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Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palato-maxillectomy patients
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Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palato-maxillectomy patients A.A. Salem*, E.A. Shakel 1, A.A. Sadakha, E.M. Kassem 2, A.A. El-Segai 3 Faculty of Dentistry, Tanta University, Egypt Received 21 April 2014; revised 14 October 2014; accepted 20 October 2014
Abstract Objectives: To evaluate clinically, radio-graphically and electro-myographically the added value after converting conventional obturator to implant retained one using Zygomatic implant for patients with acquired partial palatomaxillary defect, as regards residual tissue preservation, masticatory muscle activity and quality of the life. Methods: Eight patients were selected form Prosthodontic Clinic of the Faculty of Dentistry, Tanta University with palatomaxillary defects. The conventional hollow type obturator was fabricated for each patient. After 6 months of obturator insertion, each patient received tapered threaded implant at the Zygomatic bone of the resected side. During Osseointegration period, all patients continued using the conventional hollow obturators. After another 6 months the obturator was connected to the implant by ball and socket attachment. Clinical and radiographic evaluation of the abutment teeth in addition to Electromyographic evaluation of masseter and temporalis muscles and assessment of the oral health related quality of life were done. Results: For the abutment teeth, there was no statistically significant difference in gingival index, tooth mobility, and bone level in comparison between conventional obturator and implant retained obturator. Implant retained obturator showed significant improvement over conventional obturator in patient quality of life. In addition, increase of muscle activity of the masseter and temporalis muscles in patients with implant retained obturator was recorded. Conclusion: The implant retained obturator highly improved the masticatory function and Oral Health Related Quality of Life (OHRQOL) in comparison to conventional obturator. © 2014, Production and Hosting by Elsevier B.V. on behalf of the Faculty of Dentistry, Tanta University.
Keywords: Zygomatic implant; Retained obturator; Partial palato-maxillectomy
* Corresponding author. Tel.: þ20 01005872082 (mobile). E-mail addresses: [email protected], [email protected] (A.A. Salem), [email protected], eman.abdelmageed@ dent.tanta.edu.eg (E.A. Shakel), [email protected], [email protected] (A.A. Sadakha), [email protected] (E.M. Kassem), [email protected], [email protected] (A.A. El-Segai). Peer review under the responsibility of the Faculty of Dentistry, Tanta University. 1 2 3
Tel.: þ20 0111856850 (mobile). Tel.: þ20 0126475122 (mobile). Tel.: þ20 0111905559 (mobile).
http://dx.doi.org/10.1016/j.tdj.2014.10.003 1687-8574/© 2014, Production and Hosting by Elsevier B.V. on behalf of the Faculty of Dentistry, Tanta University. Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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A.A. Salem et al. / Tanta Dental Journal xx (2014) 1e6
1. Introduction The term maxillectomy refers to surgical removal of a part or all of the maxilla [1]. Maxillary defect creates dysfunction of stomatognathic system such as mastication, speech, bolus transportation and various degrees of cosmetic deformity. Moreover, the negative psychological impact is tremendous [2]. The main objective for treating such patients with obturators is to achieve closure of the defect area and to separate the oral cavity from the sinus and nasal cavities [3]. Rehabilitation of this defect is important not only in function and aesthetics, but also in patient resocialization [4]. Stability and retention of the obturator is governed by the location and size of the defect, the number of remaining teeth, and the supporting surface of the remaining palate [5]. Stability and retention of the obturator will affect the mastication and other functions later on [6]. The required retention and stability of the obturator with implants is achieved with less complication, time, and discomfort than with other surgical procedures [7]. The larger the surgical resection, the greater the loss of support, which in turn results in increased unfavorable forces acting on the remaining abutment teeth. Positive support within the defect prevents rotation of the obturator into it. This support can be achieved by contact of the prosthesis with any anatomic structures that provides firm base. A more recent approach is the use of osseointegrated implant in zygomatic bone [8]. Most of studies on maxillary obturators retained by osseointegrated implants were isolated patient reports providing minimal data on long-term implant status and survival rates. There is no exact estimation of the added value of the implant retained obturator for acquired maxillary defect. Therefore, more studies are still important in determining the specific applications and limitations of the Zygoma implant in rehabilitation of this complex and challenging patients. 2. Patients and methods
Eight patients (5 femalese3 males) were selected from the Outpatient Prosthodontic Clinic of the Faculty of Dentistry, Tanta University, ranging in age from 20 to 58 years old. Every patient was examined to meet the inclusion criteria of the study and was informed about the aim of the study and agreed to participate in this study. The selected patients had the following 4 5
Fig. 1. Pre-operative intra-oral view showing the extent of palatomaxillary defect.
