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| CASE REPORT |
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| Year : 2015 | Volume
: 5
| Issue : 3 | Page : 136-139 |
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Delayed obturator for irradiated maxillectomy patients: Case report of two patients
Sushil Kar, Arvind Tripathi
Department of Prosthodontics, Saraswati Dental College and Hospital, Lucknow, Uttar Pradesh, India
| Date of Web Publication | 28-Apr-2016 |
Correspondence Address:
Sushil Kar
Department of Prosthodontics, Saraswati Dental College and Hospital, Lucknow, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2229-5194.181376
 Abstract | | |
Functional rehabilitation is the sequel to tumor ablation and consequent cancer-free status in most patients. Unfortunately, a plethora of reasons may play a stellar role in delayed rehabilitation. These may range from unsuitability of the remnant tissue bed for prosthesis, prolonged tissue inflammation, postirradiation unfavorable tissue changes, and secondary bacterial or fungal infection in the recipient tissue bed. In some situations, the economic status of the patient may grossly restrict the patient's effort to seek prosthetic service. These unwarranted and undesirable obstacles would lead to gross facial disfigurement and a progressive tissue shrinkage which might render the recipient site nonamenable to the seating of the prosthesis.
CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY
- When prosthodontic therapy is not conjoint with surgery, the succeeding tissue contracture, and soft tissue collapse can lead to irreversible unesthetic, and contorted facial contours
- Components of prosthesis function assessed were esthetics, speech, mastication, all of which were restored to satisfactory levels by the interim obturators. Thus, optimal restoration of esthetics and function is achievable despite a time lag in prosthodontic therapy after surgery.
Keywords: Maxillectomy, necrosis, obturator, radiation, rehabilitation
How to cite this article:
Kar S, Tripathi A. Delayed obturator for irradiated maxillectomy patients: Case report of two patients. J Interdiscip Dentistry 2015;5:136-9 |
| Introduction | |  |
Once, the patient has undergone surgical resection, the ultimate goal is appropriate prosthetic, and functional rehabilitation which restores facial contour improves mastication, improves speech and swallowing, reduces drooling, and provide lip support.[1] Studies were conducted on different types of osseous flap for implant placement, but all the patient are not suitable candidate for transplantation.[2] Establishment of functional maxillo-mandibular complex may be affected by the extent of the resection, postsurgical, and radiation associated complication. In addition to this, cooperation and socioeconomic conditions of the patient leads to delay the final restoration.
Tissue necrosis and secondary infection of the irradiated tissue are potential complications after radiation therapy.[3] These patients show chronic changes involving bone and mucosa that lead to vascular inflammation and scarring. Because of the delayed referral, final restorative goal may not be obtained. If the patient stays unrehabilitated, facial disfigurement may become so severe that prosthetic treatment may become impossible.[4] This case reports demonstrate the possibility and usefulness of delayed interim obturator for patients with low socioeconomic bracket who reported after a long period.
| Case Reports | | |
Surgical defects are usually ready to receive prosthesis in 6–9 months though this period may warrant an extension of another quarter or half year if radiotherapy is planned. The high cost of implants or cast metal framework, coupled with the fact that the rural Indian population belongs to lower socioeconomic background, meant that the only option to rehabilitate these long-term irradiated maxillectomy defects was to use prostheses made entirely of acrylic. In this case series, two patients with a history of hemimaxillectomy over a period of 5 years were rehabilitated in the form of Interim obturator prosthesis.
