Dr. Janani Iyer 1,Dr. Aishwarya Deshmukh 2 ,Dr. Jyoti Nadgere3
1Post-graduate Student
2Professor and Head of Department,
3Asso. Professor,
Department of Prosthodontics, Crown & Bridge.,
MGM DCH, Navi Mumbai
ABSTRACT
Maxillectomy defects can be acquired and/or congenital leading to a communication between the maxillary antrum and the oral cavity and oropharynx or nasopharynx. This results in impaired facial esthetics, compromised mastication, swallowing, speech, and significant reduction in the quality of life. Obturators can be given to such patients to improve function, esthetics and overall quality of life. This paper describes a clinical report of management for a patient who had undergone partial maxillectomy with surgical, interim and definitive obturators.
Keywords: Obturator, Surgical Obturator, Interim Obturator, Definitive Obturator, Maxillary defects, Maxillectomy, Maxillofacial Prosthetics, Prosthetic Rehabilitation.
Citations: : Deshmukh A, Nadgere J, Iyer J. Rehabilitation of a Hemimaxillectomy Patient with Surgical, Interim and Definitive Obturator: A Case Report. J Prosthodont Dent Mater 2022:3(1):62-71.
INTRODUCTION
Absence or loss of some or all of the soft palate and/or hard palate results in insufficient structure with altered function of the remaining structure. To prevent this and to help the patient in deglutition and speech, defects must be restored with prosthesis1.1
According to Glossary of Prosthodontic Terms, Obturator is a prosthesis used to close a congenital or acquired tissue opening primarily of the hard palate and/or contiguous alveolar/soft tissue structures2. Ambroise Pare was the first to use artificial means to close a palatal defect as early as the 1500s. The early obturators were used to close congenital rather than acquired defects. Claude Martin described the use of a surgical obturator prosthesis in 1875. Fry described the use of impressions before surgery in 1927. Steadman described the use of acrylic resin prostheses lined with gutta-percha to hold a skin graft within a maxillectomy defect in 1956 (Desjardins, 1978; Huryn & Piro, 1989)3.
A scleral prosthesis is one technique- sensitive procedure for the accurate duplication of natural color, size, contour and orientation of the eye, which will provide realism and symmetry to the patient. The construction of scleral prosthesis involves a sequence of steps which are critical in the fabrication of a successful prosthesis.2 In this clinical report, a semi- customized scleral prosthesis is fabricated for the rehabilitation of the defect of the eye in a simple and cost- effective approach.3
Based on the phase of treatment, there are three types of Obturators- Surgical, Interim and Definitive Obturators. In this article, a case of partial maxillectomy rehabilitated with above-mentioned obturators is presented
CASE REPORT:
A 38-year-old male patient reported to the Department of Prosthodontics with a chief complaint of overgrowth in the right side of maxilla (7-8 months back). It was a known case of Mesenchymal Chondrosarcoma. Extraoral examination showed that the patient had a square facial form and a straight facial profile (Fig-1). No extraoral swelling or deviation was seen. Intraorally the lesion was seen extending from beyond the palatal surface of 17 upto the palatal surface of 14(Fig-1). Swelling had no odontogenic origin. The tumor was located on a hard palate with a size of 2.9x2.5x1.4 cm (Fig-1). Pre-operative scans were obtained (Fig-2).
HISTOLOGICAL DESCRIPTION:
It was a submucosal tumor composed of monomorphic small round cells with scant cytoplasm arranged in sheets and pseudo alveolar pattern. Nuclei were round and angulated with stippled chromatin. Prominent thin-walled branching vessels noted. Abrupt areas of mature hyaline cartilage noted. Features were those of mesenchymal chondrosarcoma. Differential Diagnosis - Salivary gland neoplasm - Pleomorphic Adenoma/Myoepithelioma. He was diagnosed with Mesenchymal Chondrosarcoma for which he had to undergo partial maxillectomy.
