The Cleft Palate-Craniofacial Journal 49(5) pp.

618621 September 2012

Copyright 2012 American Cleft Palate-Craniofacial Association

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., Isl Sarkaya, D.D.S., Ph.D.
Obturator prostheses are used to improve mastication, speech, and swallowing by
reestablishing oronasal separation and aesthetics in maxillary defect patients. A sectional
and magnetically retained functional removable speech bulb prosthesis was planned to treat the
congenitally cleft hard and soft palates of this patient. The obturator part, localized into lateral
nasal undercuts covered with sound mucosa, was used to retain the complete denture. Two
pieces of the prosthesis were joined together by a magnet in the mouth. A special hinge
mechanism was added to join the complete denture and functional velopharyngeal parts of the
prosthesis for the treatment of velopharyngeal inadequacy. Sufficient retention was obtained,
and no major complications were seen in the patients 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 palates 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 patients 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 deformities 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.

Dr. Yenisey is Assistant Professor, Department of Prosthodontics,

Faculty of Dentistry, Ondokuz, Mays University, Samsun, Turkey. Dr.
Cengiz is Assistant Professor, Department of Prosthodontics, Faculty of
Dentistry, Karaelmas University, Zonguldak, Turkey. Dr. Sarkaya 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

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
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Yenisey et al., PROSTHETIC TREATMENT OF CONGENITAL PALATE DEFECT

619

FIGURE 3 Schematic view of obturator and denture portions including the

magnets on the frontal plane.
FIGURE 1 Congenital cleft on the hard and soft palates, including uvula
on the midline.

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 hydrocolloid 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
casts 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 heatpolymerized 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 coilsround; Dentaurum Group,
Ispringen, Germany) that allowed for the flexible connection of the dynamic pharyngeal part of the prosthesis.
Positive pressure against the palatopharyngeal tissues is
generated by the spring-orthodontic loop connected with

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

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

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Cleft PalateCraniofacial Journal, September 2012, Vol. 49 No. 5

FIGURE 7 Palatal view of the finished prosthesis.

FIGURE 5 Initial insertion of the obturator part. The dental floss is
connected to the denture and obturator portions for security.

DISCUSSION
the functional part of the obturator. The spring-orthodontic 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 oropharyngeal 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.

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 6 Magnetically connected obturator and denture portions.

FIGURE 8 Frontal appearance of the finished prosthesis.

Yenisey et al., PROSTHETIC TREATMENT OF CONGENITAL PALATE DEFECT

Several materials and techniques have been described for

fabricating a hollow obturator bulb (Aramany, 1978;
Devlin and Barker, 1992; Martin et al., 1992). Treatment
alternatives 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 mucosal
coverage 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 through
successful 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 are
to 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

621

fulfilled the outlined treatment requirements and is

recommended 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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