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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 14  |  Issue : 2  |  Page : 99-102

Prosthetic rehabilitation for hemimaxillectomy


Department of Prosthodontics and Crown and Bridge, Sharad Pawar Dental College and Hospital, Wardha, Maharashtra, India

Date of Submission16-Feb-2019
Date of Decision18-Apr-2019
Date of Acceptance14-Aug-2019
Date of Web Publication25-Nov-2019

Correspondence Address:
Dr. Sharayu Nimonkar
New SBI Colony, Nisarg Nagri, Nagpur Road, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_40_19

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  Abstract 


All the acquired maxillary defects are caused due to the surgical resection of malignancies of the palate and paranasal sinuses. Their extent of resection influences the treatment outcome and also challenges a maxillofacial prosthodontist to restore them prosthetically. Obturator prosthesis is a common and effective way of rehabilitating such maxillary defects. The aim of this prosthesis is to distinct oral and nasal cavities to facilitate deglutition and articulation, to achieve acceptable esthetics, and to support orbital contents to avoid diplopia. This case report describes a definitive obturator prosthesis treatment for a young female patient who has undergone hemimaxillectomy for palatal malignancy.

Keywords: Hemimaxillectomy, maxillary defect, obturator, prosthetic rehabilitation


How to cite this article:
Nimonkar S, Belkhode VM, Sathe S, Borle A. Prosthetic rehabilitation for hemimaxillectomy. J Datta Meghe Inst Med Sci Univ 2019;14:99-102

How to cite this URL:
Nimonkar S, Belkhode VM, Sathe S, Borle A. Prosthetic rehabilitation for hemimaxillectomy. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2019 Dec 11];14:99-102. Available from: http://www.journaldmims.com/text.asp?2019/14/2/99/271550




  Introduction Top


The most effective treatment modality for the malignant tumors of the maxilla is surgical removal. This results in a large defect with oronasal or oro-antral communication.[1] Such defects can be surgically repaired with a microvascular flap. However, reconstruction is not recommended in the cases associated with surgical morbidity, technical difficulties, and notable medical complication.[2] Moreover, the surgical closure of such defect would inhibit the assessment for recurrences in follow-up appointments. Hence, prosthetic rehabilitation remains the first option of choice to treat such patients.

The defect created as a consequence of hemimaxillectomy leads to difficulties with speech, swallowing, and mastication, which eventually affects the quality of life.[3] The functional and esthetic oral rehabilitation of such patients remains one of the most challenging procedures confronting a maxillofacial prosthodontist.

Restoring the maxillary defect with obturator prosthesis helps to replace missing hard and soft tissues and also enable swallowing, mastication, and a speech by closing the oronasal or oro-antral communication.[4]

This present case report describes a prosthodontic rehabilitation of a patient undergone hemimaxillectomy with obturator prosthesis.


  Case Report Top


A 28-year-old young female patient was referred to the Department of Prosthodontics, Sharad Pawar Dental College and Hospital, from AVBRH. Her medical history revealed that she was operated for carcinoma of the palate 1 year back. Intraoral examination showed hemimaxillectomy defect on the left side involving hard palate, alveolar ridge, and dentition to the midline, making it Aramany's class I defect [Figure 1]. Oronasal communication was present. On the unaffected side, all the teeth were present and were periodontally healthy. Gingiva and palate of the nondefect side appeared normal. No abnormality was observed in the mandibular arch [Figure 2]. Treatment formulated for the case was cast metal removable definitive obturator prosthesis.
Figure 1: Maxillary defect

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Figure 2: Mandibular arch

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The preliminary impressions were made with irreversible hydrocolloid impression material (Zhermack, Italy) [Figure 3] and the primary casts were obtained [Figure 4]. The maxillary cast was surveyed for the undercuts and the necessary mouth preparations. The tripodal design was selected for the cast metal framework. Mesial rest seats were prepared on the right second molars and second premolar. Distal rest seats were prepared on the right first molar and cingulum rest on canine and central incisor.
Figure 3: Preliminary impression

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Figure 4: Preliminary cast

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The impression was then made in putty viscosity polyvinyl siloxane impression material (Aquasil), and wash impression was made in light body polyvinyl siloxane impression material (Aquasil) to record the tooth preparations, defect, and remaining structures to receive the cast metal removable framework [Figure 5].
Figure 5: Final impression

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The impression was then poured in dental stone [Figure 6] and was duplicated to obtain the refractory cast. Wax up of the framework was done and was cast in cobalt–chromium alloy. The framework was then tried in the patient's mouth and was verified for its fit. Then, the wax rims were fabricated on the framework and the centric jaw relation was made at the present vertical dimension of occlusion. After teeth arrangement, the try-in was checked for occlusion, esthetics, and seal for oronasal communication.
Figure 6: Master cast