Case 1
A 38-year-old woman was referred by her surgeon because she had undergone extensive surgical removal along with radiotherapy due to a large adenocarcinoma of the maxillae. The patient medical history revealed a partial maxillectomy on the right side including teeth from maxillary central incisor to the hamular notch and anterior part of the soft palate approximately 5 years ago [Figure 1]. Clinically, the patient had experienced impaired speech, difficulty in mastication, and leakage of liquid into the oral cavity. The combined effect of surgery and radiotherapy-induced was severe soft tissue fibrosis and scar contraction [Figure 2]. | Figure 2: Condition of the remaining dentition after through prophylaxis
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Irreversible hydrocolloid impression material (Zelgan 2002; Dentsply, Bengaluru, Karnataka, India) was selected for making the impression of the maxillary and mandibular arch using a perforated metal stock tray and poured in Type III dental stone (Dentstone; Pankaj Industries, Mumbai, Maharashtra, India). The remaining dentition was utilized as a guide for recording the maxillo-mandibular relation. The trial dentures were checked in the patient's mouth and cured with heat-cure acrylic denture base material using conventional laboratory procedures [5],[6],[7] (Lucitone 199; Dentsply, Austenal, NY, USA).
The obturator prosthesis has extended to cover the defect area along with the remaining hard and soft palate with a thickness of 2 mm all over the base. The hollowed part of the obturator base was filled with thick plaster leaving about 3 mm below the level of the remaining palatal segment. An impression of the palatal surface was taken with an irreversible hydrocolloid and poured with dental stone. The master cast obtained was trimmed. Cold cure clear acrylic resin (DPI, India) was used to fabricate a 3 mm thickness lid that covers the hollowed part of the obturator [Figure 3]. The lid was subsequently bonded to the obturator with the cold cure clear acrylic resin.[8],[9],[10]
At the insertion appointment, the fit between the defect and the denture portion of the obturator prosthesis was evaluated, which shows definitive retention, stability, and satisfactory occlusion. Treatment was completed to the esthetic and functional satisfaction of the patient [Figure 4]. | Figure 4: Soft tissues are well supported by the prosthesis with improved esthetics
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Case 2
A 35-year-old woman was reported for an evaluation for prosthetic treatment. Her primary concerns were poor facial appearance, impaired speech, and regurgitation of food into the nasal cavity. She had been diagnosed with squamous cell carcinoma of the maxillary sinus 5 years prior and had undergone a unilateral partial maxillectomy followed by postsurgical radiation therapy. Surgery in combination with radiotherapy caused fibrosis and scar contraction both intra- and extra-orally [Figure 5]. The hard palate, alveolar bone, teeth, and soft tissue on the left side were resected, but the patient had all viable maxillary teeth on the right side [Figure 6]. | Figure 5: Fibrosis and contracture of the left side of the face after radiotherapy
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 | Figure 6: Intraoral view of the maxillary defect. The patient had all viable maxillary teeth on the right side
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Prosthetic rehabilitation was planned with a closed, hollow definitive obturator following all the clinical and laboratory steps [Figure 7]. The definitive obturator prostheses restored the patients' ability to feed and swallow to a reasonable level. Speech intelligibility was assessed by asking the patients to repeatedly utter the word “Saraswati.” The patient's ability to handle oral secretions was significantly improved with the use of obturator prostheses. Acceptable esthetic results were also achieved [Figure 8]. This had a positive psychological effect on the patients, thereby enhancing her self-esteem after prosthodontic rehabilitation. Presumably, the subsequent tissue collapse about the defect will also be overcome with the prostheses. | Figure 8: Restoration of the mid-facial contour with provision of full complement of maxillary teeth on the resected side
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| Discussion | | |
