|Year : 2015 | Volume
| Issue : 1 | Page : 68-71
Prosthetic rehabilitation of the dentate maxillectomy patient from a delayed surgical to an interim obturator: A clinical case report
Angleena Y Daniel, B Vinod
Department of Prosthodontics, Christian Dental College, C.M.C and Hospital, Ludhiana, Punjab, India
|Date of Web Publication||14-Jan-2015|
Dr. Angleena Y Daniel
Department of Prosthodontics, Christian Dental College, C.M.C and Hospital, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
The surgical management of maxillary pathosis results in direct communication between the oral and nasal cavity, imposing problems such as nasal regurgitation, unintelligent speech, difficulty in deglutition and compromised esthetics. A restoration of these defects is not always possible surgically, but prosthetic rehabilitation is an established treatment modality. Early rehabilitation can improve the quality of life and reduce the psychological trauma caused by surgical excision. Surgical and interim obturators placed during the initial phase can improve the outcome of the definitive prosthesis. This article presents a case report of a patient with partial maxillectomy who has been rehabilitated with a delayed surgical and an interim obturator.
Keywords: Delayed surgical obturator, interim obturator, maxillectomy, prosthetic rehabilitation
|How to cite this article:|
Daniel AY, Vinod B. Prosthetic rehabilitation of the dentate maxillectomy patient from a delayed surgical to an interim obturator: A clinical case report. CHRISMED J Health Res 2015;2:68-71
|How to cite this URL:|
Daniel AY, Vinod B. Prosthetic rehabilitation of the dentate maxillectomy patient from a delayed surgical to an interim obturator: A clinical case report. CHRISMED J Health Res [serial online] 2015 [cited 2019 May 19];2:68-71. Available from: http://www.cjhr.org/text.asp?2015/2/1/68/149351
| Introduction|| |
The acquired defect of the maxilla after surgical resection has significant functional and esthetic consequences. The aberrant communication of the oral cavity with the nasal cavity and paranasal sinuses results in the hypernasal and unintelligent speech, difficulty in deglutition and compromised esthetics.  These oral and facial changes alter the psychological well-being of the patient. Therefore, an early attempt should be made to restore and maintain the oral function to a reasonable level. However, there is no single flap or technique sufficient to reconstruct midfacial defect, but a maxillary prosthesis has been a traditional and reliable method for the obturation of a maxillary defect.  There are three prosthetic phases for the rehabilitation of the maxillectomy patient. The initial phase includes a surgical obturator: The first prosthesis placed. It is used to minimize postoperative complications.  Surgical obturators may be classified as immediate surgical obturators and delayed surgical obturators.  The second phase of postsurgical prosthodontic treatment includes an interim obturator. The timing of an interim obturator is somewhat variable. The interim obturator, a comfortable and functional prosthesis, facilitates proper healing in a constantly changing, and tender area. The third phase includes a definite prosthesis, placed 3-6 months postsurgically, when the surgical site has completely healed.
This article is a case report describing the delayed and interim obturators for the rehabilitation of a patient who had undergone partial maxillectomy.
| Case Report|| |
A 32-year-old male patient was referred from the Department of Ear-Nose-Throat for the obturation of a partial maxillectomy defect. The patient had undergone partial maxillectomy a week ago for the surgical excision of the tumor and was fed through a nasogastric tube. The patient had difficulty in speaking due to marked hypernasality. He could not eat or swallow properly. This caused a profound psychological depression. The need and importance of rehabilitation were explained to the patient. Extra orally an incision line was evident, with the resultant collapse of soft tissue on the affected side. Intra orally a defect on the right side was present. The maxilla was resected along with the dentition and alveolar bone until the midline, suggestive of Armany's class I defect  [Figure 1]. All teeth in the left quadrant were intact. The resection site was inflamed and tender. A delayed surgical obturator was planned, to create a barrier between the nasal and oral cavity, and to enable the patient to start with an oral diet. Three weeks later when the tissues started healing at the resection site, an interim obturator with teeth was planned to restore the esthetics and function.
