JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 72-77

A systematic approach to rehabilitation for hemimaxillectomy patient


1 Department of Prosthodontics, Crown and Bridge, Faculty of Dentistry, Jamia Millia Islamia, India
2 Department of Prosthodontics, Crown and bridge, Jamia Millia Islamia, New Delhi, India

Date of Submission12-Nov-2019
Date of Acceptance02-Dec-2019
Date of Web Publication29-Jul-2020

Correspondence Address:
Dr. Eram Perwez
Department of Prosthodontics, Crown and Bridge, Faculty of Dentistry, Jamia Millia Islamia, New Delhi - 110 054
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_56_19

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   Abstract 


Any surgical intervention for the correction of maxillofacial disorders consequently leads to a compromised functionality, esthetics, and patient's general quality of life. Larger defects requiring partial or complete excision of the affected part need prosthetic rehabilitation to restore patient's standard of living. Among the team of involved doctors, a prosthodontist plays a major role in the presurgical treatment planning and postsurgical rehabilitation of such patients. This following case report illustrates the various clinical and laboratory procedures that goes in pre- and post-surgical planning and rehabilitation of patient undergone hemi-maxillectomy, with an obturator prosthesis.

Keywords: Maxillofacial prosthodontics, rehabilitation, obturator


How to cite this article:
Mallick R, Sachdeva S, Perwez E, Goyal V, Jain V. A systematic approach to rehabilitation for hemimaxillectomy patient. J Int Clin Dent Res Organ 2020;12:72-7

How to cite this URL:
Mallick R, Sachdeva S, Perwez E, Goyal V, Jain V. A systematic approach to rehabilitation for hemimaxillectomy patient. J Int Clin Dent Res Organ [serial online] 2020 [cited 2020 Aug 10];12:72-7. Available from: http://www.jicdro.org/text.asp?2020/12/1/72/291116




   Introduction Top


Successful prosthetic rehabilitation of a patient with the loss of maxillofacial structure(s) following surgery or trauma requires a coordinated teamwork of various disciplines of dentistry and other health professionals. Among all the members, the sizable role is played by a maxillofacial prosthodontist, both pre- and post-operatively, in designing and fabrication of a suitable facial prosthesis to reinstate the patient's life. The role of a maxillofacial prosthesis is not only to improve orofacial esthetics but also to restore the patient ability to perform basic functions such as mastication, deglutition, and speech.[1] The primary requisite of a successful prosthesis is to have a good fit to ensure improved patient compliance.

Glossary of Prosthodontic Terms-9 defines obturator as “a maxillofacial prosthesis used to close a congenital or acquired tissue opening, primarily of the hard palate and/or contiguous alveolar/soft tissue structures."[2] Large defects, as created by a hemimaxillectomy procedure, require restoration by a well-planned and fabricated obturator prosthesis. This case report describes various pre- and postsurgical, clinical, and laboratory procedures involved in the prosthetic rehabilitation of a patient with maxillary carcinoma, requiring hemimaxillectomy.


   Case Report Top


A 22-year-old male patient diagnosed with mucoepidermoid carcinoma of the right maxilla reported to the department of prosthodontics, crown and bridge after being referred by the department of oral and maxillofacial surgery for prosthetic rehabilitation. The patient was proposed to undergo hemimaxillectomy which involved removal of the right maxilla, including premaxilla and adjacent hard palate [Figure 1] and [Figure 2]. The patient was explained about the complete treatment and a written, signed informed consent was taken. A Class I type of obturator prosthesis according to the Aramany classification[3] was planned for the same, the fabrication of which was divided in three phases, each having a specific objective. The three stages of the division had fabrications of the surgical obturator, interim obturator/postsurgical obturator, and final/definitive obturator, respectively.[4]
Figure 1: preoperative extraoral photograph of the patient

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Figure 2: preoperative intraoral image showing the site of the defect

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Surgical obturator prosthesis fabrication

A surgical obturator is the one made using preoperative intraoral impressions and inserted at the time of the surgical procedure.[4] The obturator was placed intraorally after the affected portion of the maxilla was excised. It supports the flap and also acts as a barrier between the surgical dressing and oral cavity. It also allows the patient to perform basic functions such as feeding and speech, thereby improving the patient compliance.[1]

