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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 3  |  Page : 306-309

A case report on prosthetic rehabilitation of a patient with hemimaxillectomy: A modified technique


Department of Prosthodontics and Crown & Bridge, Manipal College of Dental Sciences, Manipal, MAHE, Manipal, Karnataka, India

Date of Submission06-Jan-2021
Date of Decision18-Apr-2021
Date of Acceptance22-Apr-2021
Date of Web Publication18-Jun-2021

Correspondence Address:
Dr. Balakrishnan Dhanasekar
Department of Prosthodontics and Crown & Bridge, Manipal College of Dental Sciences, Manipal, MAHE, Manipal, Karnataka.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_1_21

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  Abstract 

The rehabilitation of patients with disabilities secondary to acquired or congenital defects continues to be a challenge. In contrast to the small maxillofacial defect that can be properly restored surgically, large defects are challenging. When surgical reconstruction is not possible, prosthetic restoration of the facial defect is a treatment of choice. The objective of this clinical report is to present a case of rehabilitation of hemimaxillectomy in which the standard treatment procedure was modified to acquire desirable results. The treatment plan included the fabrication of a two-piece cast partial maxillary obturator with magnetic attachment. The prosthesis was evaluated for retention and stability on mastication. The assessment of subjective pain and discomfort, as well as aesthetics, was carried out. Speech intelligibility was assessed by audio–visual aid. To reduce the weight of the prosthesis, the bulb of the obturator was made hollow. Post-insertion of prosthesis, there was a significant change in clarity of speech and resonance in voice. Improvement in masticatory function and overall well-being was achieved. This boosted the confidence of the patient while communicating in society. Routine checkups after two years revealed a patient who was satisfied with the prosthesis in function and without any deleterious effect. The fabricated prosthesis improved the cosmetic as well as the functional ability of the patient, thereby giving him mental peace.

Keywords: Hemimaxillectomy, Maxillectomy, Maxillofacial Prosthesis, Obturator, Oronasal Communication


How to cite this article:
Shilpa P, Dhanasekar B, Aparna IN, Pradeep S, Nayana P. A case report on prosthetic rehabilitation of a patient with hemimaxillectomy: A modified technique. J Int Oral Health 2021;13:306-9

How to cite this URL:
Shilpa P, Dhanasekar B, Aparna IN, Pradeep S, Nayana P. A case report on prosthetic rehabilitation of a patient with hemimaxillectomy: A modified technique. J Int Oral Health [serial online] 2021 [cited 2021 Oct 26];13:306-9. Available from: https://www.jioh.org/text.asp?2021/13/3/306/318444


  Introduction Top


Acquired maxillary defects are the surgical defects resulting from the resection of oral neoplasm or a secondary infection such as mucormycosis and aspergillosis fungal infection.[1] Post-surgery, the patient is predisposed to hypernasal speech, fluid leakage into the nasal cavity, and impaired masticatory function.[2]

Large defects of the palate to restore patients surgically to normal function are challenging. The quality of function obtained with prosthetic obturation makes it the preferred mode of treatment.[2] This clinical report gives a detailed description of the fabrication of a two-piece magnet-retained hollow obturator.


  Case History Top


A 52-year-old patient was referred to the Department of Prosthodontics and Crown and Bridge, Manipal College of Dental Sciences. The patient had undergone hemimaxillectomy for palatal carcinoma and secondary infection of mucormycosis. He had a medical history of diabetes mellitus and was on Actrapid medication for three years. Intraoral examination revealed Aramany class VI type of healing surgical defect in maxilla extending till paranasal sinuses [Figure 1]A–C. The patient presented with difficulty in mastication, seepage of nasal exudates into the oral cavity, restricted mouth opening, and unintelligible speech. The treatment plan decided was the fabrication of a maxillary obturator, which was explained in detail, and written consent was taken from the patient for authorization to use photographs and video of treatment for publication purposes.
Figure 1: Intraoral clinical image