| Clinical Procedure|| |
Once the clinical examination was over, all the undercuts at the surgical site were blocked with vaselinized gauze, to prevent any trauma to the underlying tissue. The preliminary impression was made with irreversible hydrocolloid material (Algitex, DPI., Bombay Burmah Trading corp. Mum) in a perforated stock tray [Figure 2]. An impression was poured using Type-III dental stone (Kalastone; Kalabhai Pvt Ltd, Mumbai, India). The extensions of the obturator were marked on the cast, and multiple wrought wire clasps were planned. A 22 gauge round stainless steel orthodontic wire was used to fabricate clasps to engage the infrabulge retentive area of the teeth #21, #25 and #27, on the nonresected side. The defect on the cast was properly blocked, and palatal configuration was symmetrically contoured in modeling wax. The cast was invested in a flask and dewaxing was done. The clear heat-cure acrylic resin (Trevalon, Dentsply India Pvt. Ltd) was packed, and curing was done. The use of clear acrylic would help to distinguish any tissue impingement caused by the prosthesis. The prosthesis was constructed on the same day since the dismissal of the patient from the hospital was dependent upon insertion of the obturator. Furthermore, tissue contraction and edema at the surgical site could make the insertion of the prosthesis difficult if there were a delay in the insertion of the prosthesis.  The finished and polished prosthesis with proper border extension was inserted, and speech was verified to determine the exclusion of the hypernasality [Figure 3]. The peripheral seal of the prosthesis was tested by making the patient drink and eat without any resultant leakage into the nose. Pressure areas were checked using pressure indicating paste and were relieved. The patient was educated about the maintenance of the obturator and was scheduled for regular post insertion visits.
Three weeks later when the patient was examined, the healing was satisfactory for the placement of the interim obturator [Figure 4]. The preliminary impression was made, and the cast was poured. A special tray was fabricated, and border molding was done for proper extensions particularly for the lateral wall of the defect. A secondary impression was made with medium body polyvinyl siloxane (Aquasil, Dentsply Caulk) and a master cast was poured with Type-III dental stone (Kalastone; Kalabhai Pvt Ltd, Mumbai, India). All the undesired undercuts were blocked, and a temporary denture base was fabricated on the master cast. A tentative jaw relation was recorded, and teeth selection was completed. Jaw relations were transferred to a semi-adjustable articulator (Hanau; Teledyne Water Pik, Fort Collins, Colo) and teeth arrangement were completed. A wax try-in was done, and the patient's approval for esthetics was taken. A round stainless steel wrought wire 22 gauze (3M; Unitek, Monrovia, Calif) clasps were adapted for teeth #21, #25 and #27. The hollow bulb interim obturator was processed in heat polymerizing resin (Trevalon, Dentsply India Pvt Ltd) [Figure 5]. Hollow prosthesis improves the retention as the weight of the obturator to fill in the defect was reduced.  The finished and polished final prosthesis was inserted and was checked for peripheral seal [Figure 6]. The pressure areas were relieved. The patient was taught the placement and removal of an obturator and was recalled for regular post-insertion visits.
| Discussion|| |
The basic aim of prosthetic rehabilitation of a maxillectomy defect, at any stage, is to create a barrier between the oral cavity from the nasal cavity and paranasal sinuses. The surgical obturators restore and maintain function to an acceptable level during the early healing phase. An immediate surgical obturator provides a scaffold for the dressing, minimizes the initial feeling of loss, as the defect is not noticeable with the tongue, obviates the need of nasogastric tube, prevents the impairment of speech and swallowing to some extent and above all provides psychological support to the patient. Immediate surgical obturators are always favored where ever possible. Several authors support the use of surgical obturators. ,,, However, some surgeons do not favor the placement of an immediate surgical obturator due to increased anesthetic and surgical time required for fabrication and adjustment, and also retention of the prosthesis can be difficult.  Park and Kwon  recommended the use of delayed surgical obturators as an alternative to immediate surgical obturator during the initial healing phase after maxillectomy, without increasing the patient's discomfort. The delayed surgical obturator, like the immediate surgical obturator, will provide psychological, physiologic, and hygienic benefits to the patient. 
An early rehabilitation both with an immediate or a delayed surgical obturator will prevent the collapse of soft tissues and helps to overcome the esthetic and psychological problems. However, there can be certain difficulties if a delayed surgical obturator is planned especially with impression making due to facial incisions, and also due to incomplete healing. Retention of the prosthesis can also be compromised as the full extension into the defect is not recommended because it may interfere with healing, a limited oral opening, and the weight of the prosthesis.  It might not be possible to attain ideal speech and to swallow at this stage, but the adequate extension can provide sufficient contact with tissues to allow acceptable speech and swallowing. Another limitation of delayed obturator was lack of esthetics during the early rehabilitative phase, and this was overcome by the second phase of rehabilitation. Interim obturator with an artificial substitute for teeth and full extension into the defect had not only improved the patient's esthetics but also his psychological health.
| Conclusion|| |
Prosthodontic treatment should always start in the preoperative phase to render the best possible postoperative rehabilitation to the patient. However, if circumstances do not permit then a delayed surgical obturator can be considered as an alternative treatment modality. An interim obturator is a definite adjunct for functional and esthetic restoration of maxillectomy patients, between the phases of a surgical and a definitive prosthesis.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]