PRINCIPLES OF DESIGNING MAXILLOFACIAL

PROSTHESIS – MAXILARY DEFECTS

DR. LITHIYA Susan John

Post graduate student
Department of Prosthodontics
INTRODUCTION
• The reconstruction of oral defects caused mainly due to ablative tumour
resection has undergone a change in philosophy over the past three
decades.

• The aim of oral cancer treatment is not only to preserve life but also to
provide quality of life by achieving better facial aesthetics and oral
function.

• The maxillofacial prosthodontist contributes to all facets of patient care,

from diagnosis and treatment to rehabilitation.
ANATOMY OF MAXILLA
GENERAL ANATOMY
HARD PALATE
MAXILLARY SINUS
ETIOLOGY OF ACQUIRED MAXILLARY
DEFECTS
 
 MAXILLARY
MAXILLARY DEFECTS CAUSED
DEFECTS CAUSED DUE TO SURGICAL
BY DISEASE RESECTION OF
TUMOURS

MAXILLARY
DEFECTS CAUSED
DUE TO TRAUMA
MAXILLARY DEFECTS CAUSED BY DISEASE

SALIVARY GLAND
TUMOURS (PLEOMORPHIC
EPIDERMOID CARCINOMA ADENOMA, ADENOID
(MOSTLY ARISING FROM CYSTIC CARCINOMA,
THE MAXILLARY SINUS) MUCOEPIDERMOID
CARCINOMA AND
ADENOCARCINOMA)
 MALIGNANT MESENCHYMAL
TUMOURS (LYMPHOSARCOMA, BENIGN MESENCHYMAL
RHABDOMYOSARCOMA, TUMOURS (FIBROMA,
CHONDREOSARCOMA, HAEMANGIOMA,
NEUROFIBROSARCOMA, ANGIOLEIOMYOMA,
ANGIOSARCOMA AND ANGIOBLASTOMA, FIBRO
OSTEOSARCOMA) LIPOMA AND MYXOMA).
•
CLASSIFICATION OF MAXILLARY DEFECTS
 
ARMANYS CLASSIFICATION

Class 1

• Resection in this group is performed along the

midline of the maxilla; the teeth are maintained on
one side of the arch. This is the most frequent
maxillary defect.
 Class II

• The defect in this group is

unilateral, retaining of anterior
teeth on both sides and posterior
teeth on the contralateral side.

• This type of surgical resection is

favoured more than the classical
maxillectomy.
CLASS III

• The palatal defect occurs in the

central portion of the hard palate
and may involve part of the soft
palate.

• The surgery does not involve the

remaining teeth.
CLASS IV

• The defect crosses the midline

and involves both of the maxillae.

• A few teeth remain and lie in a

straight line, and may create a
unique design problem similar to
the unilateral design of
conventional removable partial
dentures
CLASS V

• The surgical defect in this

situation is bilateral and lies
posterior to the remaining teeth.

• Labial stabilization may be

needed, and splinting of
remaining teeth is advisable.
CLASS IV

• It is rare to have an acquired maxillary

defect anterior to the remaining abutment
teeth. This occurs mostly in trauma rather
than as a planned surgical intervention.

• In this class, cross-arch stabilization is

derived through a system of cross-arch
bars which will provide wide distribution of
support and retention from separated
abutment teeth.
WELLS CLASSIFICATION

• Loss of midfacial skin only

CLASS 1

• Partial maxillectomy with complete palate and orbital

CLASS II floor

• Partial maxillectomy with resection of portion of palate.

CLASS III Orbital floor and Lockwood’s ligament are intact
 • Total maxillectomy with palatectomy with orbital
support being intact
CLASS IV

• Total maxillectomy with palatectomy with loss of orbital

support.
CLASS V
CLASSIFICATION BY SPIRO

• Limited maxillectomy- removal of one wall of antrum

Class I

• Subtotal maxillectomy- removal of at least 2 walls

CLASS including palate
II

• Total maxillectomy- complete resection of maxilla

CLASS
III
CLASSIFICATION OF MAXILLARY DEFECTS BY UMINO ET AL.

CONFINED TO MAXILLARY DEFECT

1. No communication between oral and nasal cavities

2. Communication between oral and unilateral nasal cavity

3. Communication between oral and bilateral nasal cavities

Confined to anterior of soft palate in addition to hard palate

1. Communication between oral and unilateral nasal cavity

2. Communication between oral and bilateral nasal cavities

CLASSIFICATION BY DAVISON ET AL.

