CASE REPORT

Prosthetic Treatment of Congenital Hard and Soft Palate Defects

Murat Yenisey, D.D.S., Ph.D., Seda Cengiz, D.D.S., Ph.D., Isıl Sarıkaya, D.D.S., Ph.D.

Obturator prostheses are used to improve mastication, speech, and swallowing byreestablishing oronasal separation and aesthetics in maxillary defect patients. A sectionaland magnetically retained functional removable speech bulb prosthesis was planned to treat thecongenitally cleft hard and soft palates of this patient. The obturator part, localized into lateralnasal undercuts covered with sound mucosa, was used to retain the complete denture. Twopieces of the prosthesis were joined together by a magnet in the mouth. A special hingemechanism was added to join the complete denture and functional velopharyngeal parts of theprosthesis for the treatment of velopharyngeal inadequacy. Sufficient retention was obtained,and no major complications were seen in the patient’s prosthesis in periodic controls.

KEY WORDS: magnetic removable obturator, palate defect, velopharyngeal inadequacy

Defects of the hard and soft palates may be divided into

three categories: congenital, acquired, and developmental

(Taylor, 2000). In a congenital cleft palate, embryologic

development of the hard and soft palates is incomplete.

Surgical resection of a neoplastic disease results in an

acquired defect that changes the soft palate’s continuity.

Inadequacies of soft palate function may be a result of

developmental, muscular, or neurological diseases (Keyf,

2001). Absence of half to the whole of the soft palate is

termed palatopharyngeal inadequacy, and tissues modify

their functions to obtain closure of the pharynx. In these

cases, to obtain closure between the existing hard and soft

palates and pharynx, an obturator, also called a speech aid

or speech bulb prosthesis, is prepared. Its function is to

separate the oropharynx and nasopharynx (Nishigawa et

al., 2003). The aims of fabrication of the prosthesis are to

block liquid and food leakage between the pharyngeal

sections and to increase the understandability of speech

(Kanazava et al., 2000). The prosthesis consists of

pharyngeal and palatal bases that constantly transmit high

stress to supporting palatal tissues and related structures

due to the volume, weight, and functioning of the lever of

the pharyngeal section. The degree of edentulism is critical

for retention of the patient’s prosthesis (Koyama et al.,

2005; Parr et al., 2005). In addition, the teeth are the

greatest asset for retaining the obturator prosthesis.

Endosseous implants may be used to provide retention,

support, and stability for maxillofacial prostheses when the

residual anatomy is no longer capable of fullfilling these

functions (Eckert and Desjardins, 2000).

In edentulous patients with maxillary defects, effective

retention, support, and stability of an obturator prosthesis

must be obtained from residual palatal structures and by

engaging suitable undercuts within the defect. A sectional,

magnetically retained hollow obturator prosthesis is

beneficial to patients by permitting easy insertion and

removal and minimizing weight (Sasaki et al., 1984;

Mitchell et al., 1989; Devlin and Barker, 1992). After

substantial ablative surgical procedures of the maxilla,

extraoral retention can be used for stability and function of

the obturator (Martin et al., 1992).

In infancy, the treatment for congenital palate deformi-

ties is the fabrication of active or passive prosthodontic

plates to achieve functional nutrition and prevent fusion of

bone segments until after surgical treatment in childhood.

In adulthood, an active obturator (speech prosthesis) is

used. If the defect is in the hard palate, a static obturator

can be prepared (Koyama et al., 2005).

This clinical report describes the prosthetic rehabilitation

of a congenital defect of the hard and soft palates through

the use of a magnetically retained, removable obturator.

CASE REPORT

A 60-year-old, totally maxillary edentuluous male patient

was referred to the University of Ondokuz Mayis Faculty

of Dentistry, Department of Prosthodontics in Samsun,

Turkey. He had a congenital cleft on his hard and soft

Dr. Yenisey is Assistant Professor, Department of Prosthodontics,

Faculty of Dentistry, Ondokuz, Mayıs University, Samsun, Turkey. Dr.

