A HOLLOW DELAYED SURGICALOBTURATOR

FOR A BILATERAL SUBTOTALMAXILLECTOMY

PATIENT: A CLINICAL REPORT

JPD 2008;99:14-18

Most commonly intra oral defects are seen in the maxilla in the form of opening into the naso pharynx

Obturator: It is a disc or plate, natural or artificial, which closes an opening.

Maxillofacial prosthetics Chalian

USES OF AN OBTURATOR: It promotes the healing of post surgical defect

It can help to reshape and reconstruct the palatal contour

It can be used as a stent to hold dressings or packs post surgically in maxillary resections.

Maxillofacial prosthetics Chalian

3 types of obturators are available: A simple base plate type An obturator with a tail, consisting of a speech

appliance The third type is an overlay denture

Maxillofacial prosthetics Chalian

OBTURATORS FOR CONGENITAL DEFECTS OF PALATE

Post surgical obturators include: The immediate temporary obturator The temporary obturator The permanent obturator

Maxillofacial prosthetics Chalian

OBTURATORS FOR ACQUIRED DEFECTS OF PALATE

In 1978, Dr Mohammed Aramany presented the first published system of classification of postsurgical maxillary defects.

He divided all defects into 6 categories

JPD 2005;93:405-11

The general principles of removable partial denture design apply to obturator prosthesis design as well.:

The need for a rigid major connector Guide planes A design that maximizes support Rests that place supporting forces along the

long axis of the abutment tooth Direct retainers Control of the occlusal plane

JPD 2005;93:405-11

The prognosis of the obturator will improve with Size and curvature of the arch The quality of the tissue covering the ridge An abutment alignment that is curved instead of

linear The availability of teeth on the defect side for

support and retention

JPD 2005;93:405-11

Spiro, strong, shah Maxillectomy and its classification:

Limited Sub total Total

Maxillectomy means the partial or total removal of the maxillae in patients suffering from benign or malignant neoplasms.

A maxillary oral squamous cell carcinoma is generally treated with conventional surgical excision.

The resultant surgical defect includes part of the hard and soft palates.

ARTICLE

A surgical approach alone without obturation of the surgical defect will result in air, liquid, and food escaping into the maxillary sinus and nasal cavities.

Successful obturation depends on the volume of the defect, and the positioning of remaining hard and soft tissues to be used to retain, stabilize, and support the prosthesis.

Obturator designs for partial and total maxillectomy defects have included open and closed hollow obturators, inflatable obturators, and 2-piece hollow obturator prostheses

This clinical report describes the fabrication of a hollow delayed surgical/interim obturator with an unusual frontal extension

Age : 55 years

History of squamous cell carcinoma of the oral skin, oral cavity mucosa, and right maxilla and sinus.

Right infra structure maxillectomy

CLINICAL REPORT

After one year, patient complaining of acute bilateral facial pain, and purulent exudate in the right zygomatic area.

The patient underwent an extended left maxillectomy that included two thirds of the soft palate, hard palate, right and left sinuses, remaining left alveolar ridge, as well as the teeth, and inferior portion of the nasal septum involving part of the anterior nasal spine and right supero lateral zygomatic process.

5 days after the surgical procedure, the patient appeared to be healing well.

On examination, he had some crusting in the surgical defect, and there were some areas of exposed bone.

patient complained of acute pain and difficult y for

swallowing.

10 days after the surgical procedure an inter rim obturator prosthesis is fabricated.

Undercuts on the cast were blocked out with wax and special tray is fabricated by using auto polymerizing acrylic resin.

One to 2 mm of the tissue surface of the tray was removed to make space for a mouth temperature wax functional impression

Finally the definitive cast and wax were invested; the solid

obturator was processed in heat-polymerized acrylic resin

Acrylic burs were used to hollow the prosthesis from the palatal surface.

The prosthesis was placed intra orally using a rotational path of insertion.

The posterior extension was positioned first over the remaining soft palate, and the anterior portion was

then rotated upward onto the space that was originally occupied by the anterior nasal spine.

The patient returned a week later for a follow-up appointment.

He complained of inability to retain the anterior portion of the obturator, especially when speaking and swallowing.

