Clinical management of edentulous maxillectomy patient / dental courses

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CONTENTS

• 1]  Introduction
• 2]  Surgical Enhancements
• 3]  Phases Of Prosthetic Restoration
 4]  Surgical Obturator Prosthesis
 Bone Screw Retention
 Suture Retention
 Circumzygomatic Wire Retention
 Use Of The Existing Maxillary Denture
• 5]  Interim Obturator Prosthesis
• 6]  Definitive Obturator Prosthesis
• 7]  Lid Fabrication Of Hollow Obturator Prostheses
• 8]  Troubleshooting The Obturator Prosthesis
 Leakage Into The Nose
 Hypernasal Speech
• 9]  Conclusion
• 10] References
•

G.P.T-8
 maxillofacial prosthetics :
The branch of prosthodontics
concerned with the restoration and/or
replacement of the stomatognathic and
craniofacial structures with prostheses that
may or may not be removed on a regular or
elective basis

Introduction
 Tumors of the hard palate, maxillary sinus, and
sometimes the buccal mucosa or nasal cavity require
surgery called a maxillectomy or maxillary resection.
The hard palate is the anatomic floor of the maxillary
sinus.
 Depending on the extent of the tumor, maxillary
resections can be performed that do not violate the
integrity of the hard palate. Maintaining the hard palate
however, is the exception rather than the rule.

 Violation of the hard palate creates an anatomic defect
that allows the oral cavity, maxillary sinus, nasal
cavity, and nasopharynx to become one confluent
chamber.
 Lack of anatomic boundaries creates disabilities in
speech and deglutition. Air, liquids, and food bolus
escape from the oral cavity to exit the nares, making
adequate oral nutrition difficult if not impossible.
 . Speech becomes unintelligible due to hyper nasality
distorting sounds that require impounding of air within
the oral cavity.

Surgical Enhancements
 Surgical enhancements have been suggested to prepare
the defect for optimal prosthetic rehabilitation
 Some procedures offer definite advantages; others have
minimal influence on prosthetic function and primarily
add a burden of time and perhaps morbidity to the
surgical procedure,

Maintain as much hard palate as possible
 Since the edentulous patient must rely on the remnant
of the hard palate for primary retention, support, and
stability the surgeon should be encouraged to resect
only enough hard palate to allow adequate tumor
margins.
 The more ipsilateral premaxillary area that can be
maintained, the more of a tripoding prosthetic effect
that can be achieved
 This adds, stability to the prosthesis, and the increased
surface area will enhance retention.

Quality of retention depends on
 Muscular control.
 Size of surgical cavity
 availability of tissue undercut around the cavity
 Direct and indirect retention provided by any remaining
teeth.

Skin graft the cheek flap.
• In the classic maxillectomy the cheek is elevated away from
the maxillary bones, and the pterygoid muscles and the
bones are resected.
• This leaves a denuded surface on the entire cheek flap,
remnants of the pterygoid muscle bed, and soft palate
musculature originating form the pharyngeal wall
• If this area is allowed to heal by secondary intention, the
healing time will extend many weeks with a bleeding
surface.
• Eventually the surface will be covered with respiratory
epithelium migrating from the nasal cavity and nasopharynx.
• This mucosa does not serve well as prosthesis-bearing tissue
and is easily abraded.

 . Respiratory epithelium will also add to the mucous
secretions that the patient must clean from the cavity
 . A split-thickness skin graft can be placed over these
denuded surfaces at the time of tumor surgery.
 This graft will be prosthesis bearing in 10 to 14 days
and after a few weeks of maturation can be aggressively
cleaned and approximated by the prosthesis

 . Due to differential contracture of the skin graft and
the mucosa of the oral cavity, a scar band will form
along the lateral cheek at the junction of the skin graft
with the remaining buccal mucosa, and in the pterygoid
muscle area.
 It has often been stated this scar band will aid retention
because it is an anatomic undercut.

 This area can be quite mobile when the patient moves
the mandible, however, and the changes in contour
must be accommodated in the obturator impression.
 constant motion of this minimal undercut in the lateral
cheek usually makes this area of little use for retention.

