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A two-step (altered cast) impression technique in the prosthetic rehabilitation of a patient after a maxillectomy: A clinical report
A two-step (altered cast) impression technique in the prosthetic rehabilitation of a patient after a maxillectomy: A clinical report Denis Vojvodic, DMD, PhDa and Josip Kranjcic, DMDb School of Dental Medicine, University of Zagreb, Zagreb, Croatia This clinical report describes the prosthetic rehabilitation complicated by trismus (as a consequence of surgery and radiation therapy) of a patient with an acquired maxillary defect, after surgical removal of the right maxillary sinus tumor. The patient was restored with a partial removable dental prosthesis with a hollow bulb obturator to obtain orofacial rehabilitation and defect obturation. Precise obturation requires an accurate impression of the resection defect. A 2-step impression was performed because of trismus. A primary maxillary impression was made with an irreversible hydrocolloid, while a secondary (altered cast) impression was made with a silicone material by using the obturator cast framework as a tray. In that way an altered cast was produced. Subsequently, an obturator prosthesis was processed with a conventional technique. (J Prosthet Dent 2013;110:228-231) Acquired and/or congenital maxillectomy defects cause communication between the maxillary antrum and the oral cavity and oropharynx or nasopharynx, which results in impaired facial esthetics, compromised mastication, swallowing, and speech, and significant reduction in the quality of life.1-4 Prosthetic rehabilitation of patients after a maxillectomy can be managed according to the quality of supporting tissues, such as adjacent tissues, the residual palatal base, and the remaining dentition.5 According to Aramany,6,7 maxillary defects can be classified into 6 different groups based on the relationship of the defect area to the remaining abutment teeth. The classification is a useful tool for developing framework designs for obturator prostheses. It excludes patients with large palatal defects involving both sides of the dental arch and those who have only 1 remaining tooth.6 For these patients, the principle of design is similar to that of the edentulous maxillectomy patients.6 An obturator is a maxillofacial prosthesis that is used to close an acquired tissue opening, primarily of
the hard palate, and/or a contiguous alveolar or soft tissue structure that has been removed by surgery.8 In an acquired maxillary defect rehabilitation, the use of the prosthetic palatal obturator is a traditional treatment approach.5,9 Some authors8,10 prefer fabricating a partial removable dental prosthesis with an obturator retained by the remaining natural dentition, while others prefer and report the production of implant-supported obturator prostheses with conventional and/ or zygomatic implants.3,4,9,11 A wellmade maxillary obturator minimizes fluid leakage into the nasal cavity and maxillary sinus and improves swallowing, mastication, and esthetics by replacing the teeth removed during the ablative surgery. It also improves speech by allowing a separation between the oral and nasal resonance, thereby minimizing hypernasality.10 In contrast to surgical rehabilitation, the fabrication of the obturator shortens the procedure time, and the surgical site can be easily examined after removing the obturator so that tumor recurrence may be detected.12 According to Haug,10 the fabri-
cation of a definitive obturator can be considered after approximately 3 months of healing after surgery or 3 months after radiation therapy, although an interim obturator can be made approximately 10 days after the surgical ablation to facilitate closure of the resultant defect after initial healing.13 Often, as a consequence of surgery or radiation therapy of fields that include or the temporomandibular joint trismus can occur with a gradual loss of mouth-opening (10 to 15 mm or less).11,13 Normal mouth opening during nontranslating rotation of condyles (in the position of centric relation) is 20 to 25 mm, while maximum mouth opening is 40 to 60 mm.14 If trismus occurs shortly after radiation, it requires physiotherapy, the use of occlusal openers, and exercises for involved muscles. In that situation, radiation oncologists should refer the patient to a prosthodontist to begin jaw opening physiotherapy as soon as possible. An unmanaged trismus will become chronic, followed by a gradual fibrosis of the elevator muscles.13 For those patients, normal dental treat-
This article originates from the scientific project: Investigation of materials and clinical procedures in prosthetic dentistry, grant No. 065-0650445-0413 supported by the Ministry of Science, Education and Sports of the Republic of Croatia. a
Professor, Department of Prosthodontics at Clinical Hospital, Dubrava, and Department of Fixed Prosthodontics at School of Dental Medicine, University of Zagreb. b Researcher, Department of Fixed Prosthodontics at School of Dental Medicine, University of Zagreb.
