A Conservative Method of Retaining an Interim Obturator for a Total Maxillectomy Patient.

Interim obturators are indicated during the postsurgical phases. It promotes surgical healing and serves as a temporary prosthesis to rehabilitate a patient with intra-oral surgical defect. Retention is gained by wiring, surgical suturing, and other noninvasive methods to enable functional rehabilitation and easy replacement with a permanent obturator. Interim obturators serve as an easy guide for replacing with definitive obturators by indicating prosthesis extensions and the required method of retention. A more conservative and noninvasive method of retaining an interim obturator for a maxillectomy patient is described in this case report.

INTRODUCTION

The anatomical structures of hard and soft palate have a vital role in phonetics and deglutition. When these structures had to be resected due to lesions, the missing or defective structures can lead to disability or impairment. The surgical resection leaves a defect that requires interim management. The need for chemotherapy and radiotherapy postpones the definitive management in these cases to a later stage. The interim rehabilitation of a patient with defective oral and extraoral structures is a challenging task. Although surgical closure of the defect remains first and viable option, it is possible only after satisfactory surgical healing and confirmation of no recurrence of the lesion. The open communication between nasal and oral cavity during this intermediate period leaves the patient with functional disability. The loss of swallowing function, phonetics, and loss of esthetics has a major psychosocial impact on the patient's life.[1] Various techniques and materials for making an obturator are in practice. Different methods of retaining the prosthesis have been discussed in the past.[2] The choice of retaining the interim prosthesis poses a difficulty due to the soft tissue healing postoperatively. This case report discusses a conservative method of retaining an interim prosthesis, which helps in functional rehabilitation of the patient without nasal regurgitation.

CASE REPORT

A 45-year-old male patient reported to the Department of Prosthodontics with a history of surgical resection of his upper jaw. The detailed history revealed total maxillectomy was done to resect sarcoma 1 month ago [Figure 1a]. The patient was on Ryle's feed. Surgical reconstruction was attempted with the right side of the face as donor site, but was unsuccessful [Figure 1b]. On examination, the oral nasal communication was evident [Figure 1c]. Healing mucosa with no clinical evidence of recurrence of the lesion, loss of soft tissue support, were noted. The goal of the treatment was not only to provide an obturator to close the defect but also to discontinue nasal feed and facilitate oral feeding. The choice of the interim obturator to treat the defect was clear, but the method of retention of the prosthesis remained a challenge. This was over come by the innovative use of an orthodontic facebow. The patient desired to have a prosthesis that would facilitate his swallowing function without regurgitation, and not to have the prosthesis retained in the mouth. Hence, a prosthesis that can be worn during feeding and removed for the rest of the time to facilitate soft tissue healing was planned. The orthodontic facebow and the brackets to retain the head gear would accomplish the requirement of clinical situation. The subsequent appointments and the procedure were done as follows. In the first appointment, an alginate impression was made [Figure 2a]. The cast was poured with dental stone, and a denture base was fabricated using a light-cured acrylic sheet. Occlusal rims were fabricated on this denture base [Figure 2b and c]. The denture base served the dual purpose of the special tray that was used to record the maximum supporting area using a soft liner [Figure 3a] and to record the jaw relation [Figure 3b and c]. Recording the centric relation was not considered a mandatory step for fabrication of the prosthesis. The main objective of the prosthesis was to prevent oro-nasal regurgitation and to provide an appropriate seal between the oro–nasal cavities. Hence arbitrary bite registration was done [Figure 3c]. The cast was poured with dental stone. The upper and lower casts were articulated in a three point articulator with the recorded bite [Figure 3d] and teeth arrangement [Figure 3e] was done to give support to the remaining structures. A wax try-in was done for the patient [Figure 4a]. During the try-in stage, orthodontic face bow was inserted into orthodontic buccal tubes which in turn is inserted into the trial denture [Figure 4a and b]. The outer arc is inserted into head gear that gains retention from the scalp [Figure 4c]. The retention of the denture was verified during this procedure. The aim of the prosthesis was to help in enhanced feeding and to prevent regurgitation of fluids into the oro-nasal cavity. The patient was given fluids to verify regurgitation. After satisfactory intake of fluids, the patient's comfort was evaluated. The denture was processed and inserted for the patient. Any sharp flanges were smoothened, and a soft liner was added to the tissue surface. To improve retention of the prosthesis during feeding orthodontic facebow was attached to the denture with face bow brackets.

Figure 1

(a) Extraoral profile after resection, (b) donor site for surgical reconstruction, (c) intraoral oronasal communication

Figure 2

(a) Alginate Primary impression, (b and c) maxillary primary cast with defect, mandibular cast

Figure 3

(a) Secondary impression relined with soft liner, (b and c) jaw relation and inter occlusal record, (d) articulation (e) teeth arrangement

Figure 4

(a) Try in verification, (b and c) orthodontic face bow inserted into the trial denture. The outer arc is inserted into head gear with retention from the scalp

DISCUSSION

Different types of obturator with different designs are used for rehabilitation. Hollow bulb obturators, sectional obturators, CAD/CAM designed obturators are among the recent developments. Sectional obturators are indicated only in limited mouth opening cases.[2] The technique and fabrication process restricts hollow obturators to definitive prosthesis cases.[345] However, few cases of hollow obturator for interim prosthesis have been reported. The choice of using hollow obturator as an interim prosthesis was made only when a definitive prosthesis would be a similar design prosthesis. Hollow obturators with lid, inflatable obturators are among the few designs of hollow obturators.[5] Chalion described the method of duplicating the existing palatal and tooth form for a more comfortable and esthetic results and this has been reported as an alternative method of fabricating an interim prosthesis.[67] Recently, interim obturators are designed with CAD/CAM and rapid prototyping techniques.[89] Since the healing period was taken into consideration, a simple design of the obturator that requires less invasive procedure, less chairside time and a retentive method that would not interfere with the healing was chosen for the case reported. The materials commonly used in the fabrication of the interim obturators are acrylic resins. The purpose of the interim obturator is to serve as a substitute for a definitive prosthesis or until a reconstruction is planned. The choice of materials that can be used for this duration is always a simpler and economical material like acrylic resins. Different forms of resins such as microwave resins,[10] light cure resins,[11] and heat cure resins have been used for interim obturator fabrication. Considering the flexible properties and cost of silicones against the harder and cheaper acrylics, silicones are generally not used for an interim prosthesis. Nevertheless silicones as an interim choice of materials have been reported.[12]

The method of retention of a maxillofacial prosthesis still remains a grey area for a prosthodontist. Methods of retaining an interim prosthesis may be done by circumferential wiring, suturing, clasps and magnets.[13] Though implants offer more promising results, it is more commonly indicated in retaining a definitive prosthesis. Few cases where implants for retaining an interim prosthesis have been reported. There is no gold standard method suggested in the literature for the retention of an interim obturator. Retaining an obturator by extra oral devices[14] like spectacles are in practice. However, the retentive efficiency is not comparable to that of an implant. Denture duplicator[15] has been used in stabilising the prosthesis. However, there are no evidences to claim the success of this method. Despite several techniques and materials available the patients satisfaction with these obturators depends on the retention and stability. A retentive and stable prosthesis give comfort to the patient and thereby better acceptance by the patient.

CONCLUSION

The choice of an interim prosthesis depends on the surgical extent and the patients functional demand. During the healing phase of surgery, a simpler design and effective method of retention should suffice the patients need. Patients’ acceptance and comfort is more vital to the success of the intervention. Hence, the prosthesis has to be modified or designed to individual patient requirements.

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 be 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.