To evaluate nasal resonance Nasal consonants: m, n Non nasal consonants: p, b, and t .

Nasal air emission was evaluated during the production

of sounds that require implosion of oral air prior to their production, such as p and t.

Swallowing dysfunction was not suspected, a modified barium swallow study was performed to confirm normal function

The modified barium swallow study was performed using 3 consistencies:

liquid, soft (pudding), and soft solid (fruit cocktail), with and without the obturator.

In this case patient presented with Squamous cell carcinoma

The head and neck surgeon resected the tumor The maxillofacial prosthodontist fabricated a

light and retentive functional obturator. speech pathologist provided objective

assessment and rehabilitation of speech and swallowing capabilities

DISCUSSION

The method used in the fabrication of the obturator in this report involved a 2-stage procedure .

In which the obturator body and its lid were processed separately and then joined together.

Retention of a complete bilateral obturator may be supported using several methods:

Using the remaining maxillary structures, such as the

posterior third of the soft palate supporting the obturator on a lateral scar band Extending the extra oral prosthesis into the

nares Attaching it to osseointegrated implants.

Finally, referral to the speech pathologist is critical to ensure functional speech and swallowing after completion

of the obturator prosthesis.

A comprehensive assessment of speech intelligibility, vocal quality, and oro pharyngeal swallowing provides important information for prosthetic modification to prevent nasal emission while speaking and regurgitation of food while eating.

The weight of the maxillary obturator is a dislocating factor because the prosthesis often acts as a cantilever.

A more simple and accurate method which facilitates the processing of an obturator will be described.

The method is based on the use of two flasks with interchangeable parts

JPD, Dec,1969

PROCESSING A HOLLOW OBTURATOR

PROCEDURE

flasking of appliance

flask after elimination of wax

Completed hollow bulb obturator

The surgical and interim prostheses usually remain stable for only short periods of time due to the rapid initial changes in defect contours resulting from healing and scar contractures.

By using readily available materials a hollow, flexible prosthesis can be fabricated in a single office visit.

Single visit hollow obturators for edentulous patients

FORMING THE HOLLOW PROSTHESIS

An adequate amount of resilient impression material is mixed to cover the defect walls in all directions with an approximately 5 mm thickness.

A large maxillary defect generally requires 25 to 30 cc

of powder.

JPD 1978;40:426-9

The doughy material is placed against the walls of the defect to engage all available undercuts.

SEALING THE OBTURATOR: The hollowed portion of the obturator is filled

with table sugar to a level below the palatal rim.

After curing, the center of the acrylic resin is perforated with a No. 8 round bur. The cellophane should catch on the bur and pull out in a single piece

PROCEDURE FOR TWO PIECE HOLLOW OBTURATOR:

By using base plate wax with 2mm thickness wax up is done.

The modeling clay is put into the open defect area.

The wax lid & master cast with wax pattern are flasked separately.

Maxillofacial prosthetics Chalian

Fabricating a hollow obturator with visible light cured resin system

JOP 2008,17 596-598

AN INFLATABLE OBTURATOR

JPD jul,Aug 1965

Subtotal and total bilateral maxillectomy defects represent a complex challenge for the maxillofacial prosthodontist.

In this clinical report, preoperative treatment planning involving the head and neck surgeon, the maxillofacial prosthodontist, and the speech pathologist resulted in a delayed/ interim obturator that enabled the patient to speak and swallow successfully.

The technique described in this report could be performed chairside on a definitive obturator in situations in which access to critical anatomical structures is adequate

SUMMARY

Processing a hollow obturator JPD, Dec,1969, 97-103

Single visit hollow obturators for edentulous patients

JPD 1978;40:426-9

Fabricating a hollow obturators with visible light cured resin system JOP 2008; 17:596-598

Prosthodontic principles in the frame work design of maxillary obturator prostheses

JPD 2005;93:405-11.

REFERENCES

An inflatable obturator for use following maxillectomy

JPD 1965:759-63

Maxillofacial prosthetics Chalian

Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification. Head Neck 1997:309-14.

Clinical considerations improving obturator treatment

JPD OCT;1970