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Table of Contents
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 75-79

Hollow bulb obturator for congenital velopharyngeal insufficiency


1 Department of Prosthodontics, Modern Dental College and Research Centre, Indore, Madhya Pradesh, India
2 Department of Prosthodontics, Bharti Vidyapeeth Deemed University Dental College and Hospital, Sangli, Maharashtra, India
3 Department of Oral Surgery, Modern Dental College and Research Centre, Indore, Madhya Pradesh, India

Date of Web Publication5-Jan-2017

Correspondence Address:
Ruchi Jain
Department of Prosthodontics, Modern Dental College and Research Centre, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.197689

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   Abstract 

This case report describes oral rehabilitation of a patient with soft palate defect and subsequent velopharyngeal (Velopharyngeal insufficiency) insufficiency by velopharyngeal prosthesis. The successful rehabilitation of such kind of patient requires the team effort of health professionals. This case report describes fabrication of hollow bulb obturator for a completely edentulous patient who had a congenital or developmental defect of soft palate and not undergone any treatment previously. It is a challenging task for the prosthodontist to treat such patients. In VP defect, hypernasality, regurgitation of food and liquids are the common consequences if left untreated. A maxillary hollow bulb obturator was fabricated to prevent fluid leakage through nose, to maintain cleanliness, speech resonance, to improve physical and psychological health.
Clinical Relevance To Interdisciplinary Dentistry
A method to deal large velopharyngeal insufficiency with light weight prosthesis.

Keywords: Hollow bulb obturator, hypernasality, oral rehabilitation, regurgitation, soft palate defect, velopharyngeal insufficiency


How to cite this article:
Jain R, Shigli K, Srivastava R, Singh S. Hollow bulb obturator for congenital velopharyngeal insufficiency. J Interdiscip Dentistry 2016;6:75-9

How to cite this URL:
Jain R, Shigli K, Srivastava R, Singh S. Hollow bulb obturator for congenital velopharyngeal insufficiency. J Interdiscip Dentistry [serial online] 2016 [cited 2019 Dec 5];6:75-9. Available from: http://www.jidonline.com/text.asp?2016/6/2/75/197689


   Introduction Top


Maxillofacial prosthetics is the art and science of anatomic, functional, or cosmetic reconstructions, carried out by means of nonliving substitutes. [1] Velopharyngeal (VP) deficits may result from congenital or developmental, acquired and surgical resection. [2],[3] VP deficiencies may be classified on the basis of physiology and/or structural integrity into VP insufficiency and VP incompetency. [1] Often a speech pathologist works in conjunctions, to train the patient to adapt and adjust to the available compromised maxillofacial situation and function. [4],[5] It is more difficult to treat the palatal defects in edentulous patients as no natural teeth are present to take support from. In completely edentulous patients where the support taken only from the remaining bone, it is always mandatory to take care of what is remaining while keeping in mind what is lost. [6]


   Case Report Top


A 55-year-old male patient reported to the Department of Prosthodontics, Modern Dental College and Research Centre, Indore, for replacement of missing teeth and to close palatal opening extending from posterior part of the hard palate to the soft palate. He had difficulty in mastication and deglutition due to nasal reflex of food and also complained of hypernasal speech. The patient has not undergone any treatment previously for palatal opening due to fear of intrusion inside the airway passage [Figure 1].
Figure 1: Preoperative view

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Extraoral examination revealed reduced fullness due to loss of teeth. On intraoral examination, a large defect presented on the posterior part of the soft palate, making the oral and nasal cavity communicated. It may be a congenital/developmental Velopharyngeal insufficiency. Uvula showed normal mobility. V-shaped maxillary edentulous arch with shallow palate was present [Figure 2].
Figure 2: Velopharyngeal defect

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Along with the replacement of all missing teeth, hollow bulb obturator prosthesis was planned for the patient. The entire procedure explained to the patient and his consent taken.

