze strip lubricated with petroleum jelly was packed into the alveolar cleft area prior to impression making to prevent the impression material from being forced into the nasal cavity. A preliminary irreversible hydrocolloid impression was made in a stock metal tray after having modified the tray with impression compound. The lower edentulous ridge was recorded with impression compound.

The impressions were poured with dental stone to obtain primary casts. The undercuts were blocked and custom trays of auto polymerizing resin with a 2 mm wax spacer were fabricated over the primary casts. The tray extensions were then adjusted in the patient's mouth and border molding was done using low-fusing compound.

The obturator portion was molded by making the patient move her head in a circular manner from side to side, to extend her head as far forward and backward as possible and to say 'ah' and swallow.

The border molding was continued till the position and contours of the obturator were satisfactory and a complete peripheral seal was obtained. The indentations made by the tonsillar pillars and the Passavant's ridge were visible with no shiny areas and the patient was able to speak, swallow and breathe through the nostrils effectively. Lower border molding was done following the routine technique.

Final impressions were made with medium body polyvinyl siloxane impression material. Master casts of dental stone were then obtained. Shellac baseplate was adapted over the master casts to serve as temporary record bases over which wax occlusal rims were fabricated.

Jaw relations were recorded using the static method and transferred to a mean value articulator. Artificial teeth arrangement was done. Following the trial, the denture was waxed-up. Beads of wax were placed in three widely spaced areas in the hollow bulb portion to form a triad so that when replaced with acrylic resin they would serve as a guide for accurate realignment of the lid of the obturator that was fabricated separately. The denture was then polymerized in the conventional manner.[3] To make a lid for the obturator, separating medium was applied to the hollow bulb portion of the processed obturator and a dental plaster-pumice mix (1:1) was filled up to the palatal plane. Over this shellac base plate was adapted to form the lid till the indentations of the orientation beads were captured. The baseplate was then waxed up, invested and acrylized separately with heat cure acrylic resin [Figure - 3]. The plaster-pumice mix was removed from the obturator portion and the lid was realigned according to the orientation beads to cover the obturator and fused with autopolymerizing resin. After finishing and polishing the obturator was made to float in a bowl of water to ensure a complete seal. The lower complete denture was also polymerized following the routine technique.

The prosthesis was then inserted in the patients' mouth [Figure - 4] and the extensions, speech and occlusion were evaluated. Necessary adjustments were done. Speech showed a definite improvement and there was a considerable improvement in esthetics . The position of the obturator was confirmed by means of a lateral cephalogram of the patient taken with the prosthesis in place after coating the obturator portion with a radioopaque material (barium sulfate) [Figure - 5].


   Discussion Top


Cleft palate rehabilitation involves essentially a multidisciplinary approach. The size and location of the defect are important considerations in selecting the method of rehabilitation. Small defects of the alveolar ridge and hard palate are easily closed surgically where as larger hard palate and/or soft palate defects are more amenable to prosthodontic obturation.[1]

In the case presented here, early diagnosis and timely management i.e. sequential surgeries followed by orthodontic therapy would have led to a considerable decrease in the size of the defect. But unfortunately the congenital anomaly was left unattended resulting in the large size of the defect that dictated prosthodontic rehabilitation with a closed hollow bulb obturator.

The basic design of the obturator prosthesis used the available tissue bearing area extending into the defect to engage the undercuts to achieve maximum retention and stability. A hollow obturator allowed for the fabrication of a lightweight prosthesis that was readily tolerated by the patient while effectively extending into the defect where as a solid obturator in this case would be bulky and heavy that would jeopardize the supporting tissues.[4],[5] A closed hollow obturator design was adopted to prevent fluid and food collection, reduce air space and allow for maximum extension.

The technique of constructing a hollow bulb prosthesis described in this article has advantages over the conventional procedures[6],[7],[8],[9],[10],[11],[12],[13],[14] in that it is simple, time saving and allows for control of the bulb's wall thickness.

 
   References Top

1.Beumer J, Curtis TA, Marunick MT. Maxillofacial rehabilitation, prosthodontic and surgical considerations. Ishiyaku Euro America: St. Louis; 1996. p. 399-402.   Back to cited text no. 1    
2.Stewart KL, Rudd KD, Keubker WA. Clinical removable partial prosthodontics. 2nd ed. Ishiyaku Euro America Inc: St. Louis; 1997. p. 650.  Back to cited text no. 2    
3.Morrow RM, Rudd KD, Rhoads JE. Dental laboratory procedures: Complete dentures. Vol. 1. 2nd ed. Mosby: St. Louis; 1985. p. 312-24.  Back to cited text no. 3    
4.Brown KE. Peripheral considerations in improving obturator retention. J Prosthet Dent 1968;20:176-81.  Back to cited text no. 4  [PUBMED]  
5.Brown KE. Clinical considerations improving obturator treatment. J Prosthet Dent 1970;24:461-5.  Back to cited text no. 5  [PUBMED]  
6.Nidiffer TJ, Shipmon TH. The hollow bulb obturator for acquired palatal openings. J Prosthet Dent 1957;7:126-34.  Back to cited text no. 6    
7.Brown KE. Fabrication of a hollow-bulb obturator. J Prosthet Dent 1969;21:97-103.  Back to cited text no. 7  [PUBMED]  
8.El Mahdy AS. Processing a hollow obturator. J Prosthet Dent 1969;22:682-6.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Chalian VA, Barnett MO. A new technique for constructing a one-piece hollow obturator after partial maxillectomy. J Prosthet Dent 1972;28:448-53.  Back to cited text no. 9  [PUBMED]  
10.Buckner H. Construction of a denture with hollow obturator, lid and soft acrylic lining. Prosthet Dent 1974;31:95-9.  Back to cited text no. 10  [PUBMED]  
11.Tanaka Y, Gold HO, Pruzansky S. A simplified technique for fabricating a lightweight obturator. J Prosthet Dent 1977;38:638-42.  Back to cited text no. 11  [PUBMED]  
12.Browning JD, Kinderknecht J. Fabrication of a hollow obturator with fluid resin. J Prosthet Dent 1984;52:891-5.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Palmer B, Coffey KW. Fabrication of the hollow bulb obturator. J Prosthet Dent 1985;53:595-6.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Minsley GE, Nelson DR, Rothenberger SL. An alternative method for fabrication of a closed hollow obturator. J Prosthet Dent 1986;55:485-90.  Back to cited text no. 14  [PUBMED]  

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Correspondence Address:
Aruna M Bhat
Department of Prosthodontics, AB Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore - 575 018
India
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DOI: 10.4103/0970-9290.30921

PMID: 17347544

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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

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