Dr.Aishwarya Deshmukh1
, Dr.Jyoti Nadgere2 ,Dr.Janani Iyer3
1
Post-graduate Student
2
Professor and Head of Department,
3
Asso. 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.
Citation: 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
.
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;
Deshmukh A. et al: Rehabilitation of a Hemimaxillectomy patient with Obturator
The JPDM I Vol 3 I Issue 1 I 2022 62
Huryn & Piro, 1989)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 abovementioned 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
2.9×2.5×1.4 cm (Fig-1). Pre-operative scans were obtained (Fig-2).
Fig 1- Pre-operative Extra and intraoral views Fig 2- Preoperative CT Scan
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.
Deshmukh A. et al: Rehabilitation of a Hemimaxillectomy patient with Obturator
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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 graftmucosal 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
.
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).
Fig 3-Diagnostic Impressions Fig 4-Pre planning of
surgery
Fig 5- Waxed up
Obturator
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.
Fig 6- Resected tumor mass
Deshmukh A. et al: Rehabilitation of a Hemimaxillectomy patient with Obturator
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Fig 7- Immediate Surgical Obturator Fig 8- Immediate insertion of Obturator
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 selfconsciousness of wearing a denture9
.
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).
Fig 9- Wash impression Fig 10- Interim Obturator Fig 11-Insertion of Interim Obturator
Deshmukh A. et al: Rehabilitation of a Hemimaxillectomy patient with Obturator
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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
.
Fig 12- Final Impression Fig 13- Master cast with framework
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).
Deshmukh A. et al: Rehabilitation of a Hemimaxillectomy patient with Obturator
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Fig 14- Wash with Tissue conditioner
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).
Fig 15- Sectioned Cast Fig 16-Impression seated on cast Fig 17- Altered Cast
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.
Fig 18- Jaw Relation
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.
Deshmukh A. et al: Rehabilitation of a Hemimaxillectomy patient with Obturator
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Fig 19- Teeth Arrangement Fig 20-Waxed up Obturator Fig 21-Tryin
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).
Fig 22- Tissue stops Fig 23- Autopolymerizing
Shell
Fig 24- Shell filled
with Salt
Fig 25-Shell closed
with lid
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.
Fig 26- Processed Heat Cured Definitive Obturator
Deshmukh A. et al: Rehabilitation of a Hemimaxillectomy patient with Obturator
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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.
Fig 27- Postoperative Extraoral
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
Deshmukh A. et al: Rehabilitation of a Hemimaxillectomy patient with Obturator
The JPDM I Vol 3 I Issue 1 I 2022 70
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.
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