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An interim obturator was fabricated with clear self-polymerizing polymethylmethacrylate material (Rapid Repair Clear Acrylic, Dentsply India Pvt Ltd, Bengaluru, Karnataka, India), which was used as a feeding plate. After six months, an impression was taken by an irreversible hydrocolloid impression material (Dentsply zelgan plus alginate, Dentsply Sirona, USA) to obtain a primary cast. The cast was surveyed for designing the cast partial framework. As the defect was extensive in nature, to facilitate easy handling of the prosthesis, a two-piece definitive obturator was planned as the final treatment. Mouth preparation for cast partial prosthesis was done, and the secondary impression [Figure 2]C was made with polyvinyl siloxane impression material (Dentsply Aquasil, Dentsply Sirona, USA) in a two-piece sectional tray [Figure 2]A-B. Cast partial denture comprising a single palatal plate with an anterior mesh for additional acrylic retention was fabricated with rumenium alloy [Figure 3]. It was necessary to make the prosthesis light in weight to aid in retention. This was achieved by making the prosthesis hollow with modeling wax [Figure 4].
Figure 2: Two-piece custom tray for secondary impression

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Figure 3: Cast partial denture metal framework

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Figure 4: Hollowing of prosthesis

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The final definitive prosthesis was processed in heat-cured polymethyl methacrylate resin (Trevalon powder, Denture Base Material, Dentsply India Pvt Ltd, Gurgaon, India). The bulb of the obturator and underlying cast partial denture was closely approximated with intraoral neodymium magnets (round, strong, rare earth neodymium magnets N52, Disc Magnets, Perfect Magnets, Mumbai, India) [Figure 5]A-C. The magnets were submerged about 1 mm from the surface to prevent corrosion. The cast partial obturator was inserted, and the difference in speech intelligibility was noted through audio–visual recording [Video 1]. The patient was assessed for improvement in mastication, retention of the prosthesis, and subjective analysis of pain and discomfort. He was given instructions to maintain the hygiene of the prosthesis and recalled after two weeks, followed by one month and then three months. Follow-up and routine checkup after two years presented a happy patient who was pleased with the treatment outcome improving his psychological well-being.
Figure 5: Two-piece definitive obturator with magnetic attachment

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  Discussion Top


The reconstruction of maxillary defects depends on patient characteristics, such as age, medical history, and defect size. Surgical flap reconstruction requires technical expertise and is associated with the possibility of donor morbidity at the flap harvest site. In contrast, the fabrication of obturator prosthesis shortens the procedure time and offers adequate dental rehabilitation. It is possible to periodically assess the defect area easily after removing the obturator prosthesis.[3]

Materials for maxillofacial prosthetic reconstruction provide a wide range from hard polymers to soft flexible polymers and elastomers. Soft polymers and elastomers have poor edge strength, are moisture sensitive, and are difficult to process; making them a less appropriate material for the fabrication of the prosthesis.[4] The use of a sectional custom impression tray results in an accurate impression and overcomes impression difficulties in patients with limited mouth opening.[5] Two-part custom trays are made to cover maximum overlapping in impression portions, which will help in orientation of the first poured cast while pouring the remaining part of the impression.[6] One of the problems associated with oro-maxillary obturators is the insertion of the prosthesis due to compromised anatomic morphology in different planes. Hence, it is necessary to design an obturator in two sections. Subsequently, a retentive device is used to hold these two sections together as one unit. Magnetic attachments, when compared with other retentive devices, are more user-friendly and cost-effective. Prosthesis with internal extensions requires good neuromuscular coordination and precision to insert and use the prosthesis. Studies have demonstrated that the extended use of magnetic attachment for a while may result in a loss of magnetism, which can be remagnetized easily.[7] It has been estimated that dental magnets can provide about 300g of standard magnetic retentive forces that remain constant with time.[8] The weight of a maxillary obturator is often a dislocating factor.[9] Different techniques and a variety of materials have been used to fabricate a lightweight prosthesis. One such technique is the hollow obturator. After processing the prosthesis, the wall thickness is maintained by grinding the interior of the bulb. Another commonly practiced technique is covering the superior border of the hollow space with a removable or fixed lid. Materials such as sugar and ice have been used to create the hollow space during the processing of the resin. Two-step processing techniques, using preformed plastic shapes or plaster matrix, were tried by some clinicians. The acrylic resin shim and polyurethane foam were incorporated into the defect area during packing to create a hollow space, as described by some authors.[10] The technique used in this report comprises the use of a pre-shaped wax bolus to maintain a predetermined internal dimension inside the hollow space. The characteristic features of this technique include single-step processing of resin and the ability to achieve a predictable hollow space. It is a relatively simple procedure and less time-consuming when compared with other techniques. The limitation of this technique includes the difficulty in the reliable seating of wax bolus into the resin during packing, effect on the uniformity of resin thickness due to dimensional changes in wax bolus that can be influenced by curing temperature, risk of displacement of wax bolus during the final closure of the flask, and some incidences of porosities in the processed resin that were reported after processing. Further studies are suggested to evaluate the effect of this technique on the material properties of the resin after processing.[10] After a two-year observation period, the obturator exists in harmony with the surrounding tissues. It continues to function without any harmful effects.

