Dr. Bhoomi A. Parmar, Dr. Jyoti B. Nadgere, Dr. Amit M. Gaikwad
Professor and Head of Department.
Department of Prosthodontics, Crown &Bridge.
MGM Dental College and Hospital, Navi Mumbai
This clinical report describes a comprehensive prosthodontic treatment of a patient diagnosed with Mucormycosis. The treatment procedures included surgical removal of the tumour, immediate surgical plate, interim obturator, and definitive obturator. The definitive prosthesis was cobalt–chromium removable partial denture gained its support from the remaining teeth and tissues. The follow-up system revealed satisfactory results with no deterioration in the prosthesis.
Citations : Parmar B, Nadgere J, Gaikwad A. Maxillary Hollow Bulb Obturator for Rehabilitation of A Hemimaxillectomy Patient: A Clinical Case Report. J Prosthodont Dent Mater 2021;2(1): 82-88.
Oral cancer is the sixth most common malignancy in the world and the third most common in India. The disproportionately higher prevalence of head and neck neoplasm in India may be due to the use of tobacco in various forms, alcohol abuse, poor oral hygiene, deficient diet or viral infections like human papilloma virus (HPV).
Most common intraoral defects in the maxilla are in the form of an opening into the antrum and nasopharynx. Maxillary defects can be congenital, developmental, acquired, traumatic, or surgical involving the oral cavity and related anatomic structure.Patients after surgical resection have altered anatomy due to scaring, tissue contracture, lack of bony support, and tissue oedema. Surgical resection can lead to the restricted opening of the jaws and altered range of mandibular movements with fibrosis and trismus. These patients have the problem of regurgitation of water and food through nose. There may be difficulty in speech, deglutition, maintaining oral hygiene, and prosthetic treatment. To prevent this and to help the patient in deglutition and speech, defects must be rehabilitated with prosthesis. In such situations, a prosthesis called as an obturator is designed to close the opening between the residual hard and/ or soft palate and pharynx.
An obturator is a maxillofacial prosthesis used to close, cover, or maintain the integrity of the oral and nasal compartments resulting from a congenital, acquired, or developmental disease process. obturator is derived from the Latin word “obturate” which means to close or shut off.
Prosthodontic therapy for patients with acquired surgical defects of the maxilla can be divided into three phases of treatment with each phase having different objectives namely surgical obturator, temporary obturator and definitive obturator.
In large defects, the obturator is aggressively extended vertically to engage the surgical defect and horizontally to engage the undercuts at the expense of its size and weight. Increased weight of obturator makes the prosthesis uncomfortable as well as non-retentive for the patient jeopardizing its function.
To reduce the weight of prosthesis, hollow bulb obturators are fabricated. According to Wu and Schaaf, hollowing of the obturator significantly reduces prosthesis weight from 6.55% to 33.06% depending on the size of the defect.
Approximately six months after surgery, consideration maybe given to the construction of a definitive obturator prosthesis.
A 45-year-old patient reported to the department of OMFS with chief complaint of pain and swelling on left side of face. Patient complained difficulty in chewing and burning sensation in palatal region. Patient was a known diabetic for 5 years but on irregular oral medication. On extra oral examination patient reported with diffused swelling on the left side of the face, tenderness, overlying skin appeared to be normal (Fig-1). Proptosis was seen with the left eye and significant inability to close left eyelid completely. (Fig-2 & 3)
On intra oral examination patient had poor oral hygiene, palatal ulcer was present on the left side (2cm x 2cm) with whitish necrotic tissue and inflamed surrounding mucosa (Fig-4). Patient was diagnosed with Mucormycosis of palate and surgery was planned accordingly.
A surgical stent was prepared for the patient from the preoperative impression cast. (Fig-5). Following surgery, the defect of the patient was classified as Aramany’s class I defect. After a period of two weeks procedure for fabrication of temporary obturator was commenced. Impression was made in irreversible hydrocolloid impression material, and casts were procured.
Onto the cast on the side of defect shellac base plate was adapted, wax rim was fabricated, and jaw relation was performed. Teeth arrangement was done and tried in patient's mouth.
