TOPICS OF INTEREST

The Use of Biomechanical Orthodontic

Treatment Concepts for Removable
Appliances in Maxillofacial Prosthodontics.
Part I: Review of Prosthesis
Design Principles
Meade C. van Putten, Jr, DDS, MS

Maxillary cuspids are commonly included in ablative block resections in maxillectomy patients.
Although the remaining incisors are poor abutments for interim or definitive obturators, they must
be used if adequate retention and support is to be achieved. Orthodontic biomechanical concepts for
removable appliances offer solutions for the treatment of these patients. The proper application of
these concepts can improve retention, support, and force distribution to the anterior teeth and is
particularly useful in younger patients when long-term maintenance of teeth is critical. The purpose
of this article is to describe the rationale for this approach and its application to interim and
definitive Aramany Class I and II obturators.
J Prosthodont 2002;11:4-10. Copyright © 2002 by The American College of Prosthodontists.

INDEX WORDS: cancer, maxillectomy, interim and definitive obturator

L OSS OF CUSPIDS is a frequently encountered

problem in the postsurgical management of
patients with maxillary obturators. The absence of
cuspids has a significant influence on treatment
decisions and framework designs. The immediate
consequence is the need to depend on the remain-
ing incisors as abutments, despite the fact that
incisors are less than ideal abutments for the sup-
port and retention of removable prosthetic devices.
In addition, the bony support for these abutments is
often compromised as a result of surgical proce-
dures, further complicating treatment options.
The acquired defect provides minimal stability
and support for an obturator prosthesis. Although
every attempt is made to minimize obturator rota-
Associate Professor of Restorative and Prosthetic Dentistry, The Ohio
State University College of Dentistry, and Director of Maxillofacial
Prosthodontics, The A. G. James Cancer Hospital and Solove Research
Institute, Columbus, OH.
Accepted January 9, 2002.
Correspondence to: Meade C. van Putten, Jr, DDS, MS, Associate
Professor of Restorative and Prosthetic Dentistry, The Ohio State Univer-
sity College of Dentistry, 305 West 12th Avenue, Columbus, OH 43210-
1241. E-mail: vanputten.1@osu.edu
Copyright © 2002 by The American College of Prosthodontists
1059-941X/02/1101-0003$35.00/0
doi:10.1053/jpro.2002.32248
tion, it is frequently an unavoidable consequence of
the ablative procedures. Obturator movement and
rotation can cause excessive tipping, and rotational
and torquing forces on anterior abutments. Never-
theless, these teeth must be used because of the
patient’s compromised maxillary arch.1
Class I tripodal and Class II are the Aramany
maxillectomy classifications that use incisors as
abutments for obturator prostheses.2 Aramany pro-
posed avoiding placement of clasps on incisor abut-
ments of Class I linear designs.3,4 He recognized
that the physiologic limits of the incisors would
most likely be exceeded by the placement of clasps.
Curtis and Beumer5 also recognized these problems
and proposed the use of non-locking designs to
reduce stresses to incisor abutments that supported
obturators. They advocated placing a rest and re-
tainer on the incisor closest to the anterior margin
of the defect to provide adequate support and re-
tention of the prosthesis, with clasps designed to
disengage during functional and parafunctional clo-
sure. They5 also suggested post-endodontic ampu-
tation for anterior abutments with compromised
bony support to increase longevity. Although a sin-
gle clasping system was not advocated, infra-
bulge (I-bars) clasps were the predominant type
shown in their illustrations.