An integrative approach, careful employment of adequate skills, and regular assessment aid reduced the problems experienced by patients with hemimaxillectomy, thereby boosting their confidence and improving their overall health.

Acknowledgments

I would like to acknowledge and appreciate the help and assistance of colleagues during the fabrication of prosthesis and the audio–visual recording.

Financial support and sponsorship

No funding or grant received with respect to the present case. It is entirely self-funded.

Conflicts of interest

All the authors are in agreement with the content of the manuscript and have provided consent for publication.

Author contributions

SB: Conceptualization, methodology, and original draft writing; DB: Methodology, supervision, review, and editing of manuscript; Aparna IN: Supervision, reviewing the manuscript; PS: Supervision; and NP: Supervision. Finally all authors approved the article and granted permission to publish it.

Ethical policy and institutional Review board statement

The case report does not involve any human or animal subjects. Hence, no ethical approval was obtained.

Patient declaration of 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.

Data availability statement

The data is presented in the article.

 
  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.
Singh M, Limbu IK, Parajuli PK, Singh RK. Definitive obturator fabrication for partial maxillectomy patient. Case Rep Dent 2020;2020:6513210.  Back to cited text no. 2
    
3.
Goiato MC, Pesqueira AA, Ramos da Silva C, Gennari Filho H, Micheline Dos Santos D. Patient satisfaction with maxillofacial prosthesis. Literature review. J Plast Reconstr Aesthet Surg 2009;62:175-80.  Back to cited text no. 3
    
4.
Barhate AR, Gangadhar SA, Bhandari AJ, Joshi AD. Materials used in maxillofacial prosthesis: A review. Pravara Med Rev2015;7: 5-8.  Back to cited text no. 4
    
5.
Deogade SC. A novel technique of impression procedure in a hemimaxillectomy patient with microstomia. Case Rep Dent 2012;2012:272161.  Back to cited text no. 5
    
6.
Kumar B, Fernandes A, Sandhu PK. Restricted mouth opening and its definitive management: A literature review. Indian J Dent Res 2018;29:217-24.  Back to cited text no. 6
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7.
Usman M, Abdulla J, Ayappan A, Ganapathy D, Nasir NN. Oromaxillary prosthetic rehabilitation of a maxillectomy patient using a magnet retained two-piece hollow bulb definitive obturator; A clinical report. Case Rep Dent 2013;2013:190180.  Back to cited text no. 7
    
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Bhat V. A close-up on obturators using magnets: Part II. J Indian Prosthodont Soc 2006;6:148.  Back to cited text no. 8
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9.
Patil PG, Nimbalkar-Patil S. Lost wax-bolus technique to process closed hollow obturator with uniform wall thickness using single flasking procedure. J Indian Prosthodont Soc 2017;17: 84-8.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Patil PG, Patil SP. A hollow definitive obturator fabrication technique for management of partial maxillectomy. J Adv Prosthodont 2012;4:248-53.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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