The soft palatal defect blocked with gauze piece and primary impression of maxillary arch made in irreversible hydrocolloid impression material using stock tray [Figure 3] and poured in dental plaster. In retrieved primary cast, defect was blocked with gauze piece, a full spacer was adapted leaving the defect, and custom tray was fabricated using autopolymerizing acrylic resin. Border molding was carried out with low fusing impression compound by sectional method. At the defect site, the tray was perforated and tray adhesive applied. Putty material [Figure 4] used to record the defect area by asking the patient to move his head in circular manner from side to side, to swallow and to speak, while the wash impression of complete maxillary arch was made in light body rubber base impression material [Figure 5]. Final cast was poured in die stone; record base was made after blocking the defect with gauge piece and occlusal rims were fabricated. Jaw relations along with face-bow transfer was recorded [Figure 6] and transferred to a semi-adjustable articulator. Centric relation was recorded by static method using Aluwax, and a protrusive record was also made. This protrusive record was then used to determine the condylar guidance. The lateral guidance was calculated using Hanau's formula and incisal guidance kept at 10. Using these values, the tentative teeth arrangement and their angulations altered to attain a proper bilateral balanced occlusion. Dentures were processed after try-in of the waxed up dentures. In dewaxed maxillary denture base flask, hollow bulb was fabricated [Figure 7]. Modeling wax was used to block the undercuts of defect in the cast of base flask. A layer of modeling wax adapted on the walls of the defect area and three orientation grooves carved in the wax in anterior, posterior, and inferior area. Corresponding wax lid was adapted on counter flask and an orientation groove carved in the center of wax lid [Figure 8] and [Figure 9]. A thin layer of autopolymerizing acrylic resin applied over the wax of defect in base and counter flask and closed for self-curing. Then, flask was dewaxed and acrylic shim retrieved from maxillary defect area [Figure 10] and [Figure 11]. Packing done with heat cure acrylic resin in usual manner by placing the shim in position on defect using orientation groove and curing was done. Denture was finished polished and placed in patient's mouth [Figure 12] and evaluated for proper extension using pressure indicating paste. Insertion, removal, and postinsertion instructions were given, and regular follow-up was advised. The patient satisfied with the prosthesis since there was marked improvement in his speech and pronunciation.
Figure 3: Primary impression

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Figure 4: Recording of defect with putty

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Figure 5: Final impression procedures

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Figure 6: Face-bow transfer

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Figure 7: Dewaxing

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Figure 8: Hollow bulb fabrication (base flask)

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Figure 9: Hollow bulb fabrication (counter flask)

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Figure 10: Chemically cured hollow bulb (on cast)

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Figure 11: Chemically cured hollow bulb

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Figure 12: Intraoral maxillary hollow bulb obturator

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   Discussion Top


Definitive prosthodontic treatment is one of the final therapies which instituted and attempts to alleviate any anatomical and functional deficiencies. [4],[7] When surgery is not an option, prosthetic management of VP insufficiency is treated with a pharyngeal obturator whereas VP incompetence is traditionally managed by palatal lift prosthesis. [8] Obturator prostheses vary according to the location and nature of the defect. [4],[9],[10],[11],[12] Obturator also differs for developmental or congenital malformations and acquired defects. [2],[4] Controlling thickness of hollow obturator walls is important to provide adequate strength and weight of the prosthesis. [13] A full bulb is likely to increase the weight of the prosthesis and, therefore, it cannot be used successfully. A hollow bulb prosthesis is a better choice. [6] The weight of the prosthesis is reduced, making it more comfortable, efficient, retentive and increases physiologic function. [1],[13],[14] It may be open or closed and one piece or two pieces. [6],[13],[14] The literature has been reported various materials such as salt, ice, sugar, vinyl polysiloxane, [13] plaster, polyurethane foam, [14] nondetachable screw cap, and gas injection technique [6] used. The material should be biocompatible, impermeable, smooth, and easily made. [13] Disadvantages [13] of using these materials are that once the obturator is formed, the embedded material has to be removed by making a hole and sealed with autopolymerizing resin while in used method the thin autopolymerizing shim is completely surrounded by heat cure acrylic resin, as the unreacted monomer being less in heat polymerized acrylic resin, and risk of its leaching is also reduced. [15],[16]