Partial
Complete maxillectomy
maxillectomy (supra-structure
or infra-structure)
CLASSIFICATION

• VERTICAL

I. No oroantral fistula

II. Low maxillectomy (at level of sinuses and nasal cavity but not involving
orbital floor and contents

III.High maxillectomy (involving orbital contents with globe preservation)

IV. Radical maxillectomy (includes orbital exenteration with or without

resection of anterior skull base)
• HORIZONTAL

I. Unilateral alveolar and palatal resection less than or equal to half

II. Bilateral alveolar and palatal resection

III.Total alveolar and palatal resection

Classification by Triana et al.

Inferior or partial
Inferior or partial
maxillectomy,
maxillectomy with
including defects of
subtotal or total
the hemi palate and
palate defects
anterior arch

Total maxillectomy
with and without
orbital exenteration
CLASSIFICATION BY CORDEIRO ET AL.

2. Sub-total (resection of
the maxillary arch,
1. Limited (1 or 2 walls
palate, anterior and
of the maxilla, excluding
lateral walls with
the palate)
preservation of orbital
floor)

III a- Total (resection of all 6 walls of the 4. Orbito-maxillectomy

maxilla with preservation of orbital contents (resection of the orbital
• III b- Total (resection of all 6 walls of the contents and upper 5
maxilla with orbital exenteration) walls of the maxilla, with
preservation of the
palate)
CLASSIFICATION BY FUTRAN ET AL.

b. Total maxillectomy
A. Inferior
without orbital
maxillectomy
exenteration

c. Total maxillectomy
with orbital
exenteration
Classification by Rodriguez et al.

I. Unilateral dentoalveolar defect

II. Missing inferior orbital rim in addition to ipsilateral maxilla

III.Bilateral maxillary dentoalveolar loss

IV.Bilateral maxillary dentoalveolar loss and at least one orbital rim45

Classification of maxillary defects by Okay DJ et al.

THREE GROUPS

TWO SUB GROUPS

CLASS IA

• Defects that involve the hard palate but not the tooth-bearing alveolus
TREATMENT OPTIONS

LOCAL
OBTURATOR ADVANCEMENT
FLAP

FASCIO
CUTANEOUS
FREE FLAP
CLASS 1B

• Defects that involve premaxilla or any portion of maxillary alveolus and

dentition posterior to canines

• The theoretic cantilever forces over the defect are minimized.

• So movement of the obturator around the fulcrum line could be
stabilized.
FACTORS CONTRIBUTED TO STABILITY

SUPERIOR ROOT
ARCH LENGTH
MORPHOLOGY

TREATMENT OPTIONS
• A soft tissue flap is indicated without osseous reconstruction because
the remaining dentition and palate are able to support occlusal contacts
over the reconstruction with a removable partial denture.
CLASS II

• Defects that involve any portion of the tooth bearing maxillary alveolus
but included only one canine
• The anterior margin of these defects is within the premaxilla.

• Anterior transverse palatectomy defects that involve less than one half of
the palatal surface
FACTORS CONTRIBUTING TO INSTABILITY

FEWER TEETH FOR REDUCED ARCH

CLASPING SIZE AND FORM

A SIGNIFICANTLY
DIMINISHED
SUPPORTING
PALATE.
TREATMENT OPTIONS

• Obturator alone will be insufficient

• vascularized bone containing free flaps.

Class III

• Defects that involve any portion of the tooth bearing maxillary alveolus
and include canines, total palatectomy defects, and anterior transverse
palatectomy that involve more than half of the palatal surface
TREATMENT OPTIONS

• Poor prognosis

• vascularized bone-containing free flaps (VBCFF). Soft tissue

reconstruction of a Class III defect
SUBCLASSES F AND Z

• Defects that involve the inferior

orbital rim are categorized as
subclass f, whereas defects that
involve the body of the zygoma
are categorized as subclass- z.
 SURGICAL VERSUS PROSTHETIC
REHABILITATION!
• If the defect
  is the result of trauma, immediate surgical closure or
reconstruction is indicated.

• The soft tissues are approximated, the mucosa is closed, and raw
surfaces are left to granulate or are covered with a split-thickness skin
graft.

• If the defect is large, then closure may require local or regional flaps.

