Prosthetic rehabilitation of acquired maxillary defect

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Case Report

Prosthetic rehabilitation of acquired maxillary defect Gowri Sivaramakrishnan Department of Oral Health, Fiji National University, Suva, Fiji ABSTRACT

This case report describes the rehabilitation of a patient with acquired maxillary defect using heat polymerizing acrylic resin hollow bulb obturator. The aim of the prosthesis is to improve the retention of the prosthesis and the esthetics. Acquired maxillary defects caused by surgical correction of tumors or trauma can lead to various functional, esthetic and psychologic disturbances to the patient. The defect results in liquid and food escaping into the maxillary sinus and nasal cavities, causing severe speech and swallowing dysfunction with significant reduction in quality of life. The maxillofacial prosthodontist has a challenging role in the rehabilitation of the acquired defects. This clinical report describes rehabilitation of an acquired maxillary defect of a 45‑year‑old male patient using single piece closed hollow bulb obturator made with heat polymerizing acrylic resin. The bulb portion with the tissue surface of the denture was formed first followed by lid fabrication separately. The lid was attached appropriately using auto polymerising resin. The hollow bulb design improves the retention of the prosthesis when the clinical situation prevents adequate retention of the prosthesis. Furthermore for patients with financial constraints, heat polymerizing acrylic resin prosthesis provides a cost‑effective treatment. A hollow bulb obturator allows fabrication of light weight prosthesis. The weight of the prosthesis contributes significantly to the retention of the prosthesis. In cases where the defect is large or if anatomy of the defect does not contribute to the retention and stability of the prosthesis, closed hollow obturators are a good treatment option. The hollow obturator makes the prosthesis lighter in weight and thereby improves the retention of the prosthesis and improves speech. Key words: Hollow bulb, maxillary defect, obturator

Background Address for correspondence: Dr. Gowri Sivaramakrishnan, Assistant Professor in Prosthodontics, Department of Oral Health, Fiji National University, Hoodless House, Brown Street, Suva, Fiji. E‑mail: gowri.sivaramakrishnan@ gmail.com Date of Submission: 12‑06‑2014 Date of Acceptance: 04‑09‑2015

Access this article online Website: www.indjos.com DOI: 10.4103/0976-6944.171093 Quick Response Code:

Oral squamous cell carcinoma is generally treated with conventional surgical excision. The excision of hard and soft palate, results in an acquired maxillary defect with an oro‑antral communication.[1] The defect, results in liquid and food escaping into the nasal cavities causing severe speech and swallowing dysfunction with significant reduction in quality of life.[2] An obturator is an artificial substitute replacing surgical or congenital defective area. [3] Successful obturation depends on the volume of the defect and the positioning of the remaining hard and soft tissues to be used to retain, stabilize and support the prosthesis.[4] When the retention and stability of the prosthesis is compromised various obturator designs have been reported in the literature.[5‑10] The hollow bulb obturator design is an aid to improve the retention and the resonance of voice as it is light in weight. This clinical report describes the fabrication

© 2015 Indian Journal of Oral Sciences | Published by Wolters Kluwer - Medknow

of a hollow definitive obturator for a patient with a unilateral acquired maxillary defect. The method used in the fabrication of the hollow bulb obturator involved two stage procedures in which the obturator bulb and lid were processed separately and then joined together.

Case Report A 45‑year‑old male patient reported to the Department of Prosthodontics, Manipal College of Dental Sciences, Mangalore,

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the 3.0 the the

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How to cite this article: Sivaramakrishnan G. Prosthetic rehabilitation of acquired maxillary defect. Indian J Oral Sci 2015;6:145-9. 145

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for postsurgical rehabilitation of an acquired maxillary defect. The patient underwent right total maxillectomy and prosthetic rehabilitation with an interim obturator 4 years back. The patient complained of ill‑fitting obturator. Intraoral examination revealed the presence of class I maxillary defect on the right side. The left side was intact with all teeth except central incisor [Figure 1]. The mandibular arch had full complement of teeth with generalized periodontitis. Oral hygiene was poor. Various modalities of prosthetic reconstructions were discussed with the patient and the patient indicated for an economical solution. Considering the large size of the defect and the persistent complaint of ill‑fitting obturator, it was planned to fabricate a hollow bulb obturator using heat polymerizing acrylic resin. The objective of the treatment was to decrease the weight of the prosthesis and also improve the speech.

intrusion of the material into the nasal cavity and an irreversible hydrocolloid impression [Figure 2] (Imprint; Dental Products of India Limited, Mumbai, Maharashtra, India) was made. Diagnostic cast was poured in type III stone (Dentstone; Pankaj Industries, Mumbai, India). A custom tray was fabricated using autopolymerising resin (Rapid Repair; Dentsply, Milford, USA) 24 h before the procedure and border moulding was done using low fusing compound (Dental Products of India Limited, Mumbai, Maharashtra, India) to record the functional limit of surrounding soft tissue as well as the extension into the defect. Final impression was recorded with a single step dual phase impression technique using vinyl poly siloxane impression material [Figure 3]. The impression was then boxed and poured in type III stone [Figure 4]. Fabrication of the hollow bulb [Figure 5]

After through oral prophylaxis, all undesirable undercuts were blocked using a piece of moist gauze to prevent

A temporary record base extending onto the surface of the defect was fabricated using auto polymerizing acrylic resin on the master cast. Retaining clasps made of 21 gauge stainless steel wire (Everbright Dental stainless steel