4 Journal of Prosthodontics, Vol 11, No 1 (March), 2002: pp 4-10

 March 2002, Volume 11, Number 1
Another approach to obturator construction has
been the Swing-Lock design.6-8 This design is indi-
cated when major anterior abutments such as cus-
pids have been lost because it allows the distribu-
tion of retentive clasps to all remaining anterior
and posterior teeth, thereby reducing the localiza-
tion of stresses to individual abutments. Although
support and retentive forces are more widely dis-
tributed, the use of cast infrabulge clasps may dam-
age the teeth and periodontium if the prosthesis is
not properly maintained (eg, poor oral hygiene, loss
of occlusal support, etc). Furthermore, this design
can pose problems for elderly patients with limited
dexterity or poor eyesight. Consequently, frequent
follow-up, patient compliance, and prudent patient
selection are important factors when Swing-Lock
obturators are used.
A more recent approach involves the use of
osseointegrated implants.9-13 Various methods for
the placement of intraoral implants to augment
retention, support, and stability have been de-
scribed in the literature. The majority of these
reports describe implant use following mandibular
resection and in edentulous maxillectomy patients.
The cases presented are complex, and implant
placement usually is preceded by extensive bone
grafting procedures. Implant procedures generally
are postponed until it has been determined that the
area is free from disease.9
Implant placement, restoration, and mainte-
nance are more problematic in dentate maxillec-
tomy patients. The volume and density of available
bone on the affected side are severely reduced. In
addition, many patients may have received tumor-
cidal doses of radiation. Although implants can be
placed in irradiated bone, osseointegration rates
are reduced when compared with those of non-
irradiated patients. Therefore, the potential for
hard and soft tissue problems is increased.10 Many
of these patients present with trismus, which com-
plicates implant placement and restoration. Conse-
quently, implants are less frequently used in the
acquired defects of dentate maxillectomy patients.
An obturator prosthesis remains the primary
treatment option for maxillectomy patients with
remaining teeth. Although design philosophies
vary, little has changed in the basic concepts since
Aramany’s reports in the late 1970s. Parel11 has
provided an excellent review of obturator design
philosophy with an extensive review of force consid-
erations. The concept of fulcrum lines is practical
and is generally accepted by prosthodontists for the
5
evaluation of rotational movements associated with
partial denture frameworks. However, the concept
falls short of defining the 3-dimensional movement
of obturator prostheses. Defect location and size,
the quality of tissue lining the defect, the number
and condition of remaining teeth, the occlusal load,
and weight of the prosthesis all contribute to wide
variations in stability, retention, and rotation from
patient to patient.12,13 In turn, framework and clasp
designs must vary according to the conditions pre-
sented by each patient.
Orthodontic treatment concepts relating to re-
movable appliances offer an approach for the treat-
ment of dentate maxillectomy patients by altering
the way in which the remaining teeth are used. This
is particularly true for anterior teeth. Application of
these concepts can improve retention, support, and
the distribution of force to the remaining maxillary
teeth. This approach is particularly useful in
younger patients for whom long-term preservation
of teeth is critical. The purpose of this article is to
review the rationale for this approach and to de-
scribe the use of these concepts in interim and
definitive Aramany Class I and Class II obturators.
Removable Orthodontic Appliances
Removable appliances are used extensively in orth-
odontics. Such devices are used as retainers follow-
ing fixed appliance therapy. They are also used for
minor tooth movement, biteplates, and as func-
tional appliances for the correction of anterior or
posterior crossbites.14-16 Appliance design varies
considerably, depending on the objectives of ther-
apy. Removable appliances based upon retainer
design can be used effectively for the dental reha-
bilitation of maxillectomy patients.
Hawley retainers are the most common type of
removable appliance used in orthodontics.14,15 The
basic design, as described by Hawley, has not
changed much in over 80 years.14 Appliance com-
ponents include full palatal coverage with an acrylic
resin base that contacts the lingual tooth surfaces,
bilateral posterior retentive clasps, occlusal rests,
and an anterior labial bow. The most common
retentive elements are circumferential (C-clasp),
Adams, ball, and arrow clasps.
The anterior labial bow is a standard component
of the Hawley retainer. The primary function of the
bow is to maintain the positions of anterior teeth,
thereby allowing alveolar bone to mature after
fixed appliance therapy. The bow also is used as a
6 Maxillofacial Appliances; Orthodontic Changes ●
Figure 1. A labial bow extends from the lingual of the
cuspid through the incisal embrasure. The Omega loop is
approximately 5 mm wide by 7 mm high. It should rest 2
mm above the gingival margin and contact all residual
anterior dentition.
retentive clasp.16 Labial bows are usually fabricated
using stainless steel orthodontic wires in gauges
ranging from 0.028 to 0.036 inches. An Omega loop
is placed from the center of the cuspid to its distal
embrasure. The bow then passes through the in-
cisal embrasure and is anchored in the palatal
acrylic resin base. The loop is generally 5 mm wide,
7 mm high, and extends 2 mm past the gingival
margin (Fig 1). The size of the loop varies with the
size of the cuspid.
Principles of Use
The Circumferential Clasp
Stainless steel or platinum-gold-palladium wire cir-
cumferential clasps (C-clasps) are used in virtually
van Putten
all types of intraoral prosthodontic devices, with the
most common size 0.036 inches in diameter. C-
clasps are used in interim obturators because of
their flexibility, versatility, and ease of placement
into the acrylic resin base. They can also be useful
in definitive obturators where tooth morphology