• Closure of oncologic defects with local flaps, myocutaneous flaps, or

free vascularized flaps can be accomplished immediately following
resection of the tumour.
• For benign tumours, negative margins from frozen sections are a
minimal requirement for surgical closure of a palatal defect.

• If any doubt about the margins or about the benign nature of the tumour,
the defect should remain open until the permanent histologic sections
are available.

• Closure of the defect could make the subsequent surgery for persistent
tumour more difficult for the surgeon and result in a greater loss of tissue
for the patient.
 DESIGNING OF OBTURATOR PROSTHESIS
 

• Serve to separate the oral cavity from the nasal and sinus cavities and
make the oral cavity whole again for appropriate function.

• The obturator portion of the prosthesis must add stability and retention
by extending far enough into the defect to seal it and engage some small
undercuts to help in holding the prosthesis in position.
DEFINITIONS

• Obturator :1. A maxillofacial prosthesis used to close a congenital or

acquired tissue opening, primarily of the hard palate and/or contiguous
alveolar/soft tissue structures(GPT-9)

Surgical Interim Definitive

Principles in the Framework Design of Maxillary
Obturator Prosthesis by Parr GR

(2) Guide planes

(1) The need for a and other 3) A design that
rigid major components that, maximizes
connector facilitate stability support
( and bracing

(5) Direct retainers that

) Rests that place are passive at rest and
supporting forces along (6) Control of the occlusal
provide adequate
the long axis of the plane that opposes the
resistance to
abutment tooth defect, especially when it
dislodgment without
involves natural teeth.
overloading the
abutment teeth
FORCES IMPORTANT IN DESIGNING OBTURATOR

Vertical Rotational
upward forces

Anterior –
posterior
forces
FACTORS DETERMINING PROGNOSIS OF OBTURATOR

(2) The quality of the

The size (amount tissue covering the
remaining after ridge and lining the
surgery) and defect
curvature of the arch

3) An abutment (4) The availability of

alignment that is teeth on the defect
curved instead of side for support and
linear retention.
 Review
• Many designs require full coverage of the remaining palate for maximum
support.

• In all instances, the gingival margins should be relieved when they are
crossed by the major connector to avoid impingement during function.

• The uncovering of the gingival margins in such a design should be

discouraged because it is not a replacement for good oral hygiene and is
probably not necessary for tissue stimulation if good hygiene is practiced.

Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral oncology. 2009
Apr; 45(4-5):309-16.
DESIGN OF MAXILLARY OBTURATOR FRAMEWORK IN ARAMANY’S
CLASS I DEFECT -CURVED ARCH FORM
• Support is provided and shared by the remaining natural teeth, the
palate, and structures in the defect that may be contacted for this
purpose.

• The goal is to ensure that the functional load is distributed as equally as

possible to each of these structures via a rigid major connector.

• The natural teeth are aided in this action when the support regions of the
palate and the defect are loaded to their maximum, without physiologic
overload.

• A broad square or ovoid palatal form aids by providing a greater tissue

bearing surface to resist upward forces (such as occlusal load) and a
greater potential for tripodization to improve leverage.
• A tapering arch is less of an aid. Rests are placed on the most anterior
(Closest to the defect) and the mesio-occlusal surface of the most distal
abutment tooth when alignment and occlusion will permit.

• The mesio-occlusal posterior rest, most often located between adjacent

posterior teeth, is accompanied by a rest on the disto-occlusal surface of
the more anterior adjacent tooth.

• This additional rest will prevent wedging and separation of the two
adjacent teeth and will decrease the possibility of periodontal damage
from food impaction.
• Guide planes will assist in the precise placement of the prosthesis once
the teeth have been contacted.

• They will also ensure more predictable retention and add a greater
degree of stability to the prosthesis.

• Guide planes on the anterior abutment should be restricted to a

minimum vertical height (1 to 2 mm) to limit the torque on the abutment
teeth and should be physiologically adjusted.
• Important to use the palatal surfaces of the posterior teeth for additional
bracing and stability.

• An indirect retainer is usually located perpendicular to the fulcrum line

(which connects the most anterior and most posterior rests) and as far
forward as possible.

• This is usually a canine or first premolar.

• Strategically placed indirect retainers allow maximum use of leverage to

resist movement of the prosthesis in a downward direction by the pull of
gravity acting on the defect side.
• Retention is supplied by direct retainer designs that allow maximum
protection of the abutment teeth during functional movements.