Figure 1: Defect

Figure 2: Primary impression

Figure 3: Final impression

Figure 4: Working cast

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wire; Comet, Mumbai, India) were placed on 11, 12 and 16. Occlusal rims were fabricated and jaw relations were recorded at predetermined vertical dimension followed by teeth arrangement. The wax prosthesis was verified at the trial insertion appointment. This was then invested and wax was eliminated to create a mold space which was replaced by heat polymerizing acrylic resin (Trevalon; Dentsply, Milford, USA). Preparation of the lid [Figure 6]

The lid portion was waxed separately keeping in mind the contours of the palate and was acrylized using heat polymerizing acrylic resin and fused to the prosthesis using auto polymerizing acrylic resin [Figure 7].

prosthesis maintenance. The patient was scheduled for the first postinsertion adjustment 24 h and 1‑week after the insertion. This was scheduled to ensure health of the tissues, to relive the prosthesis from pressure areas on the tissues and to emphasize hygiene and home care. The patient reported satisfaction with the outcome of the treatment. The patient was placed on a 3 months recall for evaluation of the prosthesis and any recurrence of the disease.

Discussion

The prosthesis was finished, polished [Figure 8]. The prosthesis was placed intraorally using rotational path of insertion. Prosthetic retention and stability were evaluated. Prosthesis improved speech intelligibility. The patient was shown how to position and remove the prosthesis [Figure 9]. Patient was instructed on home care and

The rehabilitation of a maxillary defect involves a multidisciplinary approach. For the proper function the obturator needs to be well retained and stable inside the defect. Various means of retaining the prosthesis has been reported in the literature.[11‑13] However, the design of the prosthesis depends on the volume of the defect, residual anatomic structures, remaining natural teeth and the economic status of the patient. With the advent of implants lot many cases of prosthetic rehabilitation after

Figure 5: Fabrication of bulb portion

Figure 6: Shellac lid

Figure 7: Lid fabrication

Figure 8: Floating hollow bulb


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step procedures in which the obturator bulb and lid were processed separately and then joined together.

Figure 9: Prosthesis in situ

maxillectomy are being carried in the recent times.[14,15] In particular the zygomatic implants has been successfully used in cases of severe or almost total loss of maxilla.[16] The advantages of these implant supported prosthesis include secure, esthetic and better function replacement of the ablated hard and soft tissues. Zygoma implants are often being used in conjunction with conventional implants and are especially performed at the end of primary surgery. This can lead of avoidance of any grafting procedures. But they are not without limitations. The time and cost of the treatment cannot be met with by all standards of patients. Evaluation of the prosthesis in case of recurrence might pose problems in case of fixed therapy.[17] In the present case the available soft tissue undercuts were not very favorable for the retention of the prosthesis which could have needed intervention with implants but the patient desired a more economical solution. So acrylic was the material of choice selected. Cast partial obturators are a novel treatment of choice in case of contraindications to implants. The only concern in the fabrication of acrylic obturator is the weight of the prosthesis in case of large surgical defect. Studies conducted by Wu and Scaaf reported that hollowing the prosthesis reduced the weight of the obturator by 6.55–33.06%.[18] Furthermore, the weight of the prosthesis may act as a dislocating force. Hence a hollow bulb obturator was planned. Hollow bulb obturators are lighter in weight and improve the resonance of voice. Cast partial dentures are lighter in weight and do not pose problems to the health of the gingiva and supporting tissues.[19] In the present case the patient wanted a more esthetic appliance without the metal, though the metal was not in the esthetic zone. So heat polymerizing acrylic resin was used as an alternative. The heat polymerizing acrylic resin is easy to fabricate and adjust, esthetic, light in weight and cost‑effective which together met the patient needs. The method used in the fabrication of the hollow bulb obturator involved two 148

There are a variety of techniques that can be used to form a one‑piece hollow bulb obturator. The classic technique used previously involved the fabrication of a solid complete bulb. This was then modified to grind out the excess portion to make it hollow which was then followed by fabrication of a covering for the space that was ground out.[20] A modification of this is to shim the defect of the cast and simulate the ridge contour using wax. A template for the covering is also fabricated out of wax. Both are then processed and attached ultimately using autopolymerizing acrylic resin.[21] Materials like sugar and ice were also used for authors to create the hollow space.[22,23] In a few cases a removable lid has also been tried.[24] However, the point of concern is the uniform wall thickness of the hollow bulb. The technique used in this case report is a modification of the laboratory technique to bring out uniform thickness of the walls of the obturator using easily available and cost‑effective materials which is less time consuming as well.

Conclusion Rehabilitation of patients with acquired maxillary defects present a challenge for the maxillofacial prosthodontist. The hollow bulb design improves the retention of the prosthesis when the clinical situation prevents adequate retention of the prosthesis. Furthermore for patients with financial constraints, heat polymerizing acrylic resin prosthesis provides a cost‑effective treatment. Clinical significance

A hollow bulb obturator allows fabrication of light weight prosthesis. The weight of the prosthesis contributes significantly to the retention of the prosthesis. In cases where the defect is large or if anatomy of the defect does not contribute to the retention and stability of the prosthesis, closed hollow obturators are a good treatment option. The hollow obturator makes the prosthesis lighter in weight and thereby improves the retention of the prosthesis and improves speech. Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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