SURGICAL OBTURATOR
Surgical obturator is placed at the time of tumor resection in the operating room. They act as a barrier between the surgical dressing and the oral cavity. Help in reducing the oral contamination of the wound. Improve deglutition, speech and reduce initial feeling of loss. They reproduce normal palatal and alveolar contours4. The surgical obturator must terminate short of skin graft-mucosal junction. Clear resin is usually used for extension and pressure area to visualisation5. The posterior occlusion is not to be established on the defect side until healing is completed. Heat cure resins help to decrease infection, are non-absorbable and have no leakage of monomer6.6
Diagnostic impressions of upper and lower arch were made with irreversible hydrocolloid impression material (Coltene Coltoprint Chromatic Alginate Impression material)(Fig-3). The impressions were poured into dental stone. The operating surgeon gave the marking for surgical resection(Fig-4). The presurgical cast was trimmed and ball end clasp were placed for retention(Fig-5). After completing the wax-up, the clear heat cured(Acralyn R, Asian Acrylates, Mumbai(India)) surgical obturator was obtained with conventional denture processing(Fig-7).
The tumor mass was resected, with leaving a safety margin of healthy tissues by the operating surgeon(Fig-6). On table relining was done with autopolymerizing clear acrylic resin(DPI-RR, Dental Products of India). Thus the surgical obturator was inserted immediately following the surgery(Fig-8). The defect was Aramany’s Class 1 defect.
After initial healing was completed, the obturator was relined. For which the lateral defect was recorded by blocking the medial undercut. Impression compounds (Y Dents Impression Composition, MDM Corporation) followed by tissue conditioner (D- Soft, Medicept Dental) were used. Later it was processed with clear heat cure acrylic resin.
After 1-1.5 months the patient was recalled for the fabrication of interim obturator.
INTERIM OBTURATOR
The interim obturator is processed from the postsurgical master cast. It is placed when the surgical dressing is removed. It forms a false palate, false ridge and a bulb which is mostly hollow. It thus serves the patient for 4–6 months till the maxillary defect heals and matures. The weight is reduced which is more comfortable to the patient7. Light weight increases retention, physiological function as teeth and supporting tissues are not stressed8. The decreased pressure on the surrounding tissues aids in deglutition and regeneration of tissue. Light weight reduces the self-consciousness of wearing a denture9.9
A stock tray of appropriate size was used to record the impression. The undercuts in the medial wall were blocked out with gauze lubricated with petroleum jelly (White Petroleum Jelly, KIM Chemicals). Floss (Colgate waxed Dental Floss) was tied to gauze for easy retrieval. The lateral wall of the defect was first recorded with an impression compound. Retention grooves were made into compounds for interlocking. Later a wash made with irreversible hydrocolloid impression material (Fig-9).
A hollow bulb obturator was processed with clear heat cured acrylic resin (Fig-10). Wrap around clasp was used to improve retention. It was checked into the patient's mouth and then delivered (Fig-11).
DEFINITIVE OBTURATOR
Definitive obturator is defined as a prosthesis that artificially replaces part or all of the maxilla and the associated teeth lost due to surgery or trauma (GPT 9). Timing will vary depending on size of the defect, progress of healing, prognosis for tumor control, effectiveness of the present obturator and presence or absence of teeth10
The definitive obturator was processed at least 3-4 months after completing chemotherapy and radiotherapy. As the tissues tend to shrink following radiotherapy11.
A diagnostic cast was obtained for surveying. The framework design was confirmed after evaluation of cast. The mouth preparation was completed. And an impression was made with vinyl polysiloxane (Reprosil regular body by Dentsply) (Fig-12) in a custom tray which was fabricated from the diagnostic cast. The master cast was poured into die stone(Kalabhai Ultra Rock) (Fig-13) and a cast partial denture framework was fabricated over it(Fig-13). A tripodal design was selected for this case. Complete palate as the major connector was designed to ensure maximum distribution of the functional load to the tissue, it was provided with retention holes for the acrylic to flow. Direct retainer was planned on the right first premolar and embrasure clasp between the right first and second molars. Indirect retention provided with rests on canine, lateral incisor. Central incisor provided with rest seat and proximal plate. The framework was tried into the patient's mouth2.