  • Two sets of presurgical impressions of both the maxillary and mandibular arches were made using irreversible hydrocolloid (Zelgan 2002; Dentsply-India, Gurgaon, Haryana, India) and casts were poured using Type III gypsum material (Kalstone; Kalabhai Karson, Mumbai, Maharashtra, India). One set of cast served as a record of presurgical state, while the second set was used for the fabrication of surgical obturator.
  • Teeth in the planned resection area (right maxillary incisors, canine, premolars, and molars) were removed on the second cast, and the surrounding alveolar process was reduced to approximately 2 mm in height.
  • Clasps were fabricated, keeping in mind that it should not interfere with either the seating of prosthesis during the surgery or with the occlusion of opposing teeth. No teeth were added as they are contraindicated and might put stress on the healing surgical site.
  • Prosthesis was fabricated in clear autopolymerizing acrylic resin (DPI RR Cold Cure; Dental Products of India, Mumbai, Maharashtra, India) to facilitate visualization of the underlying tissues at the time of placement and during the healing period [Figure 3].
  • Holes were placed in the periphery to permit for suturing to the border of the defect or for circumferential wiring, as per the surgeon's requirement.
  • Prosthesis was checked on the cast for its ease in seating. The prosthesis was polished and sterilized using 4% glutaraldehyde and sent to the operating room.
Figure 3: fabricated surgical obturator

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Postsurgical/interim obturator prosthesis

After a period of 1 month, the patient was recalled to assess the primary healing. The surgical obturator along with the dressing was removed and the defect was examined [Figure 4]. Thorough examination revealed the defect to be larger than expected, and hence, a hollow bulb obturator was planned for henceforth treatment.
Figure 4: intra-oral defect after 1 month postsurgically

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  • A new set of maxillary and mandibular arch impressions was made and two sets of casts were poured. As for the surgical obturator, one set was used for the fabrication of a special tray and the other set served as a record.
  • Border molding was done using greenstick impression material (DPI Pinnacle; Dental Products of India, Mumbai, Maharashtra, India) to record the functional anatomy of the labial and buccal soft tissues. The final impression was made with polyvinylsiloxane impression material (Affinis, Coltene Whaledent) [Figure 5].
  • Casts were poured with Type IV gypsum material (high-strength dental stone) (Kalstone; Kalabhai Karson, Mumbai, Maharashtra, India). Deep undercuts in the defect area were blocked using base plate wax.
  • A thin layer of autopolymerizing resin (DPI RR Cold Cure; Dental Products of India, Mumbai, Maharashtra, India) was applied on the defect area using the sprinkle method, leaving the base of the defect open to pour water later [Figure 6].
  • After the resin layer was set, water was poured in the hollow space and the cast was refrigerated so that the hollow cavity was completely filled with ice.[5] Once the ice was set, the open end of the bulb was sealed using autopolymerizing resin (DPI RR Cold Cure; Dental Products of India, Mumbai, Maharashtra, India) using a dough technique [Figure 7].
  • The bulb was carefully removed and two holes were made on the most dependent part. One hole served as air inlet and the other as an outlet for water. The bulb was allowed to rest for some time to allow the ice to melt and drain from the hollow cavity.
  • Once all the water was drained, the two holes were sealed using autopolymerizing resin.
  • The hollow bulb obturator was fitted with retentive clasps and anterior teeth were added to enable minimum functions of speech and esthetics. No teeth were added for any occlusal functions.
  • Finished and polished prosthesis was inserted and post-operative instructions were given to the patient.
  • The patient was recalled at regular intervals of 1 week to 1 month to modify the prosthesis and examine the changes in the healing defect.
  • After a period of 6 month postinsertion of the obturator, the changes in the defect were found to be minimal and the final prosthesis was planned.
Figure 5: polyvinylsiloxane impression of healed soft tissue following the removal of the surgical obturator

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Figure 6: steps of applying autopolymerizing resin for hollow space obturator

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Figure 7: (a) set resin with ice in defect space for obturator fabrication (b) Sealed defect after freezing of poured water

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Definitive obturator prosthesis

