A simplified technique to make an immediate surgical obturator for a maxillectomy patient :Anand Farias, Chethan Hegde, D Krishnaprasad, Journal of Interdisciplinary Dentistry

CASE REPORT
Year : 2013 | Volume : 3 | Issue : 2 | Page : 125--128

A simplified technique to make an immediate surgical obturator for a maxillectomy patient

Anand Farias, Chethan Hegde, D Krishnaprasad
Department of Prosthodontics, A. B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore, Karnataka, India

Correspondence Address:
Anand Farias
Department of Prosthodontics, A. B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore, Karnataka
India

Abstract

Patients with advanced carcinomas of the maxillary sinus are often treated with surgical resection by maxillectomy and face several complications including change and difficulty in speech, deglutition, mastication and esthetics, as well as psychological discomfort following the surgery. Most of difficulties can be overcome, to an extent, with the placement of an immediate surgical obturator. This clinical report describes the fabrication of a removable immediate surgical obturator for a patient with stage 4 carcinoma of the maxilla, which uses the patient�SQ�s original occlusion and tooth position, made prior to the surgical resection and inserted at the time of surgery, to provide the patient with a means of masticatory efficiency, esthetics and psychological comfort during the healing period. Clinical Relevance to Interdisciplinary Dentistry

Highlights a team effort in the management of oral and facial carcinomas - Surgeon, Pathologist and Prosthodontist.
Provides a stable foundation for fabrication of future prosthesis.
Prosthetics to aid in the surgical management of scar tissues.
Esthetics and facial form maintained following surgery, minimizing post-surgical patient depression.

How to cite this article:
Farias A, Hegde C, Krishnaprasad D. A simplified technique to make an immediate surgical obturator for a maxillectomy patient.J Interdiscip Dentistry 2013;3:125-128

How to cite this URL:
Farias A, Hegde C, Krishnaprasad D. A simplified technique to make an immediate surgical obturator for a maxillectomy patient. J Interdiscip Dentistry [serial online] 2013 [cited 2023 Jun 1 ];3:125-128
Available from: https://www.jidonline.com/text.asp?2013/3/2/125/126877

Full Text

Introduction

Carcinoma of the maxillary sinus is relatively uncommon, and most often the patient reports to the surgeon at the advanced stages. The advanced stages of such a lesion will require extensive excision and subsequent difficulties in the prosthetic rehabilitation of the patient. The 3- and 5-year overall survival is 38% and 35%, respectively, and the disease-free survival, respectively, is 29% and 26%. The 5-year overall survival after surgery and post-operative radiotherapy is 42%. [1]

On recovery from resection surgery, the patient will be immediately aware of his/her inability to speak. Deglutition will be a problem for the patient as the defect will fail to contain food and fluid in the mouth. Removal of the alveolus will cause masticatory problems. Cosmetically, the patient will exhibit extraoral evidence of the resection due to loss of support from the musculature. [2] All these internal and external changes will influence the psychological well being of the patient, making necessary the use of an immediate surgical obturator.

We present a case report of a patient who was referred to the us with Stage IV carcinoma of the maxillary sinus that had invaded the orbit, globe of the eyeball and the duramater, which was treated with an immediate surgical obturator making use of the patient's existing tooth positions prior to surgery so as to reproduce esthetics and mastication as efficiently as possible and retained using orthodontic clasps as no other form of retention was available from the extensive resection carried out. This prosthesis was aimed at providing the patient with maximum efficiency in mastication, speech and esthetics possible in those situations following surgery.

Case History and Clinical Presentation

A 46-year-old female was referred to the Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore from the Department of ENT, K. S. Hegde Medical Academy, for the fabrication of an immediate surgical obturator.

The patient had been diagnosed as having moderately differentiated squamous cell carcinoma of the maxillary antrum (T 4 N 0 M 0 ) and had been scheduled for total maxillectomy of the left maxillary bone. [3] The surgical team expected the resection to result in a defect corresponding to Vertical III of Brown and Shaw's 2010 Classification. [4],[5]

The patient presented with insidious and intermittent nasal discharge that was associated with nasal obstruction of the left side. The discharge was associated with bleeding on several occasions. There had been a history of swelling of the left epicanthal region for the last 6 months, which was insidious in onset and associated with pain and watering of the left eye. There has been a decrease in vision in the left eye along with a history of anosmia. Retinal detachment was also present [Figure 1].{Figure 1}

Treatment plan

The following line of treatment was planned along with the surgical team from the ENT Department:

Total maxillectomy of the left maxillary bone along with resection of the tumor tissueFit and insertion of an immediate surgical obturatorFabrication of a definitive surgical obturator following radiotherapy and healing of the surgical wound. [6]