Cengiz is Assistant Professor, Department of Prosthodontics, Faculty of

Dentistry, Karaelmas University, Zonguldak, Turkey. Dr. Sarıkaya is

Prosthodontist, Amasya Oral Health Center, Amasya, Turkey.

Presented at the Turkish Prosthodontics and Implantology Association

15th Scientific Symposium, Ankara, Turkey, October 2006.

Submitted January 2010; Revised August 2010; December 2010;

Accepted December 2010.

Address correspondence to: Dr. Seda Cengiz, Karaelmas University

Dental Faculty, Department of Prosthodontics 67600 Zonguldak, Turkey.

E-mail sedabc@hotmail.com.

DOI: 10.1597/10-016

The Cleft Palate-Craniofacial Journal 49(5) pp. 618–621 September 2012’ Copyright 2012 American Cleft Palate-Craniofacial Association

618

palates, including uvula on the midline (Aramany Class 3;

Aramany, 2001) (Fig. 1). His medical history indicated that

his brother also had congenital soft and hard palate defects.

He had never used a prosthesis before and had not suffered

from hypernasal speech or nasal regurgitation of food and

liquids, but he had complained of lack of full function and

discomfort.

On the basis of examination and testing, a magnetically

retained, sectional prosthesis was indicated for this patient.

Magnets were used to allow horizontal movement between

the prosthesis and obturator parts in order to reduce

trauma in the lateral walls of the defect. The defect area

was isolated with a gauze-covered sponge coated with

petroleum jelly to prevent the movement of impression

material into the breathing passage. A preimpression

topical anesthetic was also used. A preliminary impression

of the dental arch was obtained with irreversible hydrocol-

loid impression material (Cavex Impressional; Cavex,

Haarlem, Holland). The diagnostic cast was poured with

type 3 dental stone (Giludur; BK Giulini, Ludwigshafen,

Germany). An autopolymerizing acrylic resin tray was

prepared on the stone cast. The border, including the

pharyngeal part, was molded. Zinc-oxide paste (Impression

paste, S.S. White Group, Gloucester, England) was placed

on the tray (excluding the defect area), and an impression

was taken. The impression of the defect was taken by

irreversible hydrocolloid material in a latex condom with

finger pressure, and master casts were poured. The master

cast’s shape revealed that the inner surface of the defect was

suitable for an undercut to retain and support an

obturator. The obturator part was fabricated with heat-

polymerized acrylic resin (Paladent 20; Heraeus-Kulzer

GmbH, Hanau, Germany). The correct path of insertion of

the obturator was deemed to be from posterior to anterior

(Fig. 2). The denture section, which included the teeth, was

produced in the usual manner by using heat-polymerized

acrylic resin. A pair of neodium magnets (NdFe B magnets;

Aksamagnet, Adapazari, Turkey) covered with thin epoxy

resin to prevent leakage were embedded in the acrylic resin

parts of the denture portion and obturator (Fig. 3).

The sectional obturator and pharyngeal component were

combined with a special hinge system and were attached to

the obturator section in the defect area with the help of a

pair of magnets (Fig. 4). A special hinge system was

produced with 1-mm diameter orthodontic round wire

(Remanium laboratory coils–round; Dentaurum Group,

Ispringen, Germany) that allowed for the flexible connec-

tion of the dynamic pharyngeal part of the prosthesis.

Positive pressure against the palatopharyngeal tissues is

generated by the spring-orthodontic loop connected with

FIGURE 1 Congenital cleft on the hard and soft palates, including uvula

on the midline.

FIGURE 2 Path of insertion of obturator portion on the horizontal plane.

FIGURE 3 Schematic view of obturator and denture portions including the

magnets on the frontal plane.

FIGURE 4 Schematic view of finished prosthesis on the sagittal plane.

Yenisey et al., PROSTHETIC TREATMENT OF CONGENITAL PALATE DEFECT 619

the functional part of the obturator. The spring-orthodon-

tic loop was adjusted to lightly touch the resting soft palate.