criteria: Acquired partial palato-maxillary defect Fig. 1. Almost healthy remaining maxillary teeth, Almost completely dentulous mandibular arch, Relatively good oral hygiene, Did not receive radiotherapy, did not had any systemic disease that may interfere with implantation procedure and non-Smokers. After construction of Metal framework, the Hollow bulb type of obturator was processed according to the technique of Habib and Driscol [9] Fig. 2. After 6 months of obturator insertion, each patient received one fixture4 16 mm length, and 3.7 mm diameter at the Zygomatic bone of the resected side. During Osseointegration period, all patients continued using the conventional hollow obturators after modification. After another 6 months and assurance of good Osseointegration Fig. 3, second stage surgery was performed. The obturator was modified and connected to the implant by ball and socket attachment Fig. 4. 2.1. Patient evaluation
The Abutment teeth evaluations were carried out at conventional obturator insertion, 6 and 12 months after its insertion. Also at implant retained obturator insertion, 6 and 12 months after its insertion. Clinical evaluation by gingival index was carried out according to Loe and Silness [10], Tooth mobility was tested according to Lindhe [11]. Radiographic evaluation of the bone height around the abutment teeth by Serial standardized Peri-apical radiographs were made for all abutment teeth using long cone paralleling technique and Rinn XCP5 film holder. The peri-apical radiographs were digitalized to computer
Zimmer Dental Inc., Carlsbad, CA, USA. Rinn Corporation Elgin, Company, Rochester, NY, USA.
Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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and 12 months of conventional and implant retained obturator insertion were not statistically significant. 3.1. Radiographic evaluation From Table 3 the bone loss of the abutment teeth after 6 and 12 months of conventional obturator and implant retained obturator insertion were not statistically significant. 3.2. Electromyographic results
Fig. 2. The photograph of a finished definitive obturator.
by digital camera then software ImageJ 1.426 was used to measure the linear distance in pixels between two marked points (at the alveolar crest and the root apex) of mesial and distal sides of each abutment teeth. The mean of the marginal bone loss on both mesial and distal surfaces of each abutment tooth was calculated, after that the mean of loss of the whole abutment teeth for each patient was calculated Fig. 5. Electromyographic evaluations were carried out at 12 months of using conventional obturator and 12 months of using implant retained-obturator. Electromyography signals were recorded on right and left sides during maximum voluntary clenching at centric occlusion by surface electrode to Masseter and Temporalis muscles, the amplitude of the interference pattern of each muscle is recorded. Assessment of the quality of life by a short-version of a questionnaire (translated into Arabic) [12] that measures oral health related quality of life [OHRQoL]. The questionnaire was completed by the patient without any obturator, after using the conventional obturator by 12 months and after using implant retained obturator by 12 months. The recorded results were collected, tabulated and evaluated statistically using paired T-test. These analyses were performed using statistical software SPSS7 [13]. 3. Results From Tables 1 and 2 the gingival index (GI) and Tooth Mobility (M) of the abutment teeth at, after 6 6 7
The EMG activity was measured during maximum voluntary clenching at centric occlusion. The sum of both mean values amplitude of the left and right masseter and temporalis muscles activity were recorded in Tables 4 and 5. The mean value EMG amplitude of the masseter and temporalis muscles activity of patients with conventional obturator was significantly increased when the patients used implant retained obturator. 3.3. OHRQoL Table 6 and Graph 1 showed the OHRQoL score of maxillectomy patients without any prosthesis was significantly improved when the patients were wearing conventional obturator, in addition to further significant improvement on using. 4. Discussion The great variety of maxillectomy defects and low patient numbers are usually presented as case reports. Therefore, prosthetic treatment decisions on this patient group usually based on low levels of evidence. For this, management of maxillectomy patients was the aim of this study. The conventional obturator has been primarily used successfully with variable results in patients with partial and total maxillectomy for many years [14]. However, the prosthetic rehabilitation of maxillary defects is a significant challenge in terms of creating retention and preserving existing dentition in an environment of expanded functional stress. In addition to the high risk of many problems such as poor function that may include loosening of the obturator; mastication problems; leakage of liquid, and/or food; and problems with speech, aesthetics, and social integration, with psychological sequel, could also be
Imag x system, de Gotezen, Italy. Version 11.0; SPSS Inc., Chicago, III.
Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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A.A. Salem et al. / Tanta Dental Journal xx (2014) 1e6
Fig. 3. CT scan showing osseointegrated implant.
present [15]. Since the introduction of a method that uses implants in the zygoma obturator retention has been improved [7,16,17], with better stability and retention [15,18]. Accordingly, this study aimed to evaluate clinical, radiographical and electromyographical the added values after converting conventional obturator to implant retained one, using dental implant in the zygoma. In this study to avoid personal differences between patients, the conventional obturator and implant-retained obturator were compared on the same individual. So, the size of the defect and the Fig. 5. Periapical X-ray analysis by Imag J soft-wear showing marked points (at the alveolar crest and the root apex).
number of remaining teeth were not considered. The present study showed no statistically significant differences in clinical parameters including gingival index and tooth mobility for the abutment teeth and bone Table 1 Comparison between GI difference of the abutment teeth on using conventional and implant retained obturators at different follow up periods. Time of assessment
Fig. 4. O-ring attached to the implant retained obturator.
Conventional Implant retained Paired obturator obturator T-test P value
Mean ± SD 0e6 months 0.08 ± 0.07 6e12 months 0.11 ± 0.02
0.07 ± 0.03 0.11 ± 0.03
0.8 0.4
Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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Table 2 Comparison between mobility difference of the abutment teeth on using conventional and implant retained obturators at different follow up periods. Time of assessment
Conventional Implant retained Paired obturator obturator T-test P value
Mean ± SD 0e6 months 0.57 ± .0.49 0.27 ± 0.41 6e12 months 0.60 ± 0.45 0.55 ± 0.51
0.29 0.18
Table 3 Bone loss (pixels) on using conventional and implant retained obturators at different follow up periods. Time of assessment
Conventional obturator
Implant retained obturator
Paired T-test P value
Mean ± SD
72.8 ± 48.3 115.4 ± 64.3
58.3 ± 55.6 87.1 ± 66.2
0.3 0.4
0e6 months 6e12 months
Table 4 Mean values of EMG amplitude of masseter muscle activity (microvolt) on using conventional and implant retained obturators. Mean ± SD Paired T-test P value
Conventional obturator
Implant retained obturator
62.0 ± 20.3 0.003*
115.4 ± 26.0
*Statistically significant at P 0.05.
Table 5 Mean values of EMG amplitude of temporalis muscle activity (microvolt) on using conventional and implant retained obturators. Mean ± SD Paired T-test P value
Conventional obturator
Implant retained obturator
62.25 ± 15.09 0.002*
144.1 ± 42.0
*Statistically significant at P 0.05.
levels around the abutment teeth in and between conventional obturator and implant retained obturator over the whole follow up periods. This may be explained on the basis that patients were instructed to properly use
Graph 1. Oral Health Related Quality of Life score of the patients without obturator, with conventional obturator and with implant retained obturator.
tooth pastes, brushes, and dental floss to remove food particles and dental plaque. In addition, the using of well-designed conventional obturator had no bad effect on the abutment teeth. The results of the present study revealed that rehabilitation of maxillectomy patients with conventional or implant retained obturator showed significant improvement in the general Oral health related quality of life (OHRQoL) including functional impairment, psychological disability, and social disability in comparison to patients without obturator. Moreover, there was a significant improvement in (OHRQoL) after converting the conventional obturator to implant retained obturator. This result is in agreement with Habib and Driscoll, Davo et al. [19,20]. This change may be due to the improvement of retention of the obturator, which gained by the implant leading to oral functions improvements. Additional retention prevents noticeable obturator movement during speech that improved psychological and social disabilities. The results of the present study revealed that significant increase in muscle activity of masseter and temporalis muscle after converting the conventional obturator to implant retained obturator was noted. Higher muscle activity may be considered as regards preservation of a healthy functioning muscle and good masticatory efficiency. None of the previously published researches studied the muscle activity in maxillectomy patient.