After which the trial denture was flasked and dewaxed (Fig-6) in conventional manner. During packing firstly, a layer of auto polymerizing resin was placed into the defect area (Fig-7). Once polymerized the defect was filled with salt (Fig-8) and covered with heat cure acrylic material. The flask was closed and cured, thereafter denture was retrieved (Fig-9). On retrieving the obturator two holes were made onto the tissue side surface of the denture, with the help of a syringe water was propelled from one hole inside the obturator so that the salt can withdraw from the other hole. Once all the salt was evacuated the holes were closed with auto polymerizing resin. At insertion, the pressure indicator paste (PIP) was used to inspect for any pressure areas. The denture was inserted, and post-insertion instructions were given to the patient.
After six months patient returned for final prosthesis, this time she had pain with respect to 13 and 14. On examination root canal treatment followed by i-post placement and PFM crowns with respect to 13 and 14 was planned for the patient.
After crowns cementation an impression was made in irreversible hydrocolloid impression material and cast was obtained. A custom tray was fabricated. Mouth preparation was done, and the final impression was made in polyether impression material (Fig-10), the impression was sent to laboratory for fabrication of the framework (Fig-11).
Once the framework trial was done a custom tray was fabricated on the side of the defect (Fig-12). An impression of the sound side which did not involve the defect was made for duplication of the cast, and the framework was fitted onto the duplicated cast (Fig-13).
Thereafter an impression was made onto the defect side and cast was poured. Subsequently, as mentioned above the procedure for hollow bulb obturator was carried out. The obturator was retrieved and polished (Fig-14)
Once the obturator was fabricated a cast was duplicated over the hollow bulb obturator, jaw relation and try-in was done. And the final hollow bulb obturator with teeth was processed.
The prosthesis was inserted (Fig-15) and the patient was educated regarding oral hygiene and future maintenance of the prosthesis.
Rehabilitation of patients with acquired maxillary defects can be challenging. Retention is severely compromised in these patients resulting in difficulties in speech and mastication. The hollow bulb obturator offers many advantages of being light and reduces excessive atrophy of muscles.
Matalonand LaFuente described this technique of processing of the obturator (but instead of salt he used sugar), which is later removed by drilling a hole in the superior surface and the hole is filled with autopolymerizing resin. The opening can also be filled by using a nondetachable screw cap.
The advantages of a two-piece obturator are the thickness of the obturator can be controlled thereby reducing the weight of the prosthesis. It reduces clinical time. It can be used for both completely and partially edentulous arches. The disadvantages are additional processing time required to process the lid, acrylic resin may seep into the hollow portion of the obturator, seepage of fluids is possible if the seal is improper.
Prosthodontic rehabilitation of the maxillofacial defect patient is a lengthy and involved process. However, careful treatment planning and proper implementation of the procedure can yield successful prosthesis which is acceptable functionally and esthetically.
1. Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, et al. Effect of screening on oral cancer mortality in Kerala, India: A cluster-randomised controlled trial. Lancet. 2005;365:1927–33.
2. Khandekar SP, Bagdey PS, Tiwari RR. Oral cancer and some epidemiological factors: A hospital based study. Indian J Community Med. 2006;31:157–9.
3. Kumar S, Heller RF, Pandey U, Tewari V, Bala N, Oanh KT, et al. Delay in presentation of oral cancer: A multifactor analytical study. Natl Med J India. 2001;14:13–7.
4. 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.
5. Shifman A, Finkelstein Y, Nachmani A, Ophir D. Speech-aid prostheses for neurogenic velopharyngeal incompetence. J Prosthet Dent 2000;83:99-106.
6. The glossary of prosthodontic terms. J Prosthet Dent 2005;94:10 92
7. Aramany MA. Basic principles of obturator design for partially edentulous patients: Part I: Design principles. J Prosthet Dent. 1978;40:656–62.
8. Wu YL, Schaaf NG. Comparison of weight reduction in different designs of solid and hollow obturator prostheses. J Prosthet Dent. 1989;62:214–7.
9. Nidiffer TJ, Shipmon TH. The hollow bulb obturator for acquired palatal openings. J Prosthet Dent 1957;7:126-37.
10. Matalon V, LaFuente H. A simplified method for making a hollow obturator. J Prosthet Dent 1976;36:580-2.