- Email: [email protected]
Maxillofacial prosthetic treatment after maxillectomy
MAXlLLOFACIAL PROSTHETIC TREATMENT AFTER MAXlLLECTOMY MORDECHAI SELA, DMD, KARL SEGAL, MD, RAPHAEL FEINMESSER, MD
Tumors of the oral cavity requiring maxillary resection may cause functional and aesthetic disabilities involving speech, mastication, and deglutition because food and liquids may be forced into the nasal cavity and out of the nose. To help patients overcome these difficulties, it is'essential to provide them with obturator therapy. The different types of obturators and rehabilitation after maxillary resection are described in this article.
Defects caused by surgical interventions in the head and neck region differ according to size, shape, and location (Fig 1). Surgical treatment of the maxilla can cause severe mutilation, which can be treated successfully by prosthetic rehabilitation, l The rehabilitation of such defects carries a wide range of implications on the patient's life, involving speech, mastication, deglutition, and aesthetics. The treatment is schematically divided into three phases, according to the surgery and the wound healing process. Actually, there is one continuation to be observed. This article describes the different procedures involved in preparing the many types of obturators which the patient should be treated with, beginning with the surgical phase to the definitive obturator, which should be the appropriate answer to the patient's deficiency and needs. MAXILLARY TREATMENT
RESECTIONS: PRESURGICAL AND OBTURATOR PLANNING
In the first phase, a surgical obturator 2 is prepared in cooperation with the surgeon and all other relevant diagnostic means, to determine the extent of the tumor. The surgical obturator has four basic functions: 1. Used as a bandage holder and hemostasis. 2. Provides mastication and deglutition ability, so that a feeding tube won't be needed. 3. Speech: Helps the patient to communicate with his/ her immediate environment. 4. Aesthetic appearance. A direct result of the early insertion of the surgical obturator (Fig 2) is thus an improvement of the patient's psychological condition. As previously mentioned, the extent of the resection is dependent on the site, size, and nature of the tumor. The prognosis for rehabilitation is affected by the size and the From the Maxillofacial Prosthetic Department, Hadassah-Hebrew University Hospital,Jerusalem, and the Departmentof Otolaryngology, Rabin Medical Center, Petah Tiqvah, Israel. Address reprint requests to Mordechai Seia, DMD, Maxillofacial Prosthetic Department, Hadassah-HebrewUniversityHospital, P.O. Box 12000, Jerusalem, Israel 91120. Copyright © 1996 by W.B. Saunders Company 1043-1810/96/0704-0005505.00/0
location of the defect, the presence of remaining teeth, and the integrity of the surrounding structures. A small modification at the time of surgery could greatly enhance the success of a prosthesis. The other two phases are the preparation of the intermediate obturator, and the definitive obturator. The progress from one phase to another is coordinated with the healing process of the wound. 3
RETENTION OF IMPORTANT TEETH
The presence of teeth, especially on the side of the resection, can be used to provide retention and stability for a prosthesis. During surgery, the transalveolar resection should be made through the distal aspect of the socket of the adjacent extracted tooth, to preserve the bony support of the adjacent tooth.
DENTAL TREATMENT
BEFORE SURGERY
It should be established at this stage whether the patient is to receive radiation therapy, because extractions during this period are contraindicated. Special attention should be given to the restoration of strategically important teeth so that they are immediately available as retentive and supportive elements. Any teeth which cannot be restored, and are likely to cause pain, should be extracted before the surgical resection. 4 Diagnostic casts should be made in the preoperative period together with clinical and radiographic findings. These casts are used in the evaluation of maxillofacial prosthetic treatment and provide information regarding the occlusal relationship and the usefulness of the existing dentition in terms of the design of the prosthesis. The diagnostic casts are also used for the fabrication of interim prostheses.
INTERMEDIATE OBTURATOR
PROSTHESIS
The objective of an intermediate obturator prosthesis is to provide the patient with immediate functional, postsurgical rehabilitation. The design of the prosthesis should be simple and effective and should be conducive to modification as healing progresses. For this reason, the prosthesis is fabricated in acrylic resin and soft relining materials. 5 The
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 7, NO 4 (DEC), 1996: PP 339-341
339
FIGURE 1. Post It. maxillectomy. FIGURE 3. Definitive obturator.
nasal and oral cavities are separated by the prosthesis, which enables speech and deglutition.