dictates a flexible clasp or where additional reten-
tion is required. King and Martin17 stated that
when the dentitions of patients with interim obtu-
rators display deep undercuts or when there are
divergent paths of insertion, wire clasps allow a
degree of “looseness” that will usually permit obtu-
rator seating without excessive adjustment. How-
ever, the authors also suggested that this looseness
may cause a loss of retention and reciprocation
when the obturator base is not held tightly against
the tooth. Divergent paths of insertion may also
cause wire clasps to “open up” prematurely during
use.
An orthodontic variation for C-clasps can be
used to minimize these problems. A vertical loop
placed just behind the shoulder portion of the C-
clasp reduces placement problems for interim ob-
turators with divergent paths and simplifies their
adjustment (Fig 2). Such loops have been used
extensively in fixed and removable orthodontics
appliances for over 75 years to improve the resil-
iency of wire appliances between teeth, to improve
control over tooth movements, and to simplify ad-
justment procedures.18,19
The use of vertical loops on clasps in maxillofa-
cial prosthodontic appliances offers several advan-
tages. These loops increase the capacity of the clasp
Figure 2. Vertical loops can
be placed on the shoulders
of wire C-clasps, improving
flexibility and simplifying ad-
justment procedures. A illus-
trates a loop placed on a C-
clasp on an anterior tooth.
The loop is positioned with
its outer convexity toward
the incisal surface. B illus-
trates a loop placed on a
posterior clasp. It is usually
positioned with its outer con-
vexity toward the gingival tis-
sues. Space and adjustment
concerns remain the major
determinants of loop designs.
 March 2002, Volume 11, Number 1
Figure 3. The weight of the interim prosthesis at point
A will tend to move the posterior areas of the prosthesis
inferiorly, away from the tissue. The bow is designed to
rest in the gingival third of the tooth at point B. This
places it in an area where normal tooth alignment and
contours allow it to disengage. The acrylic resin base
must rest against the lingual surface of the anterior teeth
to keep them from moving lingually at area C. Horizontal
adjustments are more effective if a loop is added on the
distal shoulder of the C-clasp at point D. The loop can be
tightened or altered, simplifying vertical adjustments
to flex into undercuts, thereby simplifying adjust-
ments. Instead of adjusting the arm of the clasp,
the width of the loop is closed or opened depending
on the desired effect. Closing the loop tightens the
clasp against the tooth and tends to lift the pros-
thesis. Additional gingival movement can be accom-
plished by altering the angle of the loop in the
vertical plane (Figs 2 and 3). If the loop is placed on
a posterior tooth, it can be used to lift the prosthesis
toward the acquired defect by bending it upward
(Fig 3). Adjustments are simplified because only
the loop is altered, and not the clasp arm. In addi-
tion, the loop simplifies seating procedures when
there are divergent paths of insertion.
Vertical loops are used primarily with interim
obturators. Because of the urgency of cancer treat-
ment, time for extensive preprosthetic treatment
planning is usually not available. Although vertical
loops can be used with definitive obturators, appli-
cations are limited because more time is afforded
for prosthodontic care before prosthesis fabrication.
The Labial Bow
The labial bow is a practical biomechanical supple-
ment to the maxillofacial prosthodontics armamen-
tarium for several reasons. The labial bow im-
7
proves: (1) force and weight distribution; (2)
prosthetic adjustment procedures; (3) ease of place-
ment; and (4) esthetics. It can be used in both
interim and definitive obturators.
The forces generated against anterior teeth by
clasps are more than adequate to cause tooth move-
ment. In their classic report on the equilibrium
theory of tooth position, Weinstein et al20 stated
that: “Differential forces, even when they are of small
magnitude, if applied over a considerable period of time can
cause important changes in tooth position.” They found
that a constant force of as little as 4 g was sufficient
to produce tooth movement. Crabb and Wilson21
found that a 30- to 40-g force (300 g/mm of mo-
ment) generated with finger springs in a removable
appliance was sufficient for retracting maxillary
canines. It follows that central and lateral incisors
would require less force to tip or retract.
The force that an obturator exerts on the abut-
ments depends on its weight and the occlusal load
to which it is subjected. Obturator weight varies
considerably and depends on its size, composition,
and the location of the defect. Interim obturators
commonly have a resting weight in excess of 25 g,
and it is not uncommon for a definitive obturator to
weigh more than 35 g.
Occlusal load on prosthetic devices varies from
patient to patient, depending on the distribution
and periodontal condition of the remaining natural
dentition, prosthetic design, masticatory force, and
patient habits. The occlusal load is usually reduced
on the defect side of the obturator as a result of
compromised support. At least one occlusal stop is
commonly placed on the affected side to give the
patient an aid in lifting and stabilizing the prosthe-
sis. Because most obturators are worn constantly,
they may inadvertently function as orthodontic ap-
pliances, given that all of the factors mentioned
above cannot be completely controlled.
Placement of a clasp on a maxillectomy patient’s
incisor may cause the tooth to be lost prematurely
if there is inadequate alveolar bone distal to it.
Arcuri and Taylor22 stated that an improvement in
the prognosis of an anterior abutment occurs when
the line of the resection passes through the middle
of the adjacent extraction site rather than extend-
ing through the interradicular bone. This approach
provides an adequate volume of bone distal to the
abutment, improving its long-term prognosis. Abut-
ments may still be lost over time due to overload-
ing, inadequate follow-up, or poor patient compli-
ance. Consequently, bone volume distal to the
8 Maxillofacial Appliances; Orthodontic Changes ● van Putten

