The maxillary immediate surgical obturator prosthesis

Treatment Complications of Head and Neck Cancers and Rehabilitation Measures: A Narrative Review

Head and neck cancers (HNCs) are malignant tumors mainly from squamous cells in the head and neck tissues. Treatment involves a multidisciplinary approach with surgery, radiotherapy, and chemotherapy. However, the long-term prognosis for patients with advanced-stage tumors is guarded, with a median survival time of approximately 24 months. HNC patients have very high rates of depression and anxiety and the highest suicide rate among all cancers due to the intense and challenging nature of the treatment, underscoring the importance of our collective efforts. Rehabilitation success depends on various factors, including tumor, patient, and treatment-related factors. Patients may require post-treatment oral rehabilitation measures, including implants, obturators, and flexible dentures. These measures are crucial, but they often need to be more utilized. Patients may face challenges in maintaining oral hygiene and managing mucositis. Additionally, it is essential to address other intricacies such as trismus, xerostomia, gustatory dysfunctions, neuropathy, speech impairments, and psychological disturbances. Unfortunately, there is little literature on post-treatment rehabilitative measures. Despite its crucial role in improving patients' quality of life, rehabilitation often receives inadequate attention compared to treatment. Our narrative review, which covers various factors that affect rehabilitation, including oral rehabilitation measures and post-treatment complications, is anticipated to deliver practical insights to professionals and inspire positive changes in their regular practice.

Troubleshooting in Designing and Fabricating a Hollow Bulb Cast Partial Denture in a Partial Maxillectomy Patient: A Case Report

The most common complication post COVID-19is mucormycosis. It is an opportunistic infection caused by the fungus mucormycetes which belongs to the order Mucorales. This infection can spread from the oral cavity to the nasal cavity and sometimes also involve the orbit. Surgical resection of the affected region followed by its prosthetic rehabilitation is one of the viable treatment options. In this case report, we will discuss the problems in designing and fabricating a hollow bulb obturator and its solutions.

Fabrication of a Definitive Obturator for a Patient With a Maxillary Defect: A Case Report

Maxillectomy defects can lead to oroantral communication, causing difficulties with chewing, swallowing, speech, and facial appearance. Prosthodontists play a crucial role in rehabilitating such defects using obturators. This case report presents the fabrication of a definitive obturator with a cast metal framework for a patient who had an acquired maxillary defect and previously experienced issues with an ill-fitting obturator. In this clinical report, the patient's canine teeth on both sides and the premolars and molars on the left side were used for rest placement. Retention was achieved by utilizing the remaining teeth, employing two embrasure Aker clasps on the left molars and premolars and a C-wrought wire clasp on the right canine. A complete palate was designed as the major connector to ensure optimal load distribution to the surrounding tissues. Additionally, an indirect retainer was planned for the right canine. This definitive prosthesis rehabilitated the patient, improving masticatory efficiency, enhancing speech clarity, and improving quality of life.

Post surgical immediate prosthetic reconstruction in patients with rhinocerebral mucormycosis: Case series

Coronavirus disease has taken a toll on everyone's lives either physically or emotionally throughout the world. One of the most serious complications occurring currently in covid-positive and recovered patients is the deadly invasive mucormycosis. There are five clinical types of mucormycosis, out of which rhino-orbito-cerebral is the most common form (44%–49%). Management includes early diagnosis, control of the underlying diseases, and aggressive medical and surgical intervention. In patients undergoing maxillectomies, the use of immediate surgical obturators has become the gold standard. The rationale for its use is threefold—functional (matrix for the surgical dressing; allows the patient to speak and swallow), hygienic (separates the maxillary surgical site from contents of the oral cavity), and psychological (restores patient's self-image by reproducing lost oral structure). This article includes two case reports of patients diagnosed with rhinocerebral mucormycosis. The surgical debridement, medical management, and immediate reconstruction using palatal obturators have been explained.