A definitive obturator prosthesis can be constructed 3 to 4 months after surgery (Fig 3). By this time the surgical site has healed and is relatively stable. The defect may be limited to the hard palate, or extend into the soft palate. In the case of smaller defects, it is not necessary to extend the obturator deeply into the defect. In larger resections, the prosthesis must extend into the defect, where it can be supported by zygomatic bone laterally, to prevent the prosthesis from being displaced superiorly as the result of masticatory forces. This will also aid in restoring the facial contour. In cases in which the bony floor of the orbit has been included in the resection, the obturator should provide support for the eye. Defects extending into the mobile soft palate require the obturator to aid the muscles in restoring palatopharyngeal closure, and are designed to function in harmony with these tissues during functional movement and must extend into the defect. The obturator part of the definitive
prosthesis should be contoured to achieve optimal sealing during function of the palatopharyngeal musculature. 6 It is inevitable in the case of larger defects that the prosthesis will move during function. The degree of movement will depend on the following factors: The shape of the defect: A circular defect, particularly in the case of edentulous patients, will allow the prosthesis to rotate in the horizontal plane. The size of the defect: The larger the defect, the less denture-bearing area is available for support and stability. The presence of teeth enhances the prosthetic prognosis (Fig 4). Every effort should be made to retain teeth or roots in an essentially edentolous case, to assist in the retention, stability, and support of the prosthesis. Care must be taken not to overload the remaining teeth. The prosthesis should be made as light as possible so that supporting tissues are not stressed unnecessarily. In edentulous patients, the flexible obturator bulb is frequently the only retentive component of the prosthesis, and retention is obtained from undercuts that are present within the defect. 6 It is therefore necessary to extend the obturator into the following areas of the defect: over the scar band into the buccal undercut; anteriorly, retention is
FIGURE 2. Surgical obturator.
FIGURE 4. Obturator in function.
DEFINITIVE O B T U R A T O R
340
MAXILLOFACIALPROSTHETICTREATMENT
achieved by extending the prosthesis over the premaxilla a n d i n t o n a s a l a p e r t u r e ; r e t e n t i o n is o b t a i n e d p o s t e r i o r l y b y e x t e n d i n g t h e o b t u r a t o r o v e r t h e n a s a l s u r f a c e of t h e r e m a i n i n g h a r d p a l a t e o r soft p a l a t e if p r e s e n t .
REFERENCES 1. Schaaf N: Prosthesis after maxillectomy. Otolaryngol Clin North Am 9:301, 1976
SELA ET AL
2. Carl W: Preoperative and immediate postoperative obturators. J Prosthet Dent 36:298, 1976 3. Brown K: Fabrication of a hollow-bulb obturator. J Prosthet Dent 21:97, 1969 4. Tautin F, Schaaf N: Superiorly based obturator. J Prosthet Dent 33:96, 1975 5. Matalon V, Lafuente H: A simplified method for making a hollow obturator. J Prosthet Dent 36:580, 1976 6. Schaaf N: Obturators on complete dentures. Dent Clin North Am 21:395, 1976
341
Tumors of the oral cavity requiring maxillary resection may cause functional and aesthetic disabilities involving speech, mastication, and deglutition because food and liquids may be forced into the nasal cavity and out of the nose. To help patients overcome these difficulties, it is'essential to provide them with obturator therapy. The different types of obturators and rehabilitation after maxillary resection are described in this article.
Defects caused by surgical interventions in the head and neck region differ according to size, shape, and location (Fig 1). Surgical treatment of the maxilla can cause severe mutilation, which can be treated successfully by prosthetic rehabilitation, l The rehabilitation of such defects carries a wide range of implications on the patient's life, involving speech, mastication, deglutition, and aesthetics. The treatment is schematically divided into three phases, according to the surgery and the wound healing process. Actually, there is one continuation to be observed. This article describes the different procedures involved in preparing the many types of obturators which the patient should be treated with, beginning with the surgical phase to the definitive obturator, which should be the appropriate answer to the patient's deficiency and needs. MAXILLARY TREATMENT
RESECTIONS: PRESURGICAL AND OBTURATOR PLANNING
In the first phase, a surgical obturator 2 is prepared in cooperation with the surgeon and all other relevant diagnostic means, to determine the extent of the tumor. The surgical obturator has four basic functions: 1. Used as a bandage holder and hemostasis. 2. Provides mastication and deglutition ability, so that a feeding tube won't be needed. 3. Speech: Helps the patient to communicate with his/ her immediate environment. 4. Aesthetic appearance. A direct result of the early insertion of the surgical obturator (Fig 2) is thus an improvement of the patient's psychological condition. As previously mentioned, the extent of the resection is dependent on the site, size, and nature of the tumor. The prognosis for rehabilitation is affected by the size and the From the Maxillofacial Prosthetic Department, Hadassah-Hebrew University Hospital,Jerusalem, and the Departmentof Otolaryngology, Rabin Medical Center, Petah Tiqvah, Israel. Address reprint requests to Mordechai Seia, DMD, Maxillofacial Prosthetic Department, Hadassah-HebrewUniversityHospital, P.O. Box 12000, Jerusalem, Israel 91120. Copyright © 1996 by W.B. Saunders Company 1043-1810/96/0704-0005505.00/0
location of the defect, the presence of remaining teeth, and the integrity of the surrounding structures. A small modification at the time of surgery could greatly enhance the success of a prosthesis. The other two phases are the preparation of the intermediate obturator, and the definitive obturator. The progress from one phase to another is coordinated with the healing process of the wound. 3
RETENTION OF IMPORTANT TEETH
The presence of teeth, especially on the side of the resection, can be used to provide retention and stability for a prosthesis. During surgery, the transalveolar resection should be made through the distal aspect of the socket of the adjacent extracted tooth, to preserve the bony support of the adjacent tooth.