Table 6 Oral Health Related Quality of Life score of the patients without obturator, with conventional obturator and with implant retained obturator. Without obturator Mean ± SD P
Conventional obturator
2.55 ± 0.392 0.519 ± 0.168 Without obturator and conventional obturator Without obturator and implant retained obturator Conventional obturator and implant retained obturator
Implant retained obturator 0.173 ± 0.187 <0.01* <0.01* <0.01*
*Statistically significant at P 0.05. Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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5. Conclusion The implant retained obturator highly improved the masticatory function and OHRQOL in comparison to conventional obturator. References [1] Academy of proshtodontics. The glossary of prosthodontic terms. J Prosth Den 2005;94:51. [2] Rogers SN, Lowe D, McNally D, Brown JS, Vaughan ED. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg 2003;61:174e81. [3] Okay D, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent 2001;86:52e60. [4] Goiato M, Pesqueira A, Silva C. Patient satisfaction with maxillofacial prosthesis: literature review. J Plastic Reconstra Aesthetic Surg 2009;62:175e83. [5] Koyama S, Sasaki K, Inai T, Watanabe M. Effects of defect configuration, size, and remaining teeth on masticatory function in post-maxillectomy patients. J Oral Rehab 2005;32:635e41. [6] Rahn AO, Goldman BG, Parr GR. Prosthodontic principles in the surgical planning for maxillary and mandibular resection patients. J Prosthet Dent 1979;42:429e33. [7] Roumanas E, Nishimura RD, Davis BK. Clinical evaluation of implants retaining edentulous maxillary obturator prosthesis. J Prosthet Dent 1997;77:184e90. [8] Yunus N, Rahman Z. Increased retention of a partial denture maxillary obturator using dental implant. Ann Dent Univ Malaya 2000;7:51e9.
[9] Habib B, Driscoll C. Fabrication of a closed hollow obturator. J Prosthet Dent 2004;91:383e90. [10] L€oe H, Silness J. Peridontal disease in pregnancy, I. Prevelance and severity. Acta Odont Scand 1963;21:533e51. [11] Lindhe J. Reattachment e new attachment text book of clinical periodontology. 2nd ed. Copenhagen: Munksgaard; 1998. p. 410. [12] Nickenig H, Wichmann M, Andreas SK, Eitner S. Oral health related quality of life in partially edentulous patients: assessments before and after implant therapy. J Cranio-Maxillofacial Surg 2008;10:101e10. [13] SPSS 14. Statistical package for social science, SPSS for windows release 14:12 standard version. Copyright. SPSS Inc; 2006. [14] Parr G, Gardner L. The evolution of the obturator framework design. J Prosthet Dent 2003;89:608e16. [15] Umino S, Masuda G, Ono S, Fujita K. Speech intelligibility following maxillectomy with and without a prosthesis: an analysis of 54 cases. J Oral Rehabil 1998;25:153e9. [16] Fukuda M, Takahashi T, Nagai H, Lino M. Implant supported edentulous maxillary obturators with milled bar attachments after maxillectomy. J Oral Maxillofac Surg 2004;62:799e807. [17] Weischer T, Schettler D, Mohr C. Titanium implants in the Zygoma as retaining elements after hemimaxillectomy. Int J Oral. Maxillofac Implants 1997;12:211e8. [18] Riley M, Walmsley A, Harris I. Magnets in prosthetic dentistry. J Prosthet Dent 2001;86:137e45. [19] Landes C. Zygoma implantesupported midfacial prosthetic rehabilitation: a 4-year follow-up study including assessment of quality of life. Clin Oral Implants Res 2005;16:313e23. [20] Davo R, Pons O, Rojas J, Carpio E. Immediate function of four Zygomatic implants: a 1-year report of a prospective study. Eur J Oral Implantol 2010;3:323e30.
Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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ScienceDirect Tanta Dental Journal xx (2014) 1e6
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Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palato-maxillectomy patients A.A. Salem*, E.A. Shakel 1, A.A. Sadakha, E.M. Kassem 2, A.A. El-Segai 3 Faculty of Dentistry, Tanta University, Egypt Received 21 April 2014; revised 14 October 2014; accepted 20 October 2014
Abstract Objectives: To evaluate clinically, radio-graphically and electro-myographically the added value after converting conventional obturator to implant retained one using Zygomatic implant for patients with acquired partial palatomaxillary defect, as regards residual tissue preservation, masticatory muscle activity and quality of the life. Methods: Eight patients were selected form Prosthodontic Clinic of the Faculty of Dentistry, Tanta University with palatomaxillary defects. The conventional hollow type obturator was fabricated for each patient. After 6 months of obturator insertion, each patient received tapered threaded implant at the Zygomatic bone of the resected side. During Osseointegration period, all patients continued using the conventional hollow obturators. After another 6 months the obturator was connected to the implant by ball and socket attachment. Clinical and radiographic evaluation of the abutment teeth in addition to Electromyographic evaluation of masseter and temporalis muscles and assessment of the oral health related quality of life were done. Results: For the abutment teeth, there was no statistically significant difference in gingival index, tooth mobility, and bone level in comparison between conventional obturator and implant retained obturator. Implant retained obturator showed significant improvement over conventional obturator in patient quality of life. In addition, increase of muscle activity of the masseter and temporalis muscles in patients with implant retained obturator was recorded. Conclusion: The implant retained obturator highly improved the masticatory function and Oral Health Related Quality of Life (OHRQOL) in comparison to conventional obturator. © 2014, Production and Hosting by Elsevier B.V. on behalf of the Faculty of Dentistry, Tanta University.
Keywords: Zygomatic implant; Retained obturator; Partial palato-maxillectomy
* Corresponding author. Tel.: þ20 01005872082 (mobile). E-mail addresses: [email protected], [email protected] (A.A. Salem), [email protected], eman.abdelmageed@ dent.tanta.edu.eg (E.A. Shakel), [email protected], [email protected] (A.A. Sadakha), [email protected] (E.M. Kassem), [email protected], [email protected] (A.A. El-Segai). Peer review under the responsibility of the Faculty of Dentistry, Tanta University. 1 2 3
Tel.: þ20 0111856850 (mobile). Tel.: þ20 0126475122 (mobile). Tel.: þ20 0111905559 (mobile).
http://dx.doi.org/10.1016/j.tdj.2014.10.003 1687-8574/© 2014, Production and Hosting by Elsevier B.V. on behalf of the Faculty of Dentistry, Tanta University. Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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A.A. Salem et al. / Tanta Dental Journal xx (2014) 1e6
1. Introduction The term maxillectomy refers to surgical removal of a part or all of the maxilla [1]. Maxillary defect creates dysfunction of stomatognathic system such as mastication, speech, bolus transportation and various degrees of cosmetic deformity. Moreover, the negative psychological impact is tremendous [2]. The main objective for treating such patients with obturators is to achieve closure of the defect area and to separate the oral cavity from the sinus and nasal cavities [3]. Rehabilitation of this defect is important not only in function and aesthetics, but also in patient resocialization [4]. Stability and retention of the obturator is governed by the location and size of the defect, the number of remaining teeth, and the supporting surface of the remaining palate [5]. Stability and retention of the obturator will affect the mastication and other functions later on [6]. The required retention and stability of the obturator with implants is achieved with less complication, time, and discomfort than with other surgical procedures [7]. The larger the surgical resection, the greater the loss of support, which in turn results in increased unfavorable forces acting on the remaining abutment teeth. Positive support within the defect prevents rotation of the obturator into it. This support can be achieved by contact of the prosthesis with any anatomic structures that provides firm base. A more recent approach is the use of osseointegrated implant in zygomatic bone [8]. Most of studies on maxillary obturators retained by osseointegrated implants were isolated patient reports providing minimal data on long-term implant status and survival rates. There is no exact estimation of the added value of the implant retained obturator for acquired maxillary defect. Therefore, more studies are still important in determining the specific applications and limitations of the Zygoma implant in rehabilitation of this complex and challenging patients. 2. Patients and methods
Eight patients (5 femalese3 males) were selected from the Outpatient Prosthodontic Clinic of the Faculty of Dentistry, Tanta University, ranging in age from 20 to 58 years old. Every patient was examined to meet the inclusion criteria of the study and was informed about the aim of the study and agreed to participate in this study. The selected patients had the following 4 5
Fig. 1. Pre-operative intra-oral view showing the extent of palatomaxillary defect.