Fabrication of the immediate surgical obturator

Impressions were made of the patient's maxillary arch using irreversible hydrocolloid (Neocolloid, Zhermack Clinical, Italy), and the extent of the surgical resection was marked out on the maxillary impression with an indelible pencil by the surgical team [Figure 2]a.{Figure 2}

The indentations of the teeth in the impression of the maxilla that was to be resected were filled with tooth-colored auto-polymerizing acrylic resin (DPI-Cold Cure, Dental Products of India, Mumbai, India). Pink auto-polymerizing pink acrylic resin (DPI-Cold Cure, Dental Products of India) was used to cover the portion of the palate to be resected as marked by the surgical team. Once set, adequate separating medium was applied to the acrylic resin and a cast was poured using Type III dental stone [Figure 2]a-d.

Orthodontic C-clasps with 22-gauge stainless steel wires were prepared and adapted to the teeth 14, 15 and 16 and modeling wax (Hindustan Modelling Wax No. 2, Hindustan Dental Products, Mumbai, India) adapted to the non-resected side and made to merge with the earlier fabricated auto-polymerizing section of the denture base [Figure 2]e. The prosthesis was then processed using heat-cured acrylic resin, retrieved, trimmed and polished [Figure 2]f, g.

The prosthesis was then disinfected using 0.2% chlorhexidine solution (Rexidin, Indoco Remedies, Aurangabad, India).

Fit and insertion of the immediate surgical obturator

Fit and insertion of the immediate surgical obturator was carried out in the operating theater.

After the surgical resection was completed [Figure 3] and reconstruction using a split-thickness graft was completed by the surgical team, the prosthesis was inserted and the borders were adjusted [7] so as to ensure a passive fit over the reconstructed flap and not to cause any irritation to the soft graft [Figure 3]. The surgical team then completed the closure of the operating site.{Figure 3}

Follow-up checkup was carried after 48 h to check and refine the borders of the prosthesis.

Unfortunately, fabrication of the definitive prosthesis has been temporarily delayed due to the development of flap necrosis during the post-operative period.

Discussion

The presence of large carcinomatous lesions generally necessitates removal of large portions of the maxilla, or even the whole maxilla. The traditional sequence of prosthetic rehabilitation of such patients involved a staged protocol of immediate, followed by interim and lastly definitive obturators as the tissues heal, adapt and stabilize. In the case presented, the extent of the resection (as the tumor had perforated the base of the skull and exposure of the dura mater was observed) resulted in a very poor prognosis and life expectancy. However, one is duty bound to provide the best of treatment care for the patient no matter what the outcome and life expectancy. It was therefore planned to fabricate the entire sequence of obturators with this in mind.

Methods of retention of an obturator vary from use of cast clasps to zygoma implants. [8],[9],[10] However, due to the extent of the tumor and the amount of tissue resection, such forms of conventional retention were not possible at this point of time.

The planned prosthesis was based on a technique given by Haraguchi et al., [11] The use of orthodontic clasps provides a means of retention, which is adequate till a definitive prosthesis can be fabricated. Traditionally, the use of teeth in the immediate obturator is avoided due the potential to injure the already compromised tissues during radiotherapy and the possible delay in healing by placing load on the healing tissues. [12] However, the incorporation of the patient's existing occlusal scheme and palatal contour provides a means by which the patient can more readily adapt to the loss of teeth and cope with defect created by surgical resection. Because the surgical team wanted to perform the surgery within 24 h of referral for the obturator, the patient's occlusal scheme was easily duplicated with the tooth-colored auto-polymerizing resin. This eliminated the need of putting the patient through further discomfort of a jaw relation and trial procedures in her presenting condition. The use of the irreversible hydrocolloid mould and auto-polymerizing acrylic resin would also eliminate the need for excessive occlusal corrections at the follow-up appointment.

We fabricated the denture base in two sections - one half in auto-polymerizing resin and the other half in heat-cured acrylic resin. The section in auto-polymerizing resin was fabricated as such to enable us to chemically bond to the teeth (which were already in auto-polymerizing resin). The other half of the denture base contained the orthodontic clasps whose retentive components were accurately positioned in the wax pattern. Use of heat-cured acrylic resin would result in a lesser distortion of this segment and thus eliminate the need for excessive corrections of the clasps, and ultimately a more comfortable treatment follow-up for the tissues and the patient as a whole.

Conclusion

The modified surgical obturator presented will overcome the immediate difficulties that were described by Desjardins and allow the patient to function till necessary radiotherapy or chemotherapy has been administered and healing has taken place. In addition to providing function, it allows for a comfortable prosthetic treatment for a patient who is going through the trauma of the cancer, surgery and recovery.

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