 Many maxillofacial texts suggest that the placement of
a skin graft will decrease the contracture of the cheek
flap
 . For practical purposes, one should view the skin graft
as a sound prosthetic bearing surface that will not be
easily abraded, does not secrete mucus, allows for
vigorous cleaning of the defect, and may aid in
retention.

Remove the inferior turbinate
 . If the hard palate is resected to expose the nasal
cavity, the inferior turbinate is also exposed.
 If the tumor does not involve the nasal cavity, the
inferior turbinate will likely not be resected.
 Anatomically this structure is only millimeters above
the cut edge of the hard palate and covered with
respiratory epithelium.
 Maintaining the inferior turbinate will preclude
extending the medial wall of the obturator bulb into the
nasal cavity

Skin graft the maxillary sinus walls.
 When tumor involves the hard palate with minimal
involvement of the maxillary sinus walls.
 The hard palate will be resected and most of the bony
wall of the sinus will remain intact.
 These walls can be prepared during surgery to allow the
bony undercuts to serve for retention or for vertical
support to keep the prosthesis from rotating into the
defect during mastication

 The sinus walls are covered with respiratory mucosa,
which must be denuded and covered with a split-
thickness skin graft.
 Grafting the sinus walls stops formation of polypoid
tissue and mucus generation within the sinus and allows
the walls to become load-bearing areas.

 Phases of Prosthetic Restoration

Surgical Obturator prosthesis
 Use of an immediate surgical obturator is less common
for the edentulous patient than the dentate patient
because of the seemingly invasive method of securing
the prosthesis.
 Methods
 1. palatal bone screw,
 2.sutures into the surrounding mucosa,
 3.andcircumzygomatic wires.

 Regardless of the method of securing the prosthesis, the
procedures needed to fabricate the surgical obturator
are identical
 Generally a auto polymerizing resin or heat cured resin
is used but not composite resins because of its brittle
nature

Bone screw retention
 The palatal bone screw can be placed through a
midpalate hole predrilled through the acrylic resin
baseplate in the midpalatal at the anterior peak of the
palatal vault.
 This position will allow placement of the screw into the
vomer.
 The hole should be drilled from the palate to the
intaglio surface and angled posteriorly.

 . A 13 to 16 mm self-tapping screw should be used to
ensure enough length to pass through the denture and
achieve adequate bone retention.
 This bone screws are usually titanium or stainless steel
and are available in mandibular fracture
armamentarium.
 A small plug of tissue conditioner or polyvinylsiloxane
over the head of the screw will keep the screw attached
to the denture in the event the patient dislodges the
denture during the postoperative period.


Suture retention
 In a previously irradiated patient, one might elect to use the
suture technique to avoid placing a bone screw in the
irradiated palate.
 2-0 silk sutures can be passed through six to eight predrilled
holes in the lateral and anterior borders of the acrylic resin
baseplate.
 Each suture is secured with a knot against the denture flange
in the middle of the suture and each one tagged with a
hemostat.
 The baseplate is then taken to the oral cavity and each suture
passed through the soft tissue and tied.

 It is not necessary to suture across the soft palate for
adequate retention and soft palate sutures are difficult
to remove when the patient is in the clinic
 . There will be slight prosthesis movement with this
technique, but the packing will be secured and the
prosthesis will not dislodge.

Circumzygomatic wire retention
 Wires are passed over the zygomatic arch and threaded
through two bilateral holes placed in the premolar area
of the baseplate flange.
 This technique is the most invasive and has greatest
morbidity when removing the wires in the clinical
setting.
 It is not commonly used.

 The palatal bone screw offers the most stability of the
three options, The bone screw, sutures, and packing can
be removed with sedation,
 Syncopal attack is un avoidable if patient is sedated or
not

Use of the existing maxillary denture
 Some texts suggest using the patient's existing denture
for the surgical obturartor and for the subsequent
interim obturator prosthesis,


Disadvantages
 1. The patient will expect it to be used throughout the
entire prosthetic period,
 2. When the surgical defect involves approximately one
half of the hard palate, maintaining comfortable
occlusion while constantly reducing and relining the
flanges of an unstable obturator prosthesis is almost
impossible.
 3. If the maxi1lary denture is ill fitting preoperatively,
it will be necessary to reline the denture prior to surgery

 As facial contracture occurs, the anterolateral border of
the denture will require significant reduction .
 It is not uncommon that the contracture is so great that
the anterior teeth are soon extended beyond the
obturator prosthesis periphery.
 The teeth on the surgical side often require facial
reduction and ultimate removal from the baseplate due
to overextension.
 If the teeth are not reduced, the lip is too protruded and
unseats the prosthesis.