Obturator Prosthesis Rehabilitation after Maxillectomy: Functional and Aesthetical Analysis in 25 Patients

The number of patients undergoing a surgical resection of the maxilla for oncological reasons is constantly increasing, the most common complication of which remains the communication between oral and nasal cavities. On the basis of data arising from the literature regarding the treatment options of maxillary oncological post-surgical defects, obturator prosthesis remains the most used worldwide. We studied 25 patients (with at least 1-year follow up) rehabilitated by obturator prosthesis after maxillary resection leading to oro-nasal communication, providing data on the objective/subjective evaluation of such rehabilitation and mastication performance measured by a two-color chewing gum test. The type of defect was classified according to the classification system proposed by Aramany. Among the patients in our study, 72% rated a higher score for either stability and retention than for aesthetic appearance, as confirmed by the Kapur score rated by clinicians. The two-color chewing gum test shows similar results as only one patient had insufficient chewing function. Interestingly, we found no correlation between the masticatory function and residual denture, confirming that the maxillary obturator remains a predictable solution in such patients regardless of the anatomical alterations following surgery.

Definitive maxillary obturator prosthesis: Timelines for fabrication and follow-up

INTRODUCTION

A definitive maxillary obturator prosthesis can be used to rehabilitate a maxillary defect with the aim of improving speech, deglutition, and elimination of oronasal regurgitation. The aims of this study were (1) to determine the time required to fabricate a definitive maxillary obturator prosthesis and (2) to compare the fabrication and follow-up times between a patient's first and second definitive maxillary obturator prosthesis.

MATERIALS AND METHODS

A retrospective review was completed of patients that had maxillary definitive obturators fabricated following head and neck surgery from 2002 to 2018 (n = 173). Demographics, clinical data, date of surgery, start date of fabrication, follow-up dates, and prosthesis follow-up data were collected.

RESULTS

The median time to delivery of the patient's first definitive maxillary obturator prosthesis from the date of surgery was 7.7 months for nonradiated patients and 9.6 months for radiated patients (P ≤ .05). Additionally, there was a significant difference in the median number of appointments to fabricate the 1st definitive maxillary obturator prosthesis as compared to the 2nd prosthesis (6 vs 5; P ≤ .05).

CONCLUSION

Fabrication timelines differed based on history of radiotherapy and patient experience. This data is helpful to set expectations for patients and practitioners regarding the process for prosthesis fabrication and follow-up.

The Role of Maxillofacial Prosthetics for the Surgically Treated Patient at National Cancer Institute-Designated Comprehensive Cancer Centers

OBJECTIVES/HYPOTHESIS

The current role of maxillofacial prosthetic care for head and neck cancer patients is not well understood. Additionally, perceived barriers for service provision are unknown. The purpose of this study was to evaluate the current role of maxillofacial prosthetic care at National Cancer Institute (NCI)-designated comprehensive cancer centers and to identify perceived barriers to care.

STUDY DESIGN

Multicenter, cross-sectional survey of head and neck division leaders at NCI-designated comprehensive cancer centers.

METHODS

Each head and neck division leader from the 47 NCI-designated comprehensive cancer centers was invited to participate. The main outcomes of this study were: 1) to evaluate the current role of maxillofacial prosthetics for the surgically treated head and neck cancer patient within NCI-designated comprehensive cancer centers and 2) to identify perceived barriers to care. Measured outcomes were obtained from an anonymous online survey and reported.

RESULTS

Twenty-eight of the 47 head and neck service chiefs responded (60% response rate). Respondents expressed preference for prosthetic rehabilitation for hard palate/upper gum, auricular, and nasal defects. Local flap or free tissue transfer was preferred for lower gum and soft palate defects. Cost-related factors were among the most reported perceived barriers to maxillofacial prosthetic care.

CONCLUSIONS

Maxillofacial prosthetics have an important role in the rehabilitation of the head and neck cancer patient. Perceived barriers for services exist, particularly as it relates to cost. Providers should be aware that these issues are likely to be more severe in regional or community centers.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:409-414, 2019.