DENTAL TREATMENT
BEFORE SURGERY
It should be established at this stage whether the patient is to receive radiation therapy, because extractions during this period are contraindicated. Special attention should be given to the restoration of strategically important teeth so that they are immediately available as retentive and supportive elements. Any teeth which cannot be restored, and are likely to cause pain, should be extracted before the surgical resection. 4 Diagnostic casts should be made in the preoperative period together with clinical and radiographic findings. These casts are used in the evaluation of maxillofacial prosthetic treatment and provide information regarding the occlusal relationship and the usefulness of the existing dentition in terms of the design of the prosthesis. The diagnostic casts are also used for the fabrication of interim prostheses.
INTERMEDIATE OBTURATOR
PROSTHESIS
The objective of an intermediate obturator prosthesis is to provide the patient with immediate functional, postsurgical rehabilitation. The design of the prosthesis should be simple and effective and should be conducive to modification as healing progresses. For this reason, the prosthesis is fabricated in acrylic resin and soft relining materials. 5 The
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 7, NO 4 (DEC), 1996: PP 339-341
339
FIGURE 1. Post It. maxillectomy. FIGURE 3. Definitive obturator.
nasal and oral cavities are separated by the prosthesis, which enables speech and deglutition.
A definitive obturator prosthesis can be constructed 3 to 4 months after surgery (Fig 3). By this time the surgical site has healed and is relatively stable. The defect may be limited to the hard palate, or extend into the soft palate. In the case of smaller defects, it is not necessary to extend the obturator deeply into the defect. In larger resections, the prosthesis must extend into the defect, where it can be supported by zygomatic bone laterally, to prevent the prosthesis from being displaced superiorly as the result of masticatory forces. This will also aid in restoring the facial contour. In cases in which the bony floor of the orbit has been included in the resection, the obturator should provide support for the eye. Defects extending into the mobile soft palate require the obturator to aid the muscles in restoring palatopharyngeal closure, and are designed to function in harmony with these tissues during functional movement and must extend into the defect. The obturator part of the definitive
prosthesis should be contoured to achieve optimal sealing during function of the palatopharyngeal musculature. 6 It is inevitable in the case of larger defects that the prosthesis will move during function. The degree of movement will depend on the following factors: The shape of the defect: A circular defect, particularly in the case of edentulous patients, will allow the prosthesis to rotate in the horizontal plane. The size of the defect: The larger the defect, the less denture-bearing area is available for support and stability. The presence of teeth enhances the prosthetic prognosis (Fig 4). Every effort should be made to retain teeth or roots in an essentially edentolous case, to assist in the retention, stability, and support of the prosthesis. Care must be taken not to overload the remaining teeth. The prosthesis should be made as light as possible so that supporting tissues are not stressed unnecessarily. In edentulous patients, the flexible obturator bulb is frequently the only retentive component of the prosthesis, and retention is obtained from undercuts that are present within the defect. 6 It is therefore necessary to extend the obturator into the following areas of the defect: over the scar band into the buccal undercut; anteriorly, retention is
FIGURE 2. Surgical obturator.
FIGURE 4. Obturator in function.
DEFINITIVE O B T U R A T O R
340
MAXILLOFACIALPROSTHETICTREATMENT
achieved by extending the prosthesis over the premaxilla a n d i n t o n a s a l a p e r t u r e ; r e t e n t i o n is o b t a i n e d p o s t e r i o r l y b y e x t e n d i n g t h e o b t u r a t o r o v e r t h e n a s a l s u r f a c e of t h e r e m a i n i n g h a r d p a l a t e o r soft p a l a t e if p r e s e n t .
REFERENCES 1. Schaaf N: Prosthesis after maxillectomy. Otolaryngol Clin North Am 9:301, 1976
SELA ET AL
2. Carl W: Preoperative and immediate postoperative obturators. J Prosthet Dent 36:298, 1976 3. Brown K: Fabrication of a hollow-bulb obturator. J Prosthet Dent 21:97, 1969 4. Tautin F, Schaaf N: Superiorly based obturator. J Prosthet Dent 33:96, 1975 5. Matalon V, Lafuente H: A simplified method for making a hollow obturator. J Prosthet Dent 36:580, 1976 6. Schaaf N: Obturators on complete dentures. Dent Clin North Am 21:395, 1976
341