The Journal of Prosthetic Dentistry
Vojvodic and Kranjcic
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September 2013 ment is almost impossible and, therefore, requires a modified treatment approach. This clinical report describes the prosthodontic rehabilitation and fabrication of an obturator used for a partially edentulous patient with an acquired unilateral maxillary defect. The impression was made in 2 steps in a similar manner as the altered cast impression technique. Precise impression of the resection defect despite trismus was possible, thus providing this patient an accurately fitting obturator prosthesis. 1 Intraoral status.
CLINICAL REPORT Six months after the surgical ablation (partial maxillectomy) of a squamous cell carcinoma mass in the right maxillary sinus, a 70-year-old woman visited the Department of Prosthodontics in the Clinical Hospital, Dubrava, seeking prosthodontic treatment. An extraoral examination revealed a collapsed right maxillary region. An intraoral examination revealed a right-side maxillary defect of the palate extending posteriorly from the premaxilla and involving the alveolar ridge, hard palate, soft palate, and uvula, with 2 remaining maxillary central incisors (Fig. 1). Based on its location, the described maxillary defect was classified as a Class II Aramany maxillary defect classification (unilateral defect located posterior to the remaining teeth), even though only 2 central incisors remained.6,7,15 The antagonistic partially edentulous mandible had no abnormal bone and/or soft tissue defects. A maxillary hollow bulb obturator prosthesis and mandibular partial removable dental prosthesis were planned for this patient. The obturator prosthesis was to be retained by Co-Cr-Mo alloy T bar clasps (Wironit; Bego, Bremen, Germany) supported by metal acrylic resin crowns with rests on the remaining central incisors. These prosthetic treatments were chosen because of the financial limitations of the patient. Maxillary central incisors were prepared, and an impression (Optosil/
Vojvodic and Kranjcic
2 Irreversible hydrocolloid impression of maxilla with crowns with rests. Xantopren L; Heraeus Kulzer, Hanau, Germany) was made to fabricate the crowns with lingual rests. Despite trismus (17 mm, measured between the incisal edges of the anterior teeth compared to normal mouth opening of 40 to 60 mm)14 and radiation therapy to the head and neck region, it was possible to make an impression of the crown preparations. However, because of to the trismus, it was impossible to make the impression of the resection defect at the same time. Removing a 1-piece impression from the oral cavity was not possible. Therefore, a 2-step (altered cast) impression technique was performed. A primary impression of the maxilla (Fig. 2) capturing the crowns with rests (on maxillary central incisors) was made with irreversible hydrocolloid impression material (Aroma Fine III; GC Corp, Tokyo, Japan). This pri-
mary impression captured all the intraoral structures on the nonresected side and part of the resection defect, but with sufficient extension for the production of a cast framework for the maxillary obturator. Removal of the impression without discomforting the patient was possible. This impression was poured in dental stone (Moldano; Heraeus Kulzer), after which a maxillary obturator cast framework was conventionally produced from Co-CrMo alloy (Wironit; Bego). The cast framework was modified in such a way that retentive mesh and dowels were added over the resection defect to ensure retention for a secondary (altered cast) impression material, and for the retention of a future acrylic resin bulb of the obturator (Fig. 3). Two metal clasps engaged the maxillary right central incisor and maxillary left central incisor of the cast framework to sta-
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3 Primary cast poured in dental stone (left), cast framework of obturator prosthesis with retentive mesh and dowels on palatal side (right).
4 Secondary (altered cast) impression; obturator cast framework with condensation silicone material inserted into resection defect.