tooth, obturator weight, occlusal load, adequate

follow-up, and patient compliance are important
factors to evaluate during diagnosis and treatment
planning for a labial bow.
The labial bow allows the prosthodontist to use
all available anterior teeth for retention, but does
not engage the teeth as aggressively as the reten-
tive arms of conventional cast or swing-lock clasps.
This improvement in force distribution is essential
to reduce abutment overloading. Because the rest-
ing weight of the prosthesis can exert a force capa-
ble of moving the abutments over time, an attempt
is made to place the bow on an area of the teeth
that will allow it to disengage as the force of gravity
acts on it during rest. Keeping the bow in the
Figure 4. These illustrations show variations in the ver-
gingival third of the teeth should allow it to disen- tical placement of the labial bow. Shaded teeth represent
gage (Fig 4). Placement in this area also allows the those lost because of surgical ablation. A illustrates the
bow to function more as a retentive clasp rather labial bow positioned in the incisal third of the anterior
than as an orthodontic appliance. teeth. B illustrates the labial bow positioned in the upper
middle third of the anterior teeth. The position in B
A further consideration is the ease of prosthetic
would typically be more retentive and allow the bow to
adjustment. The labial bow is adjusted by altering rotate deeper into an undercut, out of contact with the
the Omega loop. The bow will loosen in normal use, teeth when the posterior segment of the prosthesis moves
causing the prosthesis to move downward, away away from the underlying tissues during rest (also see
from the palate. The labial bow can be tightened by Fig 3).
squeezing the loop toward its center with orthodon-
tic pliers. This draws the bow against the anterior ered a method of hiding an obturator because it is
dentition and lifts the obturator, toward the palate not typically used in this situation.
and margins of the defect (Fig 3).
Ease of use and esthetics are also important
Framework Designs
advantages of a labial bow. The prosthesis is easy
for the patient to insert and remove on a daily basis. Design modifications for incorporation of the labial
The lack of moving elements such as gates or bow are shown in Figs 5 and 6. The Aramany Class
hinges reduces placement complications. I tripodal design is similar to the Class II arrange-
Although labial bows may not be considered ment, although in the Class II classification, a cus-
esthetic, they are more esthetically acceptable than pid would be present (Fig 5A). In both designs,
cast clasps. Labial bows are commonly visible on anterior clasps are replaced by a single bow (Fig
orthodontic retainers and do not carry the stigma of 5B). The framework is designed with an open re-
clasps. In fact, use of a labial bow could be consid- ceptacle distal-lingual to the cuspid to retain the

Figure 5. (A and B) The

Aramany Class I tripodial de-
sign is similar to the Class
II arrangement; however, in
the Class II a cuspid would be
present. Only the Class I de-
sign is shown, but both would
replace the anterior clasps
with a labial bow. The frame-
work is designed with a resin
retentive area distal and lin-
gual to the cuspid to hold the
bow. The bow contacts all re-
maining anterior teeth.
 March 2002, Volume 11, Number 1 9

Figure 6. (A and B) The Aramany Class I linear design. The lack of abutments on the affected side complicates
anterior clasp designs. Consequently, Aramany proposed avoiding use of clasps on the remaining anterior teeth. A labial
bow can be placed to utilize these teeth. Although rotation along the margin of the acquired defect is still possible, use
of the anterior teeth aids in stabilizing the prosthesis and fulfills the principle of retention placed on the teeth adjacent
to the defect. Premolar clasps are usually not needed if adequate molar retention is available.

bow. The bow is designed to contact all remaining
anterior teeth and creates adequate retention ad-
jacent to the anterior margin of the acquired de-
fect.
In an Aramany Class I linear acquired defect,
the lack of abutments on the affected side compli-
cates anterior clasp design. Aramany proposed
avoiding the use of clasps on anterior teeth (Fig
6A).2,3 The labial bow offers a solution (Fig 6B).
Although rotation along the margin of the acquired
defect is still possible, the use of anterior abutments
aids in stabilizing the prosthesis and fulfills the
principle of retention placed on the tooth adjacent
to the defect. Premolar clasps are usually not
needed if adequate molar retention is available.
Summary
Maxillectomy patients present with severely com-
promised dental arches as a result of ablative sur-
gical procedures. The remaining teeth should be
carefully evaluated to determine how they can best
be utilized because they are critical for the long-
term success of a prosthesis. The use of orthodontic
principles facilitates this utilization in an effective
yet simple manner. Improvements in force distri-
bution, ease of placement, adjustment, and esthet-
ics are compelling reasons for the consideration of
these principles.
References
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