Interim Obturator Prosthesis
 Chairside impression of the surgical site 5 to 10 days
after surgery :
 The baseplate used for the surgical obturator can be
relined and modified to serve as the interim prosthesis
 The baseplate can be border molded and relined on the
remaining hard palate.

 After this is accomplished and the base is stable, the
periphery of the surgical detect is impressed.
 Truesoft can be placed incrementally along the
periphery of the defect.
 Using this incremental shaping method creates a
hollow, light prosthesis

Patient movements, speech, and swallowing evaluation during
border molding
• The impression, of the surgical side requires that the
patient perform exaggerated head movements turning
right to left with the head level
• and then again with the neck flexed and extended.
• The mouth should be opened and closed and the
mandible moved laterally.
• The patient should also be asked to swallow.
• The clinician should maintain control of the impression
throughout the entire procedure by manually supporting
the tray

 Swallowing and head movements should always be
made with every addition of material.
 If the clinician does not use functional border molding,
the prosthesis will be less stable and the patient will
experience tissue irritation in a short time.

 The peripheries of the bulb portion will likely be 2 to 3
cm in height. There is no need to add material to fill the
entire sinus space; it only adds weight to the prosthesis
and offers little to the border seal.

 To achieve border seal and adequate speech
restoration , the posterior border will be extended over
the cut edge of the soft palate to extend to the posterior
aspect of the defect.

 the only speech sounds that are formed when air passes
through the nasal cavity are m, n, and ng,
 When air is obstructed from passing from the vocal
cords out the nose during the m, n, and ng sounds,
hyponasal speech is evident,
 This occurs frequently during the common cold when
the nasal passages become obstructed from edema or
mucus.

 Hypernasal speech occurs due to loss of air from the
oral cavity into the nasal cavity.
 In the case of the maxillectomy patient, this loss of air
occurs because of an anatomic defect in the hard palate.
 Without the obturator, the loss of air into the nasal
cavity is so great that a patient's speech is Unintelligible

 Examining the peripheral surface of the obturator bulb
and ensuring peripheral tissue contact will correct
hypernasal speech in most instances
 Final analysis for appropriate speech is to listen for
distinction between the letters m and b.

 The patient should also say the Word beat then manually
occlude the nares and again say the word beat. If there is a
difference in Sound quality between the two test words,
hypernasality remains
 If the speech is still slightly hypernasal, a slight addition of a
light or less viscous mix of material at the soft palate
junction should be attempted.

• The fit may also be tested while drinking water with the head
upright.
• The liquid should pass easily without the patient experiencing
reflux. into the nose or sinus cavity
• Patients may not be able to control liquids in the oral cavity at
the early interim phase, and drooling due to postoperative
swelling and anesthesia of the upper lip on the surgical side
from loss of the ipsilateral anteriorsuperior alveolar nerve is
often observed..

Insertion Of the interim prosthesis
 After the tissue conditioner impression the entire tray
and impression can be used as a wax pattern.
 It can be flasked, completely removed from the stone
mold, and the mold packed. auto polymerizing or heat
processed resin
 prosthesis may be hollowed further to decrease weight

 The goal is to have a well fitting light weight prosthesis.
 The prosthesis should be delivered within .a few hours of
making the impression,

 The patient should be instructed not to leave the
prosthesis out for more time than is needed to clean it
or the surgical site,
 At delivery of the prosthesis, the intaglio surface of the
remaining hardpalate area and cut edge of the hard
palate area should be checked with pressureindicating
paste,

 The tissue conditioner is placed and functional
impression is made.
 Patients must regularly use a powdered adhesive to
retain the prosthesis, so changing the tissue conditioner
to acrylic resin in the interim prosthesis allows use of
the adhesive on the hard palate area.

Revisions
 Every 10 to 14 days the next 2 months, the prosthesis
will require revisions due to tissue changes will be
happening in the surgical site.