5 Trimmed stone cast (left), secondary (altered cast) impression of resection defect (right).
6 The altered cast of oral cavity and resection defect with formed maxillary sinus (polyvinyl siloxane).
bilize the framework for the secondary (altered cast) impression and future partial removable dental prosthesis with obturator. A secondary (altered cast) impression of the resection defect was made with condensation high and low viscosity silicone materials (Optosil/ Xantopren L; Heraeus Kulzer) placed on and inserted intraorally with the obturator framework serving as the tray (Fig. 4). Because of the thickness of the cast framework, it was possible to make an impression of the entire resection defect and to remove it from the patient´s mouth. The stone cast was then modified as an altered cast; the portion of the cast corresponding to the resection defect was trimmed (Fig. 5) until it was possible to place the obturator cast framework on it
with the secondary (altered cast) impression of the resection defect. Then, the adjacent impression was poured in dental stone (Moldano; Heraeus Kulzer) to produce a definitive cast. After the definitive cast had been trimmed, and the stone had set, the predicted shape of the maxillary sinus was formed by using polyvinyl siloxane material (Exaflex Putty; GC Dental Products Corp, Aichi, Japan) to produce the concave shape of the obturator toward the sinus cavity (Fig. 6). The hollow bulb obturator was made by pouring autopolymerizing acrylic resin (Probase Cold; Ivoclar Vivadent, Schaan, Liechtenstein) in the newly formed resection defect on the altered cast, covering the retentive elements of the cast framework (Fig. 7). After the acrylic resin hollow bulb
The Journal of Prosthetic Dentistry
obturator had been formed and attached to the cast framework, it was evaluated intraorally; occlusal vertical, and horizontal dimensions were determined to be 3 mm less than the physiologic rest position.16 After the arrangement of artificial teeth, occlusion, and esthetics were verified intraorally, the partial removable dental prosthesis was processed with a heat-polymerized denture base acrylic resin (Probase Hot; Ivoclar Vivadent). The maxillary hollow bulb obturator was finished, polished, and inserted intraorally (Fig. 8). At insertion of the maxillary hollow bulb obturator, the fit and extension of denture base flanges were verified with pressure-indicating paste (Pressure Indicator Paste (PIP); Keystone Industries, Cherry Hill, NJ). Adjustments were made to compensate
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September 2013
7 Completed hollow bulb obturator in autopolymerizing acrylic resin. for the changes that occurred as a result of obturator processing. Pressure over the soft tissue was relieved with rotary cutting instruments (Komet Dental, Lemgo, Germany). Also, the occlusion was evaluated with articulating paper (Arti-Fol; Dr Jean Bausch Gmbh & Co KG, Cologne, Germany). After the obturator prosthesis fit had been verified and adjusted and the occlusion corrected, the retentive clasp arms were activated. The patient was instructed in hygiene procedures, and follow-up appointments were recommended every 3 to 6 months, or as needed, to evaluate the denture fit (especially the obturator fit at the entrance of the resection defect) and to examine the condition of the oral mucosa. The patient has been using the prosthesis for 13 months.
SUMMARY By using the 2-step (altered cast) impression technique described, it was possible, despite trismus, to make an accurate impression of the nonresected part of the maxilla and the resection defect. With the use of a secondary (altered cast) impression, the primary stone cast was modified to produce a definitive altered cast. The maxillary hollow bulb obturator ensured adequate closure of the resection defect with adequate obturator retention, stability, and support, thus improving oral function, speech, and esthetics.