   Conclusion Top


The prosthodontist plays a significant role in the complete rehabilitation of the palatal defect. Thorough knowledge and skills coupled with a better understanding the needs of the patient enable the successful rehabilitation. The instituted treatment has salved the functional, psychological, and esthetic needs of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The contribution and efforts of the team from the Department of Prosthodontics, Modern Dental College and Research Centre, is highly appreciated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Shetty NB, Shetty S, Nagraj E, D'Souza R, Shetty O. Management of velopharyngeal defects: A review. J Clin Diagn Res 2014;8:283-7.  Back to cited text no. 1
    
2.
Hooda S, Rampal N, Pawah S, Gupta A, Madan B, Shukla B, et al. Velopharyngeal defect - A case report. A Journal of Clinical Dentistry- Heal Talk 2012;4:43.  Back to cited text no. 2
    
3.
Shifman A, Finkelstein Y, Nachmani A, Ophir D. Speech-aid prostheses for neurogenic velopharyngeal incompetence. J Prosthet Dent 2000;83:99-106.  Back to cited text no. 3
    
4.
Ram HK, Shah RJ. A novel approach for velopharyngeal prosthetic rehabilitation: Case series. Int J Healthc Biomed Res 2013;1:70-6.  Back to cited text no. 4
    
5.
Johns DF, Rohrich RJ, Awada M. Velopharyngeal incompetence: A guide for clinical evaluation. Plast Reconstr Surg 2003;112:1890-7.  Back to cited text no. 5
    
6.
Dable R. A hollow bulb obturator for maxillary resection in a completely edentulous patient - A case report. J Clin Diagn Res 2011;5:157-62.  Back to cited text no. 6
    
7.
Schneider A. Method of fabricating a hollow obturator. J Prosthet Dent 1978;40:351.  Back to cited text no. 7
    
8.
Fernandez T, Harshakumar K, Ravichandran R, Lylajam S. Prosthetic rehabilitation of a velopharyngeal defect: A case report. IOSR J Dent Med Sci 2015;14:1-5.  Back to cited text no. 8
    
9.
Tuna SH, Pekkan G, Gumus HO, Aktas A. Prosthetic rehabilitation of velopharyngeal insufficiency: Pharyngeal obturator prostheses with different retention mechanism. Eur J Dent 2010;4:81-7.  Back to cited text no. 9
    
10.
Yoshida H, Michi K, Yamashita Y, Ohno K. A comparison of surgical and prosthetic treatment for speech disorders attributable to surgically acquired soft palate defects. J Oral Maxillofac Surg 1993;51:361-5.  Back to cited text no. 10
    
11.
Wolfaardt JF, Wilson FB, Rochet A, McPhee L. An appliance based approach to the management of palatopharyngeal incompetency: A clinical pilot project. J Prosthet Dent 1993;69:186-95.  Back to cited text no. 11
    
12.
Saunders TR, Oliver NA. A speech-aid prosthesis for anterior maxillary implant-supported prostheses. J Prosthet Dent 1993;70:546-7.  Back to cited text no. 12
    
13.
Alva H, Prasad KD, Prasad AD. Prosthodontic rehabilitation of a patient with hollow bulb obturator: A case report. NUJHS 2012;2:60-2.  Back to cited text no. 13
    
14.
Agarwal P, Shah RJ. Case report: Two piece hollow bulb obturator for postsurgical partial maxillectomy defect in dentulous patient. Indian J Basic Appl Med Res 2012;2:438-42.  Back to cited text no. 14
    
15.
Kurian BP, Kumar RP, Shajahan PA. Maxillectomy defect rehabilitation with obturator prosthesis - A case report. Int J Contemp Dent 2011;2:118-21.  Back to cited text no. 15
    
16.
Chalian VA, Drane JB, Standish SM. Multidisciplinary Practice. Maxillofacial Prosthesis. Baltimore: The Williams and Wilkins Co.; 1972. p. 133-57.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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