Immediate obturation for partial maxillectomy

British Journal of Oral and Maxillofacial Surgery (1988) 26, 255-251 0 1988 The British Association of Oral and Maxillofacial Surgeons

IMMEDIATE

OBTURATION

FOR PARTIAL

MAXILLECTOMY

R. D. WELFARE, B.D.s., F.D.S.R.C.S. and D. M DAVIS, Ph.D., B.D.s., F.D.S.R.C.S. Department

of

King’s College School Prosthetic Dentistry, Dentistry, University of London

of

Medicine

and

Summary. Modifications of the split maxillectomy prosthesis, secured with a transnasal wire, are recommended to ensure ease of obturation of the surgical cavity and, subsequently, rapid replacement of the original stent.

Introduction

Immediate obturation of the fenestration of a maxillary defect following resection of a tumour is necessary to secure effective separation of the oral and nasal cavities and so permit comfortable speech and swallowing. Additionally, during healing, an obturator may be required to support the face and position a split skin graft on the walls of the surgical cavity. For this to be effective it is usually necessary to provide temporary fixation for the prosthesis from the facial skeleton, and sometimes also from the residual maxilla, in preference to packing the cavity with gauze which is sutured in place. One common method is to link the immediate, ‘short-term’ prosthesis supporting the obturator to suspensory wires, which are passed as a loop over the zygomatic arch or, in its absence, through holes drilled in the zygomatic-frontal sutures. The wire passes downward through the cheek wall to a ring to which the obturator is secured. However, this method has two major disadvantages; ascending infection around the circumzygomatic wires may produce trismus; the entire obturator-prosthesis may need to be withdrawn to inspect the healing cavity or to modify the obturator, especially if it is causing pain or is ineffective in sealing the defect. Under these circumstances the wires have to be detached in some way, and later reattached. More recently a split maxillectomy prosthesis has been recommended, permitting removal of that part of the obturator overlying the affected side only (Smith, 1977; Bowerman & Conroy, 1981). This enables the obturator to be removed and replaced, thereby allowing early inspection and, if necessary, modification of the shape of the temporary bung or, if appropriate, replacement of a pack in the surgical cavity. Such a prosthesis is designed with a linking pin and tube system, and retained by a trans-nasal .wire over the hard palate on the unaffected side. In edentulous cases a bone screw into the residual palate may additionally stabilise the prosthesis. However, with this design, it is often difficult to position the two halves of the prostheses correctly so that the tubes are aligned to allow easy insertion of the locking pin. This is especially a problem when first moulding the obturator in gutta percha, impression compound or silicone putty, and the following modifications are therefore recommended.

(Received 5 February

1987; ucceped

255

25 March

1987)

256

BRITISH

JOURNAL

OF

ORAL

Materials

& MAXILLOFACIAL

SURGERY

and method

In conjunction with the surgeon, the split prosthesis is designed incorporating a 3 mm square tube cut in three sections through which passes a locking pin. The pin should be tapered over the initial 2 mm in all directions, to allow easy centralisation. The middle section of tube should be attached to the ‘resected side’ and an acrylic extension carried across onto the ‘unaffected side’ covering the residual maxilla in the form of a tapering dovetail. Also, in order to avoid tilting the distal aspect of the unsupported prosthesis into the cavity, another acrylic tab should extend onto the unaffected half distally into a small recess in the surface of the acrylic base (Fig. IA & B).

Fig. Figure dovetail

1 (A & B)-The and posterior

IA B B

two sections are linked by a 3 mm square pin and tube, with the tapered central tab used to align the second part during insertion of the obturator. Note the posterior and anterior wire loops for transnasal fixation.

Fig. Figure

2-The

central

incisor

attached

2

to the locking

pin ensures

easy withdrawal.

IMMEDIATE

FOR

OBTURATION

Fig Figure

3A

PARTIAL

257

MAXILLECTOMY

& B

3 (A & B)-The detachable acrylic peg, linked by three tubes to the superior ‘affected’ side of the prosthesis, to which the obturator is secured.

surface

of the

The unaffected side of the base is wired transnasally into position via two small loops located on the anterior and posterior borders. Care is required in positioning the loops and tying the wires so that they do not interfere with the lip and cause ulceration when lip movement begins to recover. It is then an easy matter to pack the cavity or shape the stent and join the two halves with the bolt which is attached to an area of the base carrying one or two incisor teeth (Fig. 2). In place of the traditional ‘goal post’ wire loop used to secure the stent a tapered acrylic peg linked by three small posts and tubes to the superior surface of the prosthesis is sufficient to relate the obturator to the denture (Fig. 3A & B). Then, when the cavity is extensive, the obturator is made both detachable and, if necessary, in several parts. In this way the sectional prosthesis may be removed first and the obturator second, avoiding wide opening of the jaws, and excessive stretching of the soft tissues with the attendant and unnecessary risk of tearing open the healing incision line. Acknowledgements We wish to thank Professor R. M. Watson David Kench for their technical assistance.

for his helpful

advice,

and Messrs.

Paul Eckhardt

and

References Smith, P. L. (1977). Splints and obturators used in the surgical and prosthetic management of maxillary defects. Proceedings of The Institute of Maxillofacial Technology & International Facial Prosthetic Workshop, Part III, p. 10. Bowerman, J. & Conroy, B. (1981). Maxillofacial prosthetics: general principles. In: Operative Surgery, Head & Neck Part 1, Ed. Wilson, J. S. P., 3rd Ed., pp. 141-63. London: Butterworth.