Vojvodic and Kranjcic
8 Completed removable dental prosthesis with hollow bulb obturator.
REFERENCES 1. Ortegon SM, Martin JW, Lewin JS. A hollow delayed surgical obturator for a bilateral subtotal maxillectomy patient: a clinical report. J Prosthet Dent 2008;99:14-8. 2. Depprich RA, Handschel JG, Meyer U, Meissner G. Comparison of prevalence of microorganisms on titanium and silicone/ polymethyl methacrylate obturators used for rehabilitation of maxillary defects. J Prosthet Dent 2008;99:400-5. 3. Sharma AB, Beumer J. Reconstruction of maxillary defects: the case for prosthetic rehabilitation. J Oral Maxillofac Surg 2005;63:1770-3. 4. Al-Salehi SK, Calder ID, Lamb DJ. Magnetic retention for obturators. J Prosthodont 2007;16:214-8. 5. Bilhan H, Geckili O, Bural C, Sonmez E, Guven E. Prosthetic rehabilitation of a patient after surgical reconstruction of the maxilla: a clinical report. J Prosthodont 2011;20:74-8. 6. Aramany MA. Basic principles of obturator design for partially edentulous patients. Part I: classification. J Prosthet Dent 2001;86:559-61. 7. Aramany MA. Basic principles of obturator design for partially edentulous patients. Part II: design principles. J Prosthet Dent 2001;86:562-8. 8. Sullivan M, Gaebler C, Beukelman D, Mahanna G, Marshall J, Lydiatt D, et al. Impact of palatal prosthodontic intervention on communication performance of patient’s maxillectomy defects: a multilevel outcome study. Head Neck 2002;24:530-8. 9. Kim DD, Ghali GE. Dental implants in oral cancer reconstructions. Dent Clin North Am 2011;55:871-82. 10.Haug SP. Maxillofacial prosthetic management of the maxillary resection patient. Atlas Oral Maxillofac Surg Clin North Am 2007;15:51-68.
11.Cheng AC, Koticha TN, Tee-Khin N, Wee AG. Prosthodontic management of an irradiated maxillectomy patient with severe trismus using implant-supported prostheses: a clinical report. J Prosthet Dent 2008;99:344-50. 12.Depprich R, Naujoks C, Lind D, Ommerborn M, Meyer U, Kübler NR, et al. Evaluation of the quality of life of patients with maxillofacial defects after prosthodontic therapy with obturator prostheses. Int J Oral Maxillofac Surg 2011;40:71-9. 13.Kramer DC, Taylor TD. Clinical maxillofacial prosthetics. Carol Stream: Quintessence Publishing; 2000. p. 37-52. 14.Okeson JP. Management of temporomandibular disorders and occlusion. 7th ed. St. Louis: Mosby; 2012. p. 93-108. 15.Parr GR, Tharp GE, Rahn AO. Prosthodontic principles in the framework design of maxillary obturator prostheses. J Prosthet Dent 2005;93:405-11. 16.Vojvodic D, Jerolimov V, Celebic A. Prosthetic rehabilitation of a cleft palate patient: a clinical report. J Prosthet Dent 1996;76:230-2. Corresponding author: Dr Josip Kranjcic School of Dental Medicine, University of Zagreb Department of Prosthodontics at Clinical Hospital, Dubrava Av. G. Suska 6, 10000 Zagreb CROATIA E-mail: [email protected] Copyright © 2013 by the Editorial Council for The Journal of Prosthetic Dentistry.