 Patients should be advised that adjustments are needed
if pain or bleeding occurs or if the prosthesis will not
seat. However, they should be reassured that increased
hypernasality and nasal reflux is primarily a nuisance;
there will be no physical or medical complications .

 The prosthesis should be evaluated to determine if the
prosthesis will seat completely and not move with jaw
and head movements.
 If movement of the mandible creates movement of the
prosthesis after border reduction, more material should
be reduced in the overextended areas.
 Some visits may require removal of considerable bulk
of existing material due to tissue contraction

 When the' surgical site becomes more stable, then fewer
major adjustments needed

 DEFINITIVE OBTURATOR PROSTHESIS

Preliminary impression
 The preliminary impression should offer maximum
extension within the surgical site.
 When maxillary surgical cavity is, large, regardless of
the tissue or bony undercuts within the cavity, it is not
necessary to block the cavity with gauze prior to the
impression.
 Blocking of the defect adds time and patient
discomfort, and the material often shifts during the
impression,

 It is important to block palatal fistulas that open into
intact maxillary sinus or nasal cavities.
 Impression material can mushroom into the intact
cavities and tear from the impression during removal of
the tray.
 This is most likely to occur with alginate impression
materials

Final impression
 The custom acrylic resin tray should extend 2 to 3 mm
into the cavity.
 It should extend beyond the scar band and superior to
the cut edge of the hard and soft palates, leaving space
for 5 to 8 mm of compound to add to the surgical site.
 There may be cast undercuts within the surgical cavities
which must be blocked out

 The remaining palate should be impressed first. The
borders and cut edge of the palate should be border
molded and then impressed with a definitive impression
material.
 Performing this initial step creates a stable tray for the
addition of the cavity impression Compound ,this
should be added incrementally to the periphery of the
surgical side

 The cavity is convex from inferior to superior. At the
height of the convexity, the cavity walls begin to turn
toward the center of the cavity.
 At this point the superior aspect of the prosthesis bulb
should terminate. Superior extension beyond the
greatest convexity adds weight to the prosthesis but
adds no retention.

 It should be border moulded with impression wax with
incremental addition.
 A posterior palatal seal can also be placed.

Jaw relationship records
 Maxillectomy patients have loss of facial contour on
the surgical side proportional to the amount of bone that
is resected
 Infrastructure maxillectomies have minimal facial
disfigurement.

 if the floor of the orbit is resected, the globe is also displaced.
 Often the maxillary resection crosses the midline, and if the
nasal spine is resected, the nose· is unsupported There is a
desire to use the obturator prosthesis to support the facial
tissues.
 Unfortunately these tissues are fibrotic and can only be
minimally displaced by the prosthesis border.
 Trying to push the contracted tissues into their preoperative
position can cause overextension of the prosthesis borders.
 This creates considerable dislodging force on the prosthesis

 Attempting to maintain the dentition in its normal
position will cause dislodging forces.
 Normal prosthetic landmarks cannot be used to position
the dentition.
 Processed record bases are ideal for jaw relationship
records for the maxillofacial prosthetic patient. Because
of the missing structures and unusual reconstructions,
prosthetic retention and stability are greatly
compromised.

 Blocking out routine undercuts and the undercuts within the
surgical area adds to the instability of the conventional record
base.
 Blocking out these undercuts will result in a trial base that
does not extend to the periphery or the defect
 This trial base makes no Contact with the surgical side of the
face.
 There will be no retention of the prosthesis except for the
adhesive on the hard palate.
 The prosthesis will fall into the oral cavity when attempting to
establish the occlusal plane and rotate into the defect when
attempting the centric relation record.

 Without maximum extension of the record one cannot
determine the optimal position of the teeth to support
the lip and cheek.
 It is quite common that retention becomes worse as the
wax rim is added in its preoperative position
 A Compromise must be reached between tissue support
and prosthesis retention.