Altered cast technique was used to record the soft tissue. For which, a custom tray was fabricated over the master cast which contained the framework. The lateral border of defect was recorded with the impression compound. Later retentive holes were made into the compound. A wash was made with tissue conditioner (Fig-14).
The master cast was sectioned along the hard tissue to provide retention groves (Fig- 15). The impression was seated on the cast (Fig-16). It was reversed and beading and boxing was done. Later it was poured with dental sone (Fig-17).
A layer of hard wax (Cavex Set up Hard) was adapted over the framework placed on the obtained cast from altered cast technique. Modelling wax (Deepti Dental Products) was used for fabricating wax rims. Jaw relation was recorded (Fig-18). The record was transferred to the articulator and mounted.
Following teeth selection, the teeth setting was completed (Fig-19,20). The obturator was tried in the patient's mouth (Fig-21). The required adjustments were made. Waxed up articulator was then processed to obtain heat cured clear hollow bulb obturator.
Until dewaxing the conventional steps for denture processing were followed. A 1 mm spacer with modelling wax was adapted over the defect area. 3-4 tissue stops were made (Fig- 22).
A thin layer of autopolymerizing acrylic resin was adapted over the wax (Fig-23). Later the shell was filled with salt (Fig-24) and closed with a lid made from autopolymerizing resin (Fig-25). The shell was removed. Two holes were made into the shell for removing the salt. The modelling wax was removed. The heat cured resin was manipulated according to the manufacturer's instructions. It was adapted over the defect area; the shell was then positioned over it. The heat cured resin (Acralyn R) was adapted over the remainder cavity and the flask was closed and clamps placed over it. The processing was completed.
The obturator was retrieved and finished and polished (Fig-26). Then finally inserted into the patient, final adjustments were made (Fig-27). Patient was recalled after a week.
DISCUSSION
Prosthetic intervention with maxillary obturator prosthesis is necessary to restore the contours of the resected palate and to recreate the functional separation of the oral cavity and sinus and nasal cavities12. This should occur at the time of surgical resection, and it will be necessary for the remainder of the patient’s life13.
In the present study thus, we planned all the three obturators for the patient to modify tissues immediately following the surgery and to improve the quality of life of the patient.
The obturators can cause long term pressure on the residual soft tissue, which can be increased due to the post-operative pain, and the reconstructive flap surgery can cause secondary injuries to patients, both in donor sites and recipient sites15. In the present study due to severity of the carcinoma, flap closure was avoided. Moreno et al. reported no significant difference in speech intelligibility between patients rehabilitated with obturators or flaps17.
In several studies, it has been shown that surgical reconstruction may have advantages in terms of function and aesthetic outcomes. The surgical obturator was fabricated with heat cured acrylic resin, which was inserted immediately post-surgery. Surgical obturator holds the dressing in place until the initial healing period. After which it was relined with tissue conditioner to improve fit. Similar technique was followed by Dalkiz et al6.The interim obturator was fabricated for the patient after healing was complete and the tissues had matured. Hollow bulb heat cured interim obturator was light in weight and was given to the patient for 4-6 months until the completion of chemo and radio therapy as described by Gay WD et al13. As the tissues were not completely healed and to prevent unwanted forces on the healing tissues, tooth arrangement was avoided and only a closed hollow bulb obturator was given to the patient as suggested by Bhandari et al7.
After completion of the therapies, we had given a waiting period of 3 months for the tissues to modify, after which the hollow bulb definitive obturator was fabricated. The cast partial denture framework was fabricated with a tripodal design according to the principles given by Aramany et al2. Later altered cast technique was used to record the tissues similar to a technique by Vojvodic D et al10. Definitive obturator can be a closed or open bulb. Closed bulbs are preferred over open bulbs as there are chances of collection of fluids and secretion in the open bulb type. Closed bulb obturators can be made hollow to reduce their weights7. In this case we have fabricated a closed hollow bulb definitive obturator for the patient. Though it is difficult to improve the quality of life for hemimaxillectomy patients compared with patients with conventional prostheses, this can be achieved with skill, knowledge and experience of specialists3.