the hard palate, and/or a contiguous alveolar or soft tissue structure that has been removed by surgery.8 In an acquired maxillary defect rehabilitation, the use of the prosthetic palatal obturator is a traditional treatment approach.5,9 Some authors8,10 prefer fabricating a partial removable dental prosthesis with an obturator retained by the remaining natural dentition, while others prefer and report the production of implant-supported obturator prostheses with conventional and/ or zygomatic implants.3,4,9,11 A wellmade maxillary obturator minimizes fluid leakage into the nasal cavity and maxillary sinus and improves swallowing, mastication, and esthetics by replacing the teeth removed during the ablative surgery. It also improves speech by allowing a separation between the oral and nasal resonance, thereby minimizing hypernasality.10 In contrast to surgical rehabilitation, the fabrication of the obturator shortens the procedure time, and the surgical site can be easily examined after removing the obturator so that tumor recurrence may be detected.12 According to Haug,10 the fabri-
cation of a definitive obturator can be considered after approximately 3 months of healing after surgery or 3 months after radiation therapy, although an interim obturator can be made approximately 10 days after the surgical ablation to facilitate closure of the resultant defect after initial healing.13 Often, as a consequence of surgery or radiation therapy of fields that include or the temporomandibular joint trismus can occur with a gradual loss of mouth-opening (10 to 15 mm or less).11,13 Normal mouth opening during nontranslating rotation of condyles (in the position of centric relation) is 20 to 25 mm, while maximum mouth opening is 40 to 60 mm.14 If trismus occurs shortly after radiation, it requires physiotherapy, the use of occlusal openers, and exercises for involved muscles. In that situation, radiation oncologists should refer the patient to a prosthodontist to begin jaw opening physiotherapy as soon as possible. An unmanaged trismus will become chronic, followed by a gradual fibrosis of the elevator muscles.13 For those patients, normal dental treat-
This article originates from the scientific project: Investigation of materials and clinical procedures in prosthetic dentistry, grant No. 065-0650445-0413 supported by the Ministry of Science, Education and Sports of the Republic of Croatia. a
Professor, Department of Prosthodontics at Clinical Hospital, Dubrava, and Department of Fixed Prosthodontics at School of Dental Medicine, University of Zagreb. b Researcher, Department of Fixed Prosthodontics at School of Dental Medicine, University of Zagreb.
The Journal of Prosthetic Dentistry
Vojvodic and Kranjcic
229
September 2013 ment is almost impossible and, therefore, requires a modified treatment approach. This clinical report describes the prosthodontic rehabilitation and fabrication of an obturator used for a partially edentulous patient with an acquired unilateral maxillary defect. The impression was made in 2 steps in a similar manner as the altered cast impression technique. Precise impression of the resection defect despite trismus was possible, thus providing this patient an accurately fitting obturator prosthesis. 1 Intraoral status.
CLINICAL REPORT Six months after the surgical ablation (partial maxillectomy) of a squamous cell carcinoma mass in the right maxillary sinus, a 70-year-old woman visited the Department of Prosthodontics in the Clinical Hospital, Dubrava, seeking prosthodontic treatment. An extraoral examination revealed a collapsed right maxillary region. An intraoral examination revealed a right-side maxillary defect of the palate extending posteriorly from the premaxilla and involving the alveolar ridge, hard palate, soft palate, and uvula, with 2 remaining maxillary central incisors (Fig. 1). Based on its location, the described maxillary defect was classified as a Class II Aramany maxillary defect classification (unilateral defect located posterior to the remaining teeth), even though only 2 central incisors remained.6,7,15 The antagonistic partially edentulous mandible had no abnormal bone and/or soft tissue defects. A maxillary hollow bulb obturator prosthesis and mandibular partial removable dental prosthesis were planned for this patient. The obturator prosthesis was to be retained by Co-Cr-Mo alloy T bar clasps (Wironit; Bego, Bremen, Germany) supported by metal acrylic resin crowns with rests on the remaining central incisors. These prosthetic treatments were chosen because of the financial limitations of the patient. Maxillary central incisors were prepared, and an impression (Optosil/
Vojvodic and Kranjcic
2 Irreversible hydrocolloid impression of maxilla with crowns with rests. Xantopren L; Heraeus Kulzer, Hanau, Germany) was made to fabricate the crowns with lingual rests. Despite trismus (17 mm, measured between the incisal edges of the anterior teeth compared to normal mouth opening of 40 to 60 mm)14 and radiation therapy to the head and neck region, it was possible to make an impression of the crown preparations. However, because of to the trismus, it was impossible to make the impression of the resection defect at the same time. Removing a 1-piece impression from the oral cavity was not possible. Therefore, a 2-step (altered cast) impression technique was performed. A primary impression of the maxilla (Fig. 2) capturing the crowns with rests (on maxillary central incisors) was made with irreversible hydrocolloid impression material (Aroma Fine III; GC Corp, Tokyo, Japan). This pri-
mary impression captured all the intraoral structures on the nonresected side and part of the resection defect, but with sufficient extension for the production of a cast framework for the maxillary obturator. Removal of the impression without discomforting the patient was possible. This impression was poured in dental stone (Moldano; Heraeus Kulzer), after which a maxillary obturator cast framework was conventionally produced from Co-CrMo alloy (Wironit; Bego). The cast framework was modified in such a way that retentive mesh and dowels were added over the resection defect to ensure retention for a secondary (altered cast) impression material, and for the retention of a future acrylic resin bulb of the obturator (Fig. 3). Two metal clasps engaged the maxillary right central incisor and maxillary left central incisor of the cast framework to sta-
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3 Primary cast poured in dental stone (left), cast framework of obturator prosthesis with retentive mesh and dowels on palatal side (right).