  • Primary impressions of the maxillary arch with blocked out defect were made using irreversible hydrocolloid (Zelgan 2002; Dentsply-India, Gurgaon, Haryana, India).
  • Casts were poured with Type III gypsum material (dental stone) (Kalstone; Kalabhai Karson, Mumbai, Maharashtra, India) and were surveyed using Ney surveyor. A metal framework was planned to support the obturator.
  • Occlusal rests were planned on the remaining premolars and second molar. Guide planes on the anterior teeth were restricted to a height of 1–2 mm. The fulcrum line for indirect retention was planned along the premolars. Mouth preparations were done accordingly.
  • Retentive loops were provided on the side of the defect for the attachment of the obturator bulb.
  • The final impression was recorded using light-body addition silicone material (Aquasil LV; Dentsply International, Milford, Delaware, USA). The casts were obtained as done previously and the cast metal framework was fabricated on the refractory cast.
  • After the trial of the framework [Figure 8], an acrylic special tray is attached to the retentive loops. Border molding was done to record the functional anatomy of the labial and buccal soft tissues. Once the final impression was made, the extensions were checked for adequacy.
  • Mastercast was poured and the temporary denture base was fabricated with the framework in place on the defect side.
  • Jaw relation recordings and teeth arrangement were done [Figure 9].
  • Denture processing, finishing, and polishing were carried out in a conventional manner.
  • The obturator prosthesis was then inserted in the patient's mouth and checked for extensions, stability, and retention. The patient's speech and occlusion were also evaluated [Figure 10].
  • The patient was advised to wear the prosthesis continuously and measured for prosthesis maintenance and care. Postinsertion checkup was done at 24-h, 1-week, 1-month, and 3-month interval.
Figure 8: framework trial (a) Intraoral view (b) extraoral view

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Figure 9: framework trial after teeth arrangement (a) intraoral view (b) extraoral view

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Figure 10: extraoral image of the patient after definitive prosthesis insertion

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   Discussion Top


Intraoral congenital or acquired maxillary defects presenting as antrum or nasopharynx opening are a common site.[4] Acquired defects are common following hemimaxillectomy procedures for carcinoma eradication. The procedure leads to increased patient morbidity and a poor quality of life. Thus, it is important to provide these patients with prosthetic rehabilitation to help better adapt to the unaccounted changes in lifestyle. Obturator prostheses are an attractive treatment modality which helps in restoring not only the functional aspects but also addresses orofacial esthetic needs. A well-planned and executed treatment not only requires a skilled surgeon but also requires a team of specialized, experienced, and coordinated health care professionals to ease the pre- and post-operative trauma incurred by the patient. This not only ensures smooth proceedings with a reduction in time requirement but also ensures utmost care for the patient. Among all the members of the team, a significant role is played by the maxillofacial prosthodontist, who is responsible for the best possible prosthetic rehabilitation of the patient. This case report provides a systematic approach followed in the prosthetic rehabilitation of a mucoepidermoid carcinoma patient following hemimaxillectomy procedure using an obturator device. The article, in particular, highlights the need and importance of having a prosthodontist as a part of the health-care team from the beginning of the treatment and rehabilitative procedures.

Of the numerous classification systems for maxillectomy defects,[6] Aramany classification proposed in 1978[3],[7] is popularly used, segregating the different postsurgical maxillary defects.[3],[7] Different authors have presented a variety of obturator designs, varying in some aspect or the other, for the repair of acquired maxillary defects.[3],[8] However, these designs are either bulky or present with tedious, complex fabrication procedures. Hollow bulb obturator is a viable alternative which adopts a simplified approach and can have increased patient acceptance. In the above-presented case, a hollow bulb obturator was fabricated in three stages namely: surgical, interim, and definitive prosthesis for a Class I Aramany, i.e., a defect involving resection along the midline with the maintenance of the opposite side of the arch. Staged fabrication not only resulted in a better definitive prosthesis but also helped achieve better patient compliance and acceptance.