criteria: Acquired partial palato-maxillary defect Fig. 1. Almost healthy remaining maxillary teeth, Almost completely dentulous mandibular arch, Relatively good oral hygiene, Did not receive radiotherapy, did not had any systemic disease that may interfere with implantation procedure and non-Smokers. After construction of Metal framework, the Hollow bulb type of obturator was processed according to the technique of Habib and Driscol [9] Fig. 2. After 6 months of obturator insertion, each patient received one fixture4 16 mm length, and 3.7 mm diameter at the Zygomatic bone of the resected side. During Osseointegration period, all patients continued using the conventional hollow obturators after modification. After another 6 months and assurance of good Osseointegration Fig. 3, second stage surgery was performed. The obturator was modified and connected to the implant by ball and socket attachment Fig. 4. 2.1. Patient evaluation
The Abutment teeth evaluations were carried out at conventional obturator insertion, 6 and 12 months after its insertion. Also at implant retained obturator insertion, 6 and 12 months after its insertion. Clinical evaluation by gingival index was carried out according to Loe and Silness [10], Tooth mobility was tested according to Lindhe [11]. Radiographic evaluation of the bone height around the abutment teeth by Serial standardized Peri-apical radiographs were made for all abutment teeth using long cone paralleling technique and Rinn XCP5 film holder. The peri-apical radiographs were digitalized to computer
Zimmer Dental Inc., Carlsbad, CA, USA. Rinn Corporation Elgin, Company, Rochester, NY, USA.
Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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and 12 months of conventional and implant retained obturator insertion were not statistically significant. 3.1. Radiographic evaluation From Table 3 the bone loss of the abutment teeth after 6 and 12 months of conventional obturator and implant retained obturator insertion were not statistically significant. 3.2. Electromyographic results
Fig. 2. The photograph of a finished definitive obturator.
by digital camera then software ImageJ 1.426 was used to measure the linear distance in pixels between two marked points (at the alveolar crest and the root apex) of mesial and distal sides of each abutment teeth. The mean of the marginal bone loss on both mesial and distal surfaces of each abutment tooth was calculated, after that the mean of loss of the whole abutment teeth for each patient was calculated Fig. 5. Electromyographic evaluations were carried out at 12 months of using conventional obturator and 12 months of using implant retained-obturator. Electromyography signals were recorded on right and left sides during maximum voluntary clenching at centric occlusion by surface electrode to Masseter and Temporalis muscles, the amplitude of the interference pattern of each muscle is recorded. Assessment of the quality of life by a short-version of a questionnaire (translated into Arabic) [12] that measures oral health related quality of life [OHRQoL]. The questionnaire was completed by the patient without any obturator, after using the conventional obturator by 12 months and after using implant retained obturator by 12 months. The recorded results were collected, tabulated and evaluated statistically using paired T-test. These analyses were performed using statistical software SPSS7 [13]. 3. Results From Tables 1 and 2 the gingival index (GI) and Tooth Mobility (M) of the abutment teeth at, after 6 6 7
The EMG activity was measured during maximum voluntary clenching at centric occlusion. The sum of both mean values amplitude of the left and right masseter and temporalis muscles activity were recorded in Tables 4 and 5. The mean value EMG amplitude of the masseter and temporalis muscles activity of patients with conventional obturator was significantly increased when the patients used implant retained obturator. 3.3. OHRQoL Table 6 and Graph 1 showed the OHRQoL score of maxillectomy patients without any prosthesis was significantly improved when the patients were wearing conventional obturator, in addition to further significant improvement on using. 4. Discussion The great variety of maxillectomy defects and low patient numbers are usually presented as case reports. Therefore, prosthetic treatment decisions on this patient group usually based on low levels of evidence. For this, management of maxillectomy patients was the aim of this study. The conventional obturator has been primarily used successfully with variable results in patients with partial and total maxillectomy for many years [14]. However, the prosthetic rehabilitation of maxillary defects is a significant challenge in terms of creating retention and preserving existing dentition in an environment of expanded functional stress. In addition to the high risk of many problems such as poor function that may include loosening of the obturator; mastication problems; leakage of liquid, and/or food; and problems with speech, aesthetics, and social integration, with psychological sequel, could also be
Imag x system, de Gotezen, Italy. Version 11.0; SPSS Inc., Chicago, III.
Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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A.A. Salem et al. / Tanta Dental Journal xx (2014) 1e6
Fig. 3. CT scan showing osseointegrated implant.
present [15]. Since the introduction of a method that uses implants in the zygoma obturator retention has been improved [7,16,17], with better stability and retention [15,18]. Accordingly, this study aimed to evaluate clinical, radiographical and electromyographical the added values after converting conventional obturator to implant retained one, using dental implant in the zygoma. In this study to avoid personal differences between patients, the conventional obturator and implant-retained obturator were compared on the same individual. So, the size of the defect and the Fig. 5. Periapical X-ray analysis by Imag J soft-wear showing marked points (at the alveolar crest and the root apex).
number of remaining teeth were not considered. The present study showed no statistically significant differences in clinical parameters including gingival index and tooth mobility for the abutment teeth and bone Table 1 Comparison between GI difference of the abutment teeth on using conventional and implant retained obturators at different follow up periods. Time of assessment
Fig. 4. O-ring attached to the implant retained obturator.
Conventional Implant retained Paired obturator obturator T-test P value
Mean ± SD 0e6 months 0.08 ± 0.07 6e12 months 0.11 ± 0.02
0.07 ± 0.03 0.11 ± 0.03
0.8 0.4
Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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Table 2 Comparison between mobility difference of the abutment teeth on using conventional and implant retained obturators at different follow up periods. Time of assessment
Conventional Implant retained Paired obturator obturator T-test P value
Mean ± SD 0e6 months 0.57 ± .0.49 0.27 ± 0.41 6e12 months 0.60 ± 0.45 0.55 ± 0.51
0.29 0.18
Table 3 Bone loss (pixels) on using conventional and implant retained obturators at different follow up periods. Time of assessment
Conventional obturator
Implant retained obturator
Paired T-test P value
Mean ± SD
72.8 ± 48.3 115.4 ± 64.3
58.3 ± 55.6 87.1 ± 66.2
0.3 0.4
0e6 months 6e12 months
Table 4 Mean values of EMG amplitude of masseter muscle activity (microvolt) on using conventional and implant retained obturators. Mean ± SD Paired T-test P value
Conventional obturator
Implant retained obturator
62.0 ± 20.3 0.003*
115.4 ± 26.0
*Statistically significant at P 0.05.
Table 5 Mean values of EMG amplitude of temporalis muscle activity (microvolt) on using conventional and implant retained obturators. Mean ± SD Paired T-test P value
Conventional obturator
Implant retained obturator
62.25 ± 15.09 0.002*
144.1 ± 42.0
*Statistically significant at P 0.05.
levels around the abutment teeth in and between conventional obturator and implant retained obturator over the whole follow up periods. This may be explained on the basis that patients were instructed to properly use
Graph 1. Oral Health Related Quality of Life score of the patients without obturator, with conventional obturator and with implant retained obturator.
tooth pastes, brushes, and dental floss to remove food particles and dental plaque. In addition, the using of well-designed conventional obturator had no bad effect on the abutment teeth. The results of the present study revealed that rehabilitation of maxillectomy patients with conventional or implant retained obturator showed significant improvement in the general Oral health related quality of life (OHRQoL) including functional impairment, psychological disability, and social disability in comparison to patients without obturator. Moreover, there was a significant improvement in (OHRQoL) after converting the conventional obturator to implant retained obturator. This result is in agreement with Habib and Driscoll, Davo et al. [19,20]. This change may be due to the improvement of retention of the obturator, which gained by the implant leading to oral functions improvements. Additional retention prevents noticeable obturator movement during speech that improved psychological and social disabilities. The results of the present study revealed that significant increase in muscle activity of masseter and temporalis muscle after converting the conventional obturator to implant retained obturator was noted. Higher muscle activity may be considered as regards preservation of a healthy functioning muscle and good masticatory efficiency. None of the previously published researches studied the muscle activity in maxillectomy patient.