4 Secondary (altered cast) impression; obturator cast framework with condensation silicone material inserted into resection defect.
5 Trimmed stone cast (left), secondary (altered cast) impression of resection defect (right).
6 The altered cast of oral cavity and resection defect with formed maxillary sinus (polyvinyl siloxane).
bilize the framework for the secondary (altered cast) impression and future partial removable dental prosthesis with obturator. A secondary (altered cast) impression of the resection defect was made with condensation high and low viscosity silicone materials (Optosil/ Xantopren L; Heraeus Kulzer) placed on and inserted intraorally with the obturator framework serving as the tray (Fig. 4). Because of the thickness of the cast framework, it was possible to make an impression of the entire resection defect and to remove it from the patient´s mouth. The stone cast was then modified as an altered cast; the portion of the cast corresponding to the resection defect was trimmed (Fig. 5) until it was possible to place the obturator cast framework on it
with the secondary (altered cast) impression of the resection defect. Then, the adjacent impression was poured in dental stone (Moldano; Heraeus Kulzer) to produce a definitive cast. After the definitive cast had been trimmed, and the stone had set, the predicted shape of the maxillary sinus was formed by using polyvinyl siloxane material (Exaflex Putty; GC Dental Products Corp, Aichi, Japan) to produce the concave shape of the obturator toward the sinus cavity (Fig. 6). The hollow bulb obturator was made by pouring autopolymerizing acrylic resin (Probase Cold; Ivoclar Vivadent, Schaan, Liechtenstein) in the newly formed resection defect on the altered cast, covering the retentive elements of the cast framework (Fig. 7). After the acrylic resin hollow bulb
The Journal of Prosthetic Dentistry
obturator had been formed and attached to the cast framework, it was evaluated intraorally; occlusal vertical, and horizontal dimensions were determined to be 3 mm less than the physiologic rest position.16 After the arrangement of artificial teeth, occlusion, and esthetics were verified intraorally, the partial removable dental prosthesis was processed with a heat-polymerized denture base acrylic resin (Probase Hot; Ivoclar Vivadent). The maxillary hollow bulb obturator was finished, polished, and inserted intraorally (Fig. 8). At insertion of the maxillary hollow bulb obturator, the fit and extension of denture base flanges were verified with pressure-indicating paste (Pressure Indicator Paste (PIP); Keystone Industries, Cherry Hill, NJ). Adjustments were made to compensate
Vojvodic and Kranjcic
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September 2013
7 Completed hollow bulb obturator in autopolymerizing acrylic resin. for the changes that occurred as a result of obturator processing. Pressure over the soft tissue was relieved with rotary cutting instruments (Komet Dental, Lemgo, Germany). Also, the occlusion was evaluated with articulating paper (Arti-Fol; Dr Jean Bausch Gmbh & Co KG, Cologne, Germany). After the obturator prosthesis fit had been verified and adjusted and the occlusion corrected, the retentive clasp arms were activated. The patient was instructed in hygiene procedures, and follow-up appointments were recommended every 3 to 6 months, or as needed, to evaluate the denture fit (especially the obturator fit at the entrance of the resection defect) and to examine the condition of the oral mucosa. The patient has been using the prosthesis for 13 months.