Neglecting timely prosthodontic cooperation may cause inappropriate facial contour which is almost impossible to reconstruct. In the absence of immediate obturation, soft tissues remain unsupported and collapse dramatically, and esthetic and/or possible psychological problems may occur. The borders of the defect may collapse more rapidly if support of the immediate obturator is neglected and in a few years after surgery, the healing period, especially the anterior and lateral border of the defect migrates toward the center of the defect causing facial esthetic problems. For both the patients, levator anguli oris and levator labii superior muscles may have been contracted and elevated the comissura as they originate from the maxilla which is already resected. Muscles such as zygomaticus major and minor may also have an effect on the elevation of the comissura considering the surgical procedure. Nevertheless, the problem is more than an elevation of the comissura but a collapse of the left mid-facial region which even causes the deviation of the nose hip. Therefore, the lack of support and soft tissue contraction due to radiotherapy is thought to have been more effective on the facial deformity.[11]
An interim obturator can be fabricated with the approval of referring surgeon, in the absence of any recurrence of disease, and once sufficient time has elapsed following radiotherapy to ensure complete healing of tissues in the region of the defect. The remaining maxillary and mandibular dentition should be restored to optimal health to provide retention, support, and stability to the obturator prosthesis.[12] Acrylic resin is useful to restore the excised structures since the prosthesis may help in repositioning the upper lip musculature, providing better esthetics, and function. Prosthesis device has served to obturate oro-nasal communication, to provide a functional and esthetic replacement for missing teeth, and supporting tissues. In all cases, the obturator portion of the prostheses was made smooth to reduce the possibility of trauma to the mucosa; therefore, improve tolerance of the prosthesis. The weight of the prostheses was reduced because of hollowness. Because of the inability of the patients to meet the cost of fabrication of either implants or cast metal framework, definitive obturation was not undertaken. The results so far are encouraging. The removable nature of the prostheses allows for the inspection of the surgical site to check for evidence of recurrence of disease.[13],[14]
| Conclusion | | |
Satisfactory functional and esthetic results can be achieved in patients with extensive maxillary defects using obturator prostheses fabricated using readily available materials when socioeconomic status, orofacial condition, and delayed referral contradicts a definitive mode of treatment.
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 | | |
| 1. | Haug SP. Maxillofacial prosthetic management of the maxillary resection patient. Atlas Oral Maxillofac Surg Clin North Am 2007;15:51-68.  |
| 2. | Kim DD, Dreher MA. The fibula free flap in maxillary reconstruction. Atlas Oral Maxillofac Surg Clin North Am 2007;15:13-22. |
| 3. | Ackerman AJ. The prosthetic management of oral and facial defects following cancer surgery. J Prosthet Dent 1955;5:413-38. |
| 4. | Desjardins RP. Early rehabilitative management of the maxillectomy patient. J Prosthet Dent 1977;38:311-8. [ PUBMED] |
| 5. | Huryn JM, Piro JD. The maxillary immediate surgical obturator prosthesis. J Prosthet Dent 1989;61:343-7. |
| 6. | Birnbach S. Immediate surgical sectional stent prosthesis for maxillary resection. J Prosthet Dent 1978;39:447-50. [ PUBMED] |
| 7. | Keyf F. Obturator prostheses for hemimaxillectomy patients. J Oral Rehabil 2001;28:821-9. |
| 8. | Penn M, Grossmann Y, Shifman A. A preplanned surgical obturator prosthesis for alternative resection lines in the anterior region. J Prosthet Dent 2003;90:510-3. |
| 9. | Arcuri MR, Taylor TD. Clinical Maxillofacial Prosthetics. Chicago: Quintessence; 2000. p. 103-16. |
| 10. | Heggie AA, MacFarlane WI, Warneke SC. Immediate prosthetic replacement following major maxillary surgery. Aust N Z J Surg 1980;50:370-4. [ PUBMED] |
| 11. | Minsley GE, Warren DW, Hinton V. Physiologic responses to maxillary resection and subsequent obturation. J Prosthet Dent 1987;57:338-44. [ PUBMED] |
| 12. | Park KT, Kwon HB. The evaluation of the use of a delayed surgical obturator in dentate maxillectomy patients by considering days elapsed prior to commencement of postoperative oral feeding. J Prosthet Dent 2006;96:449-53. |
| 13. | Lang BR, Bruce RA. Presurgical maxillectomy prosthesis. J Prosthet Dent 1967;17:613-9. [ PUBMED] |
| 14. | Beumer J, Curtis TA, Marunick MT. Maxillofacial Rehabilitation: Prosthodontic and Surgical Considerations. St. Louis: Elsevier; 1996. p. 225-47. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
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