CONCLUSION
Prosthodontic rehabilitation of the maxillofacial defect patient is a lengthy and involved process. However, if attention is paid to the proper sequencing and details of treatment, it can be one of the most satisfying procedures. The problems experienced by hemimaxillectomy patients are reduced if a team approach is adopted and specialists are careful to apply skill and experience at all stages and keep the patient under regular review.
REFERENCES
1. Ali R, Altaie A, Nattress B. Rehabilitation of oncology patients with hard palate defects part 3: Construction of an acrylic hollow box obturator. Dent Update. 2015;42(7):612– 20.
2. Aramany MA. Basic principles of obturator design for partially edentulous patients. Part II: Design principles. J Prosthet Dent. 2001;86(6):562–8.
3. Keyf F. Obturator prostheses for hemimaxillectomy patients. J Oral Rehabil. 2001;28(9):821–9.
4. Ali MM, Khalifa N, Alhajj MN. Quality of life and problems associated with obturators of patients with maxillectomies. Head Face Med. 2018;14(1):1–9.
5. Corsalini M, Barile G, Catapano S, Ciocia A, Casorelli A, Siciliani R, et al. Obturator prosthesis rehabilitation after maxillectomy: Functional and aesthetical analysis in 25 patients. Int J Environ Res Public Health. 2021;18(23).
6. Dalkiz M, Dalkiz AS. The effect of immediate obturator reconstruction after radical maxillary resections on speech and other functions. Dent J. 2018;6(3).
7. Bhandari A. Maxillary obturator. J Dent Allied Sci. 2017;6(2):78.
8. Mousa MA, Abdullah JY, Jamayet NB, Alam MK, Husein A. Biomechanical stress in obturator prostheses: A systematic review of finite element studies. Biomed Res Int. 2021;2021.
9. Dholam KP, Bachher G, Gurav S V. Changes in the quality of life and acoustic speech parameters of patients in various stages of prosthetic rehabilitation with an obturator after maxillectomy. J Prosthet Dent 2020;123(2):355–63.
10. Vojvodic D, Kranjcic J. A two-step (altered cast) impression technique in the prosthetic rehabilitation of a patient after a maxillectomy: A clinical report. J Prosthet Dent. 2013;110(3):228–31.
11. Parr GR, Gardner LK. The evolution of the obturator framework design. J Prosthet Dent. 2003;89(6):608–10.
12. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: Introducing a new classification. Lancet Oncol [Internet]. 2010;11(10):1001–8.
13. Gay WD, King GE. Applying basic prosthodontic principles in the dentulous maxillectomy patient. J Prosthet Dent. 1980;43(4):433–5.
14. Andrades P, Militsakh O, Hanasono MM, Rieger J, Rosenthal EL. Current strategies in reconstruction of maxillectomy defects. Arch Otolaryngol - Head Neck Surg. 2011;137(8):806–12.
15. Leoncini E, Ricciardi W, Cadoni G, Arzani D, Petrelli L, Paludetti G, et al. Adult height and head and neck cancer: A pooled analysis within the INHANCE Consortium. Head Neck. 2014;36(10):1391.
16. Cao Y, Yu C, Liu W, Miao C, Han B, Yang J, et al. Obturators versus flaps after maxillary oncological ablation: A systematic review and best evidence synthesis. Oral Oncol.2018;82(14):152–61.
17. Eckardt A, Teltzrow T, Schulze A, Hoppe M, Kuettner C. Nasalance in patients with maxillary defects - Reconstruction versus obturation. J Cranio-Maxillofacial Surg. 2007;35(4–5):241–5.
18. Peker K. Health-Related Quality of Life in Maxillectomy Patients Rehabilitated with Obturator Prostheses: A Literature Review. Diagnosis Manag Head Neck Cancer. 2017;
19. Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: A classification system of defects. J Prosthet Dent. 2001;86(4):352–63.
20. Brandão TB, Vechiato Filho AJ, De Souza Batista VE, De Oliveira MCQ, Santos-Silva AR. Obturator prostheses versus free tissue transfers: A systematic review of the optimal approach to improving the quality of life for patients with maxillary defects. J Prosthet Dent. 2016;115(2):247-253.