Treatment Outcome with Delayed Maxillary Obturator Prosthesis: Case Series of Four Patients

A series of four patients is presented to indicate the possibility of success with delayed prosthodontic rehabilitation of acquired maxillary defects. Four patients with a history of hemi-maxillectomy in the past 3 to 5 years were rehabilitated with definitive obturator prostheses. All had partial maxillectomy on the right side. Because of delayed referral to the prosthodontic facility, immediate surgical and interim obturation was not planned. Definitive obturator prostheses were fabricated following the necessary steps and delivered to the patients. Prosthesis function was subsequently reassessed in these patients every fortnight for the first 3 months then once every quarter for the next 3 years, followed by once a year. Individual patient responses were evaluated at regular intervals. Components of prosthesis function assessed were esthetics, speech, mastication, and salivary control, all of which were restored to satisfactory levels by the definitive obturators. Thus, optimal restoration of esthetics and function is achievable despite a time lag in prosthodontic therapy after surgery.

Rehabilitation of post surgical maxillectomy defects using interim obturators-a case series

Prosthetic rehabilitation of extensive maxillectomy defects are exigent given the difficulties faced due to loss of palatal bone,teeth and surrounding supporting tissues which help in retention, support and stability of the prosthesis. An interim maxillary obturator is a prosthesis which is made after surgical resection of a portion or all of one or both maxilla where initial healing is completed. Frequently many or all teeth in the defect area are replaced by this prosthesis. It plays a vital role in preventing the facial disfigurement and irritation to the surgical site thereby enhancing the healing and restores the functional capabilities such as speech, mastication, deglutition etc. To gain better retention and stability, preservation of the unaffected regions is needed which can be achieved by proper surgical planning and designing of the prosthesis. This case series describes rehabilitation of three extensive maxillectomy defects with hollow open and closed interim obturators.

Surgical obturator duplicating original tissue-form restores esthetics and function in oral cancer

Oral cancer treatment primarily focused on the surgical removal of cancer tissues followed by surgical/prosthetic reconstruction. Restoration of the missing structures immediately after surgery shortens recovery time and allows patient to return to community as a functioning member. The most practiced surgical obturators are simple resin prosthetic bases without incorporation of the teeth. This article highlights a technique to fabricate a surgical obturator that duplicates patient’s original tissue form including teeth, alveolus and palatal tissues. The obturator is placed immediately after surgery and make patient feel unaware of surgical deformity. The obturator prosthesis fabricated with this technique supports soft tissues and minimizes the scar contracture. We have clinically tried this technique in 11 patients. Patients’ satisfaction level was recorded on visual analogue scale (VAS) and it ranges between 74% and 94% (with average of 87%). Four different prosthodontists have visually evaluated facial asymmetry of patients at 6 mo recall and their average perception on VAS varies between 71% and 93% (with average of 84%).

Obturator prosthesis for hemimaxillectomy patients

Rehabilitation of hemimaxillectomy patients can be challenging. The most common problem with prosthetic treatment in such patients is in getting adequate retention, stability, and support. The size and location of the defect usually influences the amount of impairment and difficulty in prosthetic rehabilitation. The obturator prosthesis is commonly used as an effective means for rehabilitating hemimaxillectomy cases. In cases of large maxillary defects, movement of the obturator prosthesis is inevitable and requires a form of indirect retention to limit the rotation of the prosthesis. The goal of prosthodontics is rehabilitation of missing oral and extraoral structures along with restoration of the normal functions of mastication, speech, swallowing, appearance, and so on. Malignancies are common in the oral region, which are treated through surgical intervention. Surgical intervention creates communication between the oral cavity, nasal cavity, and maxillary sinus. In such cases, it is very difficult for the patient to perform various normal functions like mastication, swallowing, speaking, and so on. Prosthodontic rehabilitation with obturator prosthesis restores the missing structures and acts as a barrier between the communication among the various cavities.

Effect of varying bulb height on articulation and nasalance in maxillectomy patients with hollow bulb obturator

PURPOSE

To evaluate the effect of bulb height of hollow bulb obturator prosthesis on articulation and nasalance.