SUMMARY By using the 2-step (altered cast) impression technique described, it was possible, despite trismus, to make an accurate impression of the nonresected part of the maxilla and the resection defect. With the use of a secondary (altered cast) impression, the primary stone cast was modified to produce a definitive altered cast. The maxillary hollow bulb obturator ensured adequate closure of the resection defect with adequate obturator retention, stability, and support, thus improving oral function, speech, and esthetics.
Vojvodic and Kranjcic
8 Completed removable dental prosthesis with hollow bulb obturator.
REFERENCES 1. Ortegon SM, Martin JW, Lewin JS. A hollow delayed surgical obturator for a bilateral subtotal maxillectomy patient: a clinical report. J Prosthet Dent 2008;99:14-8. 2. Depprich RA, Handschel JG, Meyer U, Meissner G. Comparison of prevalence of microorganisms on titanium and silicone/ polymethyl methacrylate obturators used for rehabilitation of maxillary defects. J Prosthet Dent 2008;99:400-5. 3. Sharma AB, Beumer J. Reconstruction of maxillary defects: the case for prosthetic rehabilitation. J Oral Maxillofac Surg 2005;63:1770-3. 4. Al-Salehi SK, Calder ID, Lamb DJ. Magnetic retention for obturators. J Prosthodont 2007;16:214-8. 5. Bilhan H, Geckili O, Bural C, Sonmez E, Guven E. Prosthetic rehabilitation of a patient after surgical reconstruction of the maxilla: a clinical report. J Prosthodont 2011;20:74-8. 6. Aramany MA. Basic principles of obturator design for partially edentulous patients. Part I: classification. J Prosthet Dent 2001;86:559-61. 7. Aramany MA. Basic principles of obturator design for partially edentulous patients. Part II: design principles. J Prosthet Dent 2001;86:562-8. 8. Sullivan M, Gaebler C, Beukelman D, Mahanna G, Marshall J, Lydiatt D, et al. Impact of palatal prosthodontic intervention on communication performance of patient’s maxillectomy defects: a multilevel outcome study. Head Neck 2002;24:530-8. 9. Kim DD, Ghali GE. Dental implants in oral cancer reconstructions. Dent Clin North Am 2011;55:871-82. 10.Haug SP. Maxillofacial prosthetic management of the maxillary resection patient. Atlas Oral Maxillofac Surg Clin North Am 2007;15:51-68.
11.Cheng AC, Koticha TN, Tee-Khin N, Wee AG. Prosthodontic management of an irradiated maxillectomy patient with severe trismus using implant-supported prostheses: a clinical report. J Prosthet Dent 2008;99:344-50. 12.Depprich R, Naujoks C, Lind D, Ommerborn M, Meyer U, Kübler NR, et al. Evaluation of the quality of life of patients with maxillofacial defects after prosthodontic therapy with obturator prostheses. Int J Oral Maxillofac Surg 2011;40:71-9. 13.Kramer DC, Taylor TD. Clinical maxillofacial prosthetics. Carol Stream: Quintessence Publishing; 2000. p. 37-52. 14.Okeson JP. Management of temporomandibular disorders and occlusion. 7th ed. St. Louis: Mosby; 2012. p. 93-108. 15.Parr GR, Tharp GE, Rahn AO. Prosthodontic principles in the framework design of maxillary obturator prostheses. J Prosthet Dent 2005;93:405-11. 16.Vojvodic D, Jerolimov V, Celebic A. Prosthetic rehabilitation of a cleft palate patient: a clinical report. J Prosthet Dent 1996;76:230-2. Corresponding author: Dr Josip Kranjcic School of Dental Medicine, University of Zagreb Department of Prosthodontics at Clinical Hospital, Dubrava Av. G. Suska 6, 10000 Zagreb CROATIA E-mail: [email protected] Copyright © 2013 by the Editorial Council for The Journal of Prosthetic Dentistry.