• On the anterior abutment, a 19- or 20-gauge wrought wire clasp of the “I-
bar” design is often used to engage a 0.25 mm under cut on the mid
labial surface of this abutment.

• Additional protection is afforded to this tooth by splinting it to one or two

adjacent teeth with full crowns when possible or acid-etch composite
resin techniques when crowns are not possible.

• Other possibilities include a variety of cast clasp assemblies located on

the height of contour for frictional retention only.
• The posterior retainer is most often a cast circumferential clasp using
0.25 mm undercut on the buccal surface.

• The placement of posterior clasps facing in both an anterior and

posterior direction will aid in retaining both the anterior and posterior
portions of the prosthesis.
Design of maxillary obturator framework in Aramany’s Class I defect-
Linear Arch Form

• Class I defect when there are no anterior teeth present or when one
does not desire to use the anterior teeth.

• The remaining posterior teeth are usually in a relatively straight line.

• In the linear design, support is provided by the remaining posterior teeth

and the palatal tissues.

• Retention is usually provided by the combined use of buccal premolar

retention and lingual molar retention.
DESIGN OF MAXILLARY OBTURATOR FRAMEWORK IN ARAMANY’S
CLASS II DEFECT

• Class II includes arches in which the

premaxilla and the premaxillary dentition on
the contralateral side is maintained.

• A single, unilateral defect is located posterior

to the remaining teeth.

• a bilateral, tripodal design can always be used.

• Support – rests and plate

• Double rests are used between adjacent posterior teeth. Guide plane
location and size is similar to the class I situations with full use of palatal
surfaces of the posterior teeth.
• An indirect retainer located opposite the fulcrum line and as far forward
as possible usually is located on the canine or first premolar and
completes the tripodal design.
• Adjacent abutment should be engaged with direct retainer design that
resists downward displacement but tends to rotate, disengage, or flex
when upward forces are applied.

• A cast circumferential claps or an I-bar clasp is frequently used in a

0.25mm undercut when the retentive terminus can be located on the
fulcrum line.

• A 19-gauge wrought wire clasp in a 0.5mm or less mesiofacial undercut

is also a frequent choice.

• Additional protection can be provided for this tooth by splinting it to one

or two teeth adjacent to it.
• The posterior retainer is most frequently a cast circumferential clasp
using a 0.2mm distobuccal undercut.

• The anterior facing clasp will also serve to aid additional clasps, placed
opposite the fulcrum line from the defect.

• Canine is frequently the location of the indirect retainer and also serves
as an additional (but optional) retentive site, engaged with a 19-gauge
wrought wire clasp in a 0.25mm undercut.

• Canine is important in resisting occlusally directed forces and will receive

severe stress.
DESIGN OF MAXILLARY OBTURATOR FRAMEWORK IN ARAMANY’S
CLASS III DEFECT

• Class III involves a midline defect of the hard palate and may include a
variable portion of the soft palate as well

• Support is supplied by the remaining natural teeth via widely separated

and bilaterally located rests.

• The canines and molars are usually selected to generate the largest
quadrilateral shape possible while avoiding alignment and occlusion and
hygiene problems, and providing good aesthetics.
Bilateral symmetry of the major connector design and avoidance of
the rugae area is desirable when possible.

Guide planes are usually short because they are located on the
palatal surfaces of the posterior teeth.

The proximal surfaces may be liberally used if edentulous spaces are

present.
• Indirect retention is not required because each terminus is supported by
a direct retainer; therefore, rotation around a common fulcrum should not
occur.

• Retention is often provided with cast retainers using 0.25 mm undercuts

on the facial surfaces of the teeth.

• These may be circumferential retainers; I-bars, or modified T-bars,

depending on the location of the retentive sites, the aesthetic
requirements, and the presence of tissue undercuts.
DESIGN OF MAXILLARY OBTURATOR FRAMEWORK IN ARAMANY’S
CLASS IV DEFECT
• Support is usually provided by rests located centrally on all of the
remaining teeth. channel rests or multiple mesio-occlusal and disto-
occlusal results are often designed.

• The defect should also be engaged to use, as much as possible, any

sites within the defect that may be contacted.

• These are the midline of the palatal incision, when palatal mucosa has
been preserved to cover this region, the floor of the orbit, the bony
pterygoid plates, and the anterior surfaces of the temporal bone
• Retentive sites should be located on the facial surfaces of the remaining
teeth and the lateral wall of the surgical defect via the superolateral
extension of the obturator section in the engagement of the lateral scar
band.