METHOD

A total of 10 patients, who were to undergo maxillectomy falling under Aramany class-I and II, with normal speech and hearing pattern were selected for the study. They were provided 2 maxillary obturators, one extending full height of the defect and other with bulb height approximately up to inferior nasal concha. The patients were asked to wear each obturator for 6 weeks and the speech analysis was done to measure changes in articulation and nasalance at 6 different stages of treatment i.e. preoperative, postoperative (after complete healing), 24h and 6 weeks after providing full bulb height obturator and reduced bulb height obturator. Articulation was measured objectively for distortion, addition, substitution and omission by speech pathologist and nasalance was measured by Dr. SPEECH software.

RESULT

Comparison between full and reduced bulb height for nasalance and articulation, showed that there was no statistical significant difference (P>0.05) between the two for both the parametres.

CONCLUSION

Articulation and nasality improves after providing obturator. Articulation and nasalance both are independent of bulb height.

Quality of life in head and neck cancer patients after tumor therapy and subsequent rehabilitation: an exploratory study

PURPOSE

The aim of the study was to evaluate patient-reported quality of life effects of post-treatment intraoral and extraoral rehabilitation in head and neck cancer by repeated measures.

METHODS

Fifty-nine patients were involved. Basic socio-demographic, oncological and epidemiological data were gathered, and the type of rehabilitation was recorded. For the assessment of quality of life changes, two widely used brief questionnaires, the University of Washington Quality of Life Questionnaire and the Head and Neck module of the European Organization of Research and Treatment for Cancer Quality of Life Questionnaire, were used. The questionnaires were administered to patients two times: the first time after tumor therapy, but before rehabilitation (upon arriving for rehabilitation) and the second time 6 months after the application of any particular method of rehabilitation. Quality of life data were gathered prospectively, while socio-demographic data were gathered from patient files.

RESULTS

Quality of life after rehabilitation was significantly enhanced as compared to the post-treatment status, in all domains of both questionnaires (p < 0.05 and p < 0.01, Mann-Whitney U).

CONCLUSIONS

The results support the hypothesis that post-treatment maxillofacial rehabilitation in head and neck cancer does not only restore lost physical capabilities, but also brings about profound changes in patients' quality of life in general.

Speech rehabilitation of maxillectomy patients with hollow bulb obturator

Aim:

To evaluate the effect of hollow bulb obturator prosthesis on articulation and nasalance in maxillectomy patients.

Materials and Methods:

A total of 10 patients, who were to undergo maxillectomy, falling under Aramany classes I and II, with normal speech and hearing pattern were selected for the study. They were provided with definitive maxillary obturators after complete healing of the defect. The patients were asked to wear the obturator for six weeks and speech analysis was done to measure changes in articulation and nasalance at four different stages of treatment, namely, preoperative, postoperative (after complete healing, that is, 3-4 months after surgery), after 24 hours, and after six weeks of providing the obturators. Articulation was measured objectively for distortion, addition, substitution, and omission by a speech pathologist, and nasalance was measured by Dr. Speech software.

Results:

The statistical comparison of preoperative and six weeks post rehabilitation levels showed insignificance in articulation and nasalance. Comparison of post surgery complete healing with six weeks after rehabilitation showed significant differences in both nasalance and articulation.

Conclusion:

Providing an obturator improves the speech closer to presurgical levels of articulation and there is improvement in nasality also.

New technique to fabricate an immediate surgical obturator restoring the defect in original anatomical form

The presence of oral cancer can necessitate the surgical removal of all or part of the maxilla, leaving the patient with a defect compromising the oral cavity's integrity and function. The immediate postoperative restoration of esthetics, deglutition, and speech shortens recovery time in the hospital and expedites the patient's return to the community as a functioning member. This article describes a simple technique to fabricate an immediate surgical obturator by restoring the patient's original dentition and facial and palatal tissue form. An immediate obturator fabricated with this technique supports soft tissues after surgery and minimizes scar contracture and disfigurement and thus may have a positive effect on the patient's psychology.