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The trial prosthesis was then processed, finished, and polished in a conventional manner. Definitive obturator was inserted [Figure 7], [Figure 8], [Figure 9] and postinsertion instructions were given to the patient in the care and use of it. The patient was reviewed bimonthly for 3 months, and then, the visits were arranged to be every 3 months.
Figure 7: Intraoral view with a maxillary obturator

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Figure 8: Intraoral frontal view with maxillary obturator prosthesis

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Figure 9: Postoperative

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  Discussion Top


Surgical treatment for benign or malignant neoplasm leads to maxillary defects. Prosthetic rehabilitation of such defect with obturator prosthesis is the most recommended and opted treatment option. Obturator prosthesis is indicated when the size and extent of the deformity and local avascular condition of the tissues contraindicate the surgery and when the patient is susceptible to recurrence of the original lesion which produced the deformity.[5]

Proper design of the cast metal framework for obturator prosthesis plays a key role in the long-term successful and functional use of the prosthesis. Many authors have documented different framework designs for rehabilitating maxillary defects.[6],[7] Among them, Aramany's classification system is the most acceptable and widely used system for classifying and designing the framework for the maxillary defect.[8]

Design considerations for such cases depend on the size, location, and extent of resection, presence or absence of teeth, if teeth are present their periodontal status, and their alignment in the arch. Since anterior teeth were desired to be used in cast metal framework and remaining posterior teeth were not in a straight line, Aramany's tripodal design was planned in this case.

Providing adequate retention, stability, and support is crucial in such compromised cases where the prosthesis is subjected to various movements.[9],[10] Retention for the obturator prosthesis, in this case, was gained from the teeth by providing retentive clasps on central incisor, from the first and second molar, and from the lateral scar band and the height of the lateral wall of the defect.

Stability of the obturator prosthesis is also an important aspect that was addressed in this case by providing bracing arms on the teeth, by achieving maximal contact with the medial line of resection, by using acrylic semi-anatomic teeth, by establishing proper occlusal scheme, by eliminating premature occlusal contacts, and by widely distributed stabilizing components.

Support was provided for the obturator prosthesis from the residual maxilla and from within the defect area.

Changes in the tissues supporting obturator prosthesis are found to be faster than in any other conventional prosthesis. And hence, frequent recalls were scheduled for the patient to assess the occlusion and base adaptation and to rule out any signs of recurrence of the neoplasm.


  Conclusion Top


Treating patients with maxillectomy requires a multidisciplinary approach. The quality of life in such patients can be improved by providing a functional prosthesis that can be achieved by applying skill, knowledge, and experiences of the maxillofacial prosthodontist. Properly planned and well-designed treatment modality provided in this case in the form of obturator prosthesis helped to achieve effectual treatment outcome.

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 b'e 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.
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. 1
[PUBMED]  [Full text]  
2.
Iyer S, Thankappan K. Maxillary reconstruction: Current concepts and controversies. Indian J Plast Surg 2014;47:8-19.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Murphy J, Isaiah A, Wolf JS, Lubek JE. Quality of life factors and survival after total or extended maxillectomy for sinonasal malignancies. J Oral Maxillofac Surg 2015;73:759-63.  Back to cited text no. 3
    
4.
Keyf F. Obturator prostheses for hemimaxillectomy patients. J Oral Rehabil 2001;28:821-9.  Back to cited text no. 4
    
5.
Beumer J, Curtis TA, Firtell DN. Maxillofacial Rehabilitation. St. Louis: Mosby; 1979. p. 188-243.  Back to cited text no. 5
    
6.
Desjardins RP. Obturator prosthesis design for acquired maxillary defects. J Prosthet Dent 1978;39:424-35.  Back to cited text no. 6
    
7.
Rahn AO, Goldman BM, Parr GR. Prosthodontic principles in surgical planning for maxillary and mandibular resection patients. J Prosthet Dent 1979;42:429-33.  Back to cited text no. 7
    
8.
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. 8
    
9.
Brown KE. Peripheral consideration in improving obturator retention. J Prosthet Dent 1968;20:176-81.  Back to cited text no. 9
    
10.
Dudhekar A, Nimonkar S, Belkhode V, Borle A, Bhola R. Enhancing the esthetics with all-ceramic prosthesis. J Datta Meghe Inst Med Sci Univ 2018;13:155-7.  Back to cited text no. 10
  [Full text]  


    Figures

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



 

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