Table 6 Oral Health Related Quality of Life score of the patients without obturator, with conventional obturator and with implant retained obturator. Without obturator Mean ± SD P
Conventional obturator
2.55 ± 0.392 0.519 ± 0.168 Without obturator and conventional obturator Without obturator and implant retained obturator Conventional obturator and implant retained obturator
Implant retained obturator 0.173 ± 0.187 <0.01* <0.01* <0.01*
*Statistically significant at P 0.05. Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003
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5. Conclusion The implant retained obturator highly improved the masticatory function and OHRQOL in comparison to conventional obturator. References [1] Academy of proshtodontics. The glossary of prosthodontic terms. J Prosth Den 2005;94:51. [2] Rogers SN, Lowe D, McNally D, Brown JS, Vaughan ED. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg 2003;61:174e81. [3] Okay D, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent 2001;86:52e60. [4] Goiato M, Pesqueira A, Silva C. Patient satisfaction with maxillofacial prosthesis: literature review. J Plastic Reconstra Aesthetic Surg 2009;62:175e83. [5] Koyama S, Sasaki K, Inai T, Watanabe M. Effects of defect configuration, size, and remaining teeth on masticatory function in post-maxillectomy patients. J Oral Rehab 2005;32:635e41. [6] Rahn AO, Goldman BG, Parr GR. Prosthodontic principles in the surgical planning for maxillary and mandibular resection patients. J Prosthet Dent 1979;42:429e33. [7] Roumanas E, Nishimura RD, Davis BK. Clinical evaluation of implants retaining edentulous maxillary obturator prosthesis. J Prosthet Dent 1997;77:184e90. [8] Yunus N, Rahman Z. Increased retention of a partial denture maxillary obturator using dental implant. Ann Dent Univ Malaya 2000;7:51e9.
[9] Habib B, Driscoll C. Fabrication of a closed hollow obturator. J Prosthet Dent 2004;91:383e90. [10] L€oe H, Silness J. Peridontal disease in pregnancy, I. Prevelance and severity. Acta Odont Scand 1963;21:533e51. [11] Lindhe J. Reattachment e new attachment text book of clinical periodontology. 2nd ed. Copenhagen: Munksgaard; 1998. p. 410. [12] Nickenig H, Wichmann M, Andreas SK, Eitner S. Oral health related quality of life in partially edentulous patients: assessments before and after implant therapy. J Cranio-Maxillofacial Surg 2008;10:101e10. [13] SPSS 14. Statistical package for social science, SPSS for windows release 14:12 standard version. Copyright. SPSS Inc; 2006. [14] Parr G, Gardner L. The evolution of the obturator framework design. J Prosthet Dent 2003;89:608e16. [15] Umino S, Masuda G, Ono S, Fujita K. Speech intelligibility following maxillectomy with and without a prosthesis: an analysis of 54 cases. J Oral Rehabil 1998;25:153e9. [16] Fukuda M, Takahashi T, Nagai H, Lino M. Implant supported edentulous maxillary obturators with milled bar attachments after maxillectomy. J Oral Maxillofac Surg 2004;62:799e807. [17] Weischer T, Schettler D, Mohr C. Titanium implants in the Zygoma as retaining elements after hemimaxillectomy. Int J Oral. Maxillofac Implants 1997;12:211e8. [18] Riley M, Walmsley A, Harris I. Magnets in prosthetic dentistry. J Prosthet Dent 2001;86:137e45. [19] Landes C. Zygoma implantesupported midfacial prosthetic rehabilitation: a 4-year follow-up study including assessment of quality of life. Clin Oral Implants Res 2005;16:313e23. [20] Davo R, Pons O, Rojas J, Carpio E. Immediate function of four Zygomatic implants: a 1-year report of a prospective study. Eur J Oral Implantol 2010;3:323e30.
Please cite this article in press as: Salem AA et al., Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palatomaxillectomy patients, Tanta Dental Journal (2014), http://dx.doi.org/10.1016/j.tdj.2014.10.003