A simple technique to fabricate a surgical obturator restoring the defect in original anatomical form

Oral cancer treatment involves the surgical removal of all or part of the maxilla, leaving the patient with a defect that compromises the integrity and function of the oral cavity. The postoperative restoration of esthetics, deglutition, and speech shortens recovery time in the hospital and expedites the patient's return to the community as a functioning member. The surgical obturator is the proven treatment option in such situations. This article describes a simple technique to fabricate a surgical obturator that restores patient's original dentition and facial and palatal tissue form. The obturator fabricated with this technique utilizes the vacuum formed index of patient's original tissue form and duplicated partly in heat and partly in auto polymerizing acrylic resin. Duplication of the original tissue form helps patient to minimize the immense physiological trauma immediately after the surgical resection. The obturator fabricated with this technique supports soft tissues after surgery and minimizes scar contracture and disfigurement, and thus may have a positive effect on the patients' psychology.

Influence of immediate and permanent obturators on facial contours: a case series

INTRODUCTION

Rehabilitation of patients after surgical removal of carcinomas in facial skeleton is one of the most difficult therapies of the stomatognathic system. Significant deformation of tissues, dysfunctions of the stomatognathic system with concurrent biological imbalance of the oral cavity environment frequently affect the treatment to become arduous. Scars and contraction of the oral crevice may cause serious psychological deficiencies that are another aspect of the treatment schedule.

CASE PRESENTATION

Three Turkish patients ages 46 (male), 61 (male) and 24 (female) who experienced similar operations were rehabilitated with maxillary obturators. The situations was ideal for patient no 1. Patient no 2 could not receive an immediate obturator and patient no 3 rejected using permanent obturator. The paper describes the advantages of a surgical obturator which is constructed before operation and inserted immediately following partial maxillectomy and expresses long term complications when neglecting the use of definite obturator prosthesis, in the light of three cases.

CONCLUSION

The primary objective of oral-maxillofacial and plastic surgeons and prosthodontists when treating tumors is to eliminate disease and to improve the quality of life including the facial contours which influences the psychological condition of patient. Neglecting immediate obturator construction may cause serious facial appearance problems due to soft tissue contracture. When permanent obturator is rejected, serious contracture of soft tissues and facial disharmony is inevitable.

The evaluation of the use of a delayed surgical obturator in dentate maxillectomy patients by considering days elapsed prior to commencement of postoperative oral feeding

STATEMENT OF PROBLEM

As a prosthodontic treatment for a maxillectomy patient in the initial postoperative period, immediate surgical obturators during surgery have been advocated to restore and maintain the patient's oral function to a reasonable level. However, these may fit poorly because they are fabricated using preoperative casts.

PURPOSE

The purpose of this study was to determine the comparative usefulness of a delayed surgical obturator.

MATERIAL AND METHODS

During the period from 2000 to 2004, 29 patients underwent prosthodontic treatment after maxillectomy. Twenty-three patients who were dentate postoperatively and were treated with polyvinyl acetal (Merocel) packing and a delayed surgical obturator were included in this study. Patients who were edentulous postoperatively, who were treated with an immediate surgical obturator or whose data were incomplete were excluded. The records of 23 patients were reviewed to determine the usefulness of using a delayed surgical obturator by counting days required to start postoperative oral feeding. The median of days elapsed prior to commencement of postoperative oral feeding was compared with data from a study by Lapointe et al (1996). In the Lapointe et al study, the median days elapsed prior to beginning a clear fluid diet was 2 in the group using immediate surgical obturators. The data were analyzed using the 1-sample Wilcoxon signed rank test (alpha=.05).

RESULTS

Days elapsed prior to commencement of postoperative oral feeding were less than those reported previously. Patients with Merocel packing began oral feeding, on average, 1.48 days after the maxillectomy. The median number of days elapsed prior to commencement of postoperative oral feeding was 1. This time was earlier than the 2 days for the Lapointe et al study (P=.0074). No major postoperative care complications occurred among the maxillectomy patients treated with a delayed surgical obturator.