• If no lateral scar band exists, because a split-thickness skin graft was

not placed or because one could not be maintained, the prosthodontist
may have no choice but to use a combination of buccal and palatal
retention.
DESIGN OF MAXILLARY OBTURATOR FRAMEWORK IN ARAMANY’S
CLASS V DEFECT
• Support is provided with rests located on the mesio-occlusal surface of
the most posterior abutment.

• These rests define the fulcrum line around which most of the expected
movement will occur.

• If adjacent posterior teeth are involved double rests are used double
rests are used for reasons outlined earlier.

• Stabilization and bracing is provided by broad palatal coverage and

contact with the palatal surfaces of the remaining teeth.

• Indirect retention is provided by rests located as far forward of the

fulcrum line as possible.
• The location of the indirect retainer essentially converts the design to an
efficient large tripod that uses leverage to resist downward displacement
of the prosthesis.

• Positive rests seats are a critical necessity

• Retention is provided by I- bar retainer.

• The I-bar retainer is ideally suited for this situation. Located in a 0.25mm
mid buccal undercut very close to the fulcrum line, it provides for
resistance to dislodgement and rotates in function
DESIGN OF MAXILLARY OBTURATOR FRAMEWORK IN ARAMANY’S
CLASS VI DEFECT
• Support is provided by rests located on the disto-occlusal surfaces of the
most anterior abutment teeth.

• Doubles rests are used when adjacent posterior teeth are involved.

• Greater stability is provided by placing additional rests as far posteriorly

as possible.
• The most posterior rests, -indirect retainers, resisting the vertical
downward displacement of the anterior segment of the prosthesis.

• In extremely large class VI situations, indirect retention may not be

possible.

• Guide planes are usually located on the proximal surfaces adjacent to the
defect and should be kept to minimal length (1 to 2 mm) to avoid trauma
to the abutment teeth during expected movements of the prosthesis.

• Splinting with a cross arch tissue bar is also a possibility.

• Retention is most often provided simply with cast retainers using 0.25
mm of facial undercut.

• The I-bar located on the anterior abutment in a midfacial undercut close

to the fulcrum line can function effectively
Partial denture design concepts for maxillary defects by Curtis TA

• (1) Major connectors should be rigid.

• (2) Occlusal rests should direct occlusal forces along the long axis of the teeth,

• (3) Guide planes should be designed to facilitate stability and bracing,

• (4) Retention should be within the physiologic limits of the periodontal ligament.

• (5) Maximum support and stability should be gained from the residual soft
tissue denture bearing surfaces including the defect.
FULCRUM LINE
•

• The position of the occlusal or cingulum rests

• The size and configuration of the defect
• The magnitude and location of masticatory forces
on the defect side of the prosthesis

The classical fulcrum line may only be functional when little or no occlusal force
is evident on the defect side.
• For example, tapering arches invariably have less palatal shelf available
for support and the remaining dentition is more likely to exhibit a linear
configuration.

• If the teeth are in a linear or straight line, the fulcrum line will essentially
be identical with the tooth alignment.

• Therefore, patients with tapering arches, having linear tooth and arch
arrangements, will tend to exhibit more movement around the fulcrum
line as compared to patients with square and ovoid arch forms.
DEGREE OF MOVEMENTS

• When the pressure is released, the prosthesis will return to its former
rest position under the influence of weight and gravity.

• The size of the defect is the most important indicator of the degree of
movement of the prosthesis during function, as the larger the defect the
greater the potential for movement.
CONSIDERATIONS IN OBTURATOR PROSTHESIS DESIGN BY
DESJARDINS RP

Support

• Support is the resistance to movement of prosthesis toward the tissue.

The support available from the residual maxilla and from within the
defect both must be considered.
RESIDUAL MAXILLA SUPPORT

Residual teeth

Alveolar ridge

Residual hard palate

RESIDUAL TEETH

• Carious involvement of the remaining teeth should be treated and their

periodontal status made optimal.

• Support is also provided by the placement of occlusal rests, cingulum

rest and incisal rest.
ALVEOLAR RIDGE

• Large, broad ridge or the ridge with a square or ovoid provides better support than
the small, narrow ridge with a tapering contour.

• In patient with a retained premaxillary segment or a tuberosity, the arch form is

improved and also the support.