Framework designing of the definitive obturator was carried out by following the basic principles of removable partial denture designing. Surveying of the diagnostic cast to identify undercuts and plan an ideal design helped in avoiding insertion difficulties and increased time generally encountered with these prostheses. The rigid major connector along with multiple occlusal rests enabled directing the occlusal forces along the long axis of the remaining teeth, avoiding undue damage to the remaining teeth. In addition, guide plane incorporation enhanced stability and adequate bracing of the prosthesis. Limiting the guide plane vertical height to 1–2 mm on the anterior abutment teeth limited torque incurred by them, thereby avoiding tipping of these teeth. Indirect retention, located perpendicular to the fulcrum line, was provided by the premolars in this case. Thus, such a design enabled the achievement of maximum support from the residual soft tissues, and the retention was within physiological limits of the periodontal ligaments of the remaining teeth.[3]

Several techniques and materials such as salt, sugar, and ice along with split techniques have been used in the past to fabricate the hollow bulb obturator.[9] In one presented article, satisfactory results and successful rehabilitation have been achieved with an obturator prosthesis consisting of not only a hollow bulb but also an entirely hollow denture base resulting in a further decrease of prosthesis weight, thereby enhancing the patient acceptance.[10] However, it is the skill, knowledge, and experience of the specialist which determines the ultimate success of the prosthesis and goes a long way in improving the patient's quality of life. The use of water followed by its freezing to form ice and fabricate the hollow bulb is an innovative and supportive strategy. It avoids distortion of the bulb, providing an accurate and smooth adaptation which at time can be absent when sugar or salt is used or be technique sensitive as in case of split technique. In addition, the hollow bulb not only decreases the overall prosthesis weight but also helps add resonance to voice, thereby providing with another instance of increased patient acceptance.

The authors of this article strongly support and suggest a definitive inclusion of an experienced maxillofacial prosthodontist among the team responsible for the management of such cases. Prosthodontist will not only aid in the easy and accurate fabrication of the prosthesis but also guide in terms of surgical resection, prospective salvation of the remaining teeth and hard palate, graft placement, inferior turbinate removal, and sinus wall grafting. Such an intervention helps in planning fulcrum line in a more favorable position without compromising the surgical outcome which yet again ensures better acceptance by the patient. Short- and long-term problems faced both by the surgeon and prosthodontist as well as the patient too are avoided with such a team addition. Thus, a prosthodontists should be made an active part of treatment planning since the day a patient reports instead of taking one on board once the surgical planning has been done.


   Conclusion Top


Rehabilitation of a maxillectomy patient is a long and technique sensitive protocol that requires high care and precision. Often included late during the course, a prosthodontist instead should be consulted from the beginning, even prior to the planning of the surgical procedure. This will not only decrease the rehabilitation time but also help the patient cope with the procedure at a faster and better rate. The methodology followed for obturator construction for the particular case can be easily adopted using readily available and cost-effective materials, which becomes a necessity for a population like India with large strata of society falling in the low socioeconomic bracket. In addition, the authors also recommend that irrespective of the complexity of the case, such cases should be reported in literature. This would help identify potential alternatives and make health-care family aware about various clinical presentations and outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Keyf F. Obturator prostheses for hemimaxillectomy patients. J Oral Rehabil 2001;28:821-9.  Back to cited text no. 1
    
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The glossary of prosthodontic terms: Ninth edition. J Prosthet Dent 2017;117:e1-105.  Back to cited text no. 2
    
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Parr GR, Tharp GE, Rahn AO. Prosthodontic principles in the framework design of maxillary obturator prostheses. J Prosthet Dent 1989;62:205-12.  Back to cited text no. 3
    
4.
Singh M, Bhushan A, Kumar N, Chand S. Obturator prosthesis for hemimaxillectomy patients. Natl J Maxillofac Surg 2013;4:117-20.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Schneider A. Method of fabricating a hollow obturator. J Prosthet Dent 1978;40:351.  Back to cited text no. 5
    
6.
Durrani Z, Hussain SG, Alam SA. A study of classification systems for maxillectomy defects. JPPA 2013;1:117-24.  Back to cited text no. 6
    
7.
Aramany MA. Basic principles of obturator design for partially edentulous patients. Part I: Classification. J Prosthet Dent 1978;40:554-7.  Back to cited text no. 7
    
8.
Desjardins RP. Obturator prosthesis design for acquired maxillary defects. J Prosthet Dent 1978;39:424-35.  Back to cited text no. 8
    
9.
Sridevi JR, Kalavathy N, Jayanthi N, Manjula N. Techniques for fabricating hollow obturator: Two case reports. SRM J Res Dent Sci 2014;5:143-6.  Back to cited text no. 9
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10.
Perwez E, Tamrakar AK, Mallick R, Sachdeva S. An innovative technique of fabrication of hollow obturator for a case of hemi-maxillectomy. Ann Dent Spec 2015;3:29-32.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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