CONCLUSION

Delayed surgical obturators were successful in terms of the postoperative care of dentate maxillectomy patients and did not increase patient discomfort during early rehabilitative management.

A preplanned surgical obturator prosthesis for alternative resection lines in the anterior region

A technique is described that enables adaptation of a surgical obturator to accommodate anterior teeth that may or may not be resected with the lesion at surgery. This is designed and fabricated by placing additional clasps on the teeth in question and providing for a clasp on one of the anterior teeth that can be determined at the time of surgery, thereby allowing anterior retention of the obturator immediately postoperatively. This technique is cost-effective and useful, especially if no prosthodontist is available at the time of surgery to perform obturator modifications.

Immediate obturation of the surgical defect after partial maxillectomy in the endentulous patient

Closure of the surgical defect immediately after partial maxillectomy is the treatment of choice. The advantages are: maintaining facial contour, rapid re-establishment of speech, swallowing and mastication. A number of methods for the fixation of the immediate obturator in patients without teeth have been described. A new technique is reported where a transnasal wire holds the existing denture in position after partial maxillectomy. The method has been carried out on 7 patients with sino-nasal cancer during the period 1978-1994. The advantages of the technique are that the wire acts as an axis of rotation which together with the sponge in the cavity provide good stability of the denture. There is minimal preoperative laboratory work and simplification in replacing the surgical dressing.

Quality of life of maxillectomy patients using an obturator prosthesis

BACKGROUND

The psychosocial adaptation of patients who had undergone a resection of the maxilla for cancer of the maxillary antrum and/or hard palate with the placement of an obturator prosthesis to restore speech and eating function was studied.

METHODS

Forty-seven patients were interviewed who had a maxillectomy with an obturator prosthesis at Memorial Sloan-Kettering Cancer Center, an average of 5.2 years (SD = 2.4 years) ago, 94% of whom had some of their soft palate resected. Interviews were conducted by telephone by a trained research interviewer, using a series of questionnaires to assess their satisfaction with the functioning of their obturator, and the psychological, vocational, family, social, and sexual adjustment. Measures included the Obturator Functioning Scale (OFS). Psychosocial Adjustment to Illness Scale (PAIS), Mental Health Inventory (MHI), Impact of Event Scale, and Family Functioning Scale.

RESULTS

Using multiple regression and discriminant function analyses, satisfactory functioning of the obturator prosthesis, as measured by the OFS, was found to be (1) the most highly significant predictor of adjustment, as measured by the PAIS (p < .0001) and the MHI Global Psychological Distress Subscale (MHI-GPD) (p < .001), and (2) significantly related to their perception of the negative socioeconomic impact of cancer upon their lives. The most significant predictor of better obturator functioning were the extent of resection of their soft palate (one third or less, p < .001), and hard palate (one fourth or less, p < .01). Specific aspects of obturator functioning that most significantly correlated with better adjustment (PAIS, MHI-GPD) were: less difficulty in pronouncing words (r = .40 and r = .51, respectively, p < .01), chewing and swallowing food (r = .27-.46, p < .05), and less change in their voice quality after surgery (r = .52 and r = .56, respectively, p < .001).

CONCLUSIONS

These findings suggest that a well-functioning obturator significantly contributes to improving the quality of life of maxillectomy patients.

New surgical obturator prosthesis for hemimaxillectomy patients

Many materials have been used to make immediate and intermediate obturator prostheses for the hemimaxillectomy patient. The weight of the obturator prosthesis is a major hindrance. A new thermoplastic material, Polysar, is described to create a hollow obturator extension for immediate and intermediate lightweight obturator prostheses.

Surgical obturation using a gated prosthesis

A description is given for the fabrication of a stable, versatile surgical obturator prosthesis for the dentate patient. The wrought wire and acrylic resin prosthesis is based on the swinglock concept and allows for simple transition from wire-retained to removable obturation early in patient recovery. By using such a prosthesis, interim obturator fabrication may be delayed if the practitioner believes further healing to be desirable. In some patients, transition directly to definitive obturation may be considered.