• The healthy well-formed edentulous ridge with extensive sulci will enhance support.
RESIDUAL HARD PALATE

• The palate shelf is located perpendicular to the direction of the occlusal

stress and provides considerable support during function.

• The broad, flat palate is more conducive to support than the high
tapering palate.

• Large palatal tori and pendulous soft tissues should be removed

because the prosthesis will require relief and this will decrease the
support.
SUPPORT WITHIN DEFECT

Floor of the orbit

Pterygoid plate

Nasal septum
Floor of the orbit
• Use of the floor of the orbit for support should be minimal. It cannot be
used for support, if orbital floor has been removed then the orbital
contents will move with the movement of the prosthesis.

• Drawbacks:

• If prosthesis is extended up to the orbital floor it would make insertion

through the oral opening difficult, unless a two-piece sectional prosthesis
is used.
Pterygoid plate
• Positive contact of the prosthesis with this bony structure can be relatively extensive and adequate to
tripod the support for an obturator prosthesis.
NASAL SEPTUM

 It is a poor support for extensive prosthesis because,

 It is partly cartilage

 Has little bearing area

 Is covered with nasal epithelium.

• Residual maxilla retention

• Obturator prosthesis design differs for the dentulous and the edentulous
patient. The structures in the remaining maxilla amenable to providing
obturator retention are limited to the remaining natural teeth and the
alveolar ridge.
• Teeth

• If the defect is small and remaining teeth are stable, intra coronal
retainer can be used.

• If the defect is large and some or all teeth are weak, extra coronal
retainers should be used.

• Alveolar ridge

• A large ridge with a broad ridge crest and broad, flat palate is more
retentive than small ridge with tapering ridge crest and high, tapering
palate.
• A) Residual soft palate

• Provides posterior palatal seal and minimizes passage of food and liquid
above the prosthesis. Extension of the obturator prosthesis onto the
nasopharyngeal side of the soft palate provides

• B) Residual Hard Palate

• Under cuts along the line of palatal resection into, nasal or para nasal
cavity or medial wall of defect can increase retention.

• Obturator extension into the undercut is best provided by a soft denture

base material.
• C) Lateral Scar Band

• For adequate surgical closure, most maxillary resections are lined with
split – thickness skin graft along the anterior lateral and postero – lateral
walls of defects.

• This results in the formation of scar band which is more prominent in

laterally and postero – laterally as compared to scar band anterior to
premolar region.

• These act as good undercuts for retention.

• D) Height of lateral wall

• Engaging lateral wall of defect provides indirect retention.

• Longer radius undergoes less vertical displacement than the shorter

radius.
STABILITY
• Residual maxilla
• If natural teeth remain, the bracing components of the prosthesis
framework can be used to minimize movement in all three directions.

• It is advantageous to provide maximal bracing and to extend this

bracing interproximally when possible to minimize rotational as well as
anteroposterior movement of the prosthesis.

• In edentulous patients maximal extension of the prosthesis

commensurate with good complete denture design.

• Maximal extension into the mucobuccal fold, and especially the

distobuccal extension as the buccal flange approaches the hamular
notch, is important in minimizing movement within the horizontal plane.
STABILITY WITHIN DEFECT

• Maximal extension of the prosthesis in all lateral directions

• Impingement on the mandible in function, however, must be avoided.

• Special emphasis must be placed on maximal contact with the medial

line of resection, the anterior and lateral walls of the defect, the pterygoid
plates, and the residual soft palate.
 43.

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117(5):101-5.
• Chaurasia BD. BD Chaurasia's Human Anatomy. CBS Publishers &
Distributors Pvt Ltd New Delhi, IN; 2010.
• Beumer J, Curtis TA, Marunick MT. Maxillofacial rehabilitation:
prosthodontic and surgical considerations. Ishiyaku Euroamerica; 1996.
• Aramany MA. Basic principles of obturator design for partially
edentulous patients. Part I: Classification. J Prosthet Dent. 1978 Nov;
40(5):54-7.

• Bidra AS, Jacob RF, Taylor TD. Classification of maxillectomy defects: a

systematic review and criteria necessary for a universal description. J
Prosthet Dent. 2012 Apr; 107(4):261-70.

• Okay DJ. Prosthodontic guidelines for surgical reconstruction of the

maxilla: A 2-2---classification system of defects. J Prosthet Dent. 2001
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