To eliminate complications during insertion and removal

of the obturator, approximately 6 cm of dental floss was

used to connect the denture and bulb portions; owing to the

bulk and the location of the defect, the patient was

informed that the bulb/obturator must be inserted first,

followed by the denture portion (Figs. 5 and 6). The

necessary adjustments were made to ensure that all parts

were working cohesively and that the oral and oropharyn-

geal structures were correctly oriented to the bulb and

denture base (Fig. 7).

No major problems relating to the defect area or the

prosthesis itself were observed during clinical checks at 1

and 3 weeks, and again at 3 months (Fig. 8). The patient

was further informed of the requirement for check-ups at

6 month intervals for 3 years.

DISCUSSION

Prosthetic rehabilitation for edentulous patients with

maxillary defects is often difficult due to the absence of

natural teeth. Lack of retention, stability, and support are

common prosthodontic treatment problems for patients

who have maxillofacial defects. The quality of retention of

the obturator prosthesis is dependent on direct and indirect

retention provided by any remaining teeth, defect size,

availability of tissue undercut around the cavity, and the

development of muscular control (Sasaki et al., 1984; Keyf,

2001; Parr et al., 2005).

Depending on the location of the palatal defect, there

will be varied degrees of undercut along this location into

the nasal or paranasal cavity. The objective of prosthesis

extension is to provide resistance to vertical and horizontal

displacement. The extension should not contact the septum

or the turbinates. One way of overcoming the retention

problem is to obtain accurate reproduction of undercut

areas (Mitchell et al., 1989).

FIGURE 5 Initial insertion of the obturator part. The dental floss is

connected to the denture and obturator portions for security.

FIGURE 6 Magnetically connected obturator and denture portions.

FIGURE 7 Palatal view of the finished prosthesis.

FIGURE 8 Frontal appearance of the finished prosthesis.

620 Cleft Palate–Craniofacial Journal, September 2012, Vol. 49 No. 5

Several materials and techniques have been described for

fabricating a hollow obturator bulb (Aramany, 1978;

Devlin and Barker, 1992; Martin et al., 1992). Treatmentalternatives include the use of the magnetically retained,

sectional hollow obturator as a prosthodontic solution

(Devlin and Barker, 1992; Kanazava et al., 2000). Although

silicone material is effective for obturator prostheses

because it allows profound engagement of undercuts within

the defect (McAndrew et al., 1998), a silicone obturator has

some limitations, such as its relatively heavy weight,

deformation during mastication, difficulty in polishing,and susceptibility to fungal contamination (Wang, 1997).

In this case, powerful neodium magnets, which allow little

horizontal movement between the prosthesis and obturator

parts in order to reduce stress transmission to the lateral

walls of the defect, were used for retention. Heat-cured

acrylic resin was chosen as the base material due to the

disadvantages of silicone material mentioned earlier and

because the patient had a healthy and clotless mucosalcoverage on the internal surface of the defect.

When considering maxillary defects, implants are of

great benefit in providing retention, but their use for

support and stability may be risky and not suitable for

financial reasons for all patient groups (Eckert and

Desjardins, 2000). A magnetically retained, sectional

prosthesis has provided our patient with effective speech

and mastication without complications for 3 years throughsuccessful nasopharyngeal obturation. The patient is

satisfied by the results obtained with his prosthesis.

However, long-term follow-up is necessary to monitor the

functioning of their obturator prostheses.

CONCLUSIONS

Aims of the treatment in hard and soft palate defects areto block liquid and food leakage between oral and nasal

cavities, increase the understandability of speech, and

facilitate chewing. Implants, teeth, or hard and soft tissue

undercuts can be used for retention and stability of the

prosthesis, which can be designed as a single component or

as sections according to patient edentulism and maxillary

defects. The prosthesis that was used in the current study

fulfilled the outlined treatment requirements and isrecommended as a viable solution for similar defects in

other patients.

Acknowledgment. The authors thank Gregory T. Sullivan of OYDEM,

Ondokuz Mayis University in Samsun, Turkey, for editing an earlier

version of this manuscript.

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