 The wax up of the processed obturator base can be solid
in the area of the bulb and hollowed before jaw
relationship records.
 The bulb can be processed hollow by waxing the
external periphery of the bulb portion several
millimeters thick and pouring a stone core through the
back of the master cast or creating a stone core in the
cope of the cast, in which case there will be a hole in
the palate after processing

 The jaw relationship appointment should progress as a
routine denture appointment.
 At the try-in appointment, all records are verified
 For the patient edentulous in both arches, a cusp-less
tooth allows freedom to create a negative horizontal
overlap on the surgical side of the arch without having
to create it on the nonsurgical side

 The final palatal contours should be evaluated at the try-in
appointment. It is likely that the contours are not symmetric
because they were created arbitrarily on the surgical side
 The vault may be too high or too flat.
 Finally, pressure indicating paste can be streaked across the
palate from right to left. ‘
 Seat the prosthesis and have the patient swallow and count.
 Where the tongue makes contact with the palate, the contact
can be read in the pressure-indicating paste.
 Heavy areas should be reduced and the entire palate checked
again.
 Wax may need to be added in the palate where there is no
contact.

 If the patient lisps, air is escaping laterally from the
tongue.
 Because the teeth are positioned palatally due to facial
contracture, they may impinge on the tongue
 Prosthesis can be processed at a lower temperature than
that used to process the base.
 The clinical significant of the distortion created with
multiple processing of the resin is negligible

 The clinician may place a lid on the obturator prosthesis
or may insert the prosthesis with the bulb open for
several days until 'all of the adjustments are performed.

Insertion
 At insertion, the prosthesis should be evaluated for
pressure areas as described for interim prostheses,
including pressure-indicating paste for the residual
palate

Instructions
 Patients should continue to wear the maxillary
prosthesis or the interim prosthesis at night because
sinus secretions and saliva cannot be managed at night
without it.
 If the prosthesis is removed overnight, the soft tissue
periphery of the surgical site will change due to tissue
edema,
 and patients will report that it often requires an hour of
wearing the prosthesis in the morning before it fully
seats into position

 Mastication is also often difficult for patients with large
surgical defects and must be accomplished on the
nonsurgery side of the arch.

Lid fabrication of hollow obturator prostheses
 It will difficult for the patient to clean the inside area if
the bulb is left open and if it is not smooth
 Placing a lid on the bulb allows hollowing of the
alveolar area and into any unusual lateral undercuts

Other methods

 TROUBLESHOOTING THE OBTURATOR
PROSTHESIS

Leakage into the Nose
 Many patients eventually complain of nasal reflux and
hypernasal speech caused by escape of air.
 This may occur several months or even a few years
after insertion of the prosthesis.
 In most cases, continued fibrosis in the tissues
bordering the prosthesis is the cause.

 The prosthesis should be disclosed with a tissue-
conditioning material, and the patient should perform
functional movement.
 If swallowing and speech improve, the disclosing
material should be evaluated for the area where the
tissue conditioner is thickest.
 The speech can be tested by evaluating the m and b
sounds and the word. beat as described previously,

 The tissue condition material should be checked to see
where this reline is required and this conditioning
material is replaced with reline material later.

Hypernasal Speech
 Patients may complain of hypernasal speech at follow-
up visits
 This is because of the continued fibrosis through years
and the dysfunctions of the soft palate and pharyngeal
closure mechanism.
 For this a pharyngeal obturator must be constructed
where a small amount of soft palate is also resected
 . Some patients are unable to seat the prosthesis
because of its unusual path of insertion.
 If this procedure is unsuccessful, the hyper nasal
speech cannot be prosthetically corrected

conclusion
• The edentulous obturator patient has greater
problems in retention, speech and mastication
than the conventional maxillary denture patient
• . Finally, no matter what additional retentive
elements may be employed sound
prosthodontic principles of using bony
undercuts achieving maximum tissue
coverage without overextension, and placing
the dentition in harmony with the functional
tissue are paramount for prosthetic success
when treating the edentulous maxillectomy
patient.

 NEED IS MOTHER OF ALL
INVENTIONS

References
 1] CHELIAN, multi disciplinary practice
 2] JOHN BUMER maxillo facial
rehabilitation
 3] THOMAS. D .TAYLOR . clinical
maxillo facial prosthetics
 4] Paprocki Gj, Jocob RF, Kramer DC,
seal integrity of hollow- bulb obturator.
Int j prosthodont 1990,-3,- 457

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