Modification of surgical obturators to interim prostheses

ASSESSING

EFFECTIVE

OBTURATION

duced by Mr. B. Pyke, Chief Photographer, Medicine and Dentistry.

lateral projection indicated that the escape appeared to arise with the elevation of the soft palate (Figs. 6 and 7). However, to be sure that the escape did not arise in the distobuccal aspect of the cavity between the cheek and the obturator, simultaneous recording taken in vertex occlusal and posteroanterior projections would be required. Such a facility was not available. The opportunity was also used to identify the possible mechanisms of modified swallowing behavior that can be adopted by individuals to avoid nasal escape of fluid when not wearing an obturator. In the first situation, one subject was able to restrict the passage of liquid to the remaining contact between the residual palate and dorsum of the tongue (Fig. 8). In another subject, there was evidence of altered tongue posture to create a channel over which liquid flowed into the oropharynx (Fig. 9). SUMMARY

AND

King’s

College,

School of

REFERENCES 1. 2. 3. 4.

5. 6.

7.

CONCLUSIONS

8.

The use of lung function tests and sequential radiography appear to be suitable complementary methods of contrasting the effectiveness of obturator prostheses provided in the management of maxillectomy patients. The creation of an oral seal, demonstrable by normal subjects during swallowing and in the production of certain speech sounds, appears to be unobtainable in the management of maxillectomy. Effective obturation produces sufficient separation of the oral cavity from the nasal cavity to permit efficient swallowing and intelllgible speech. These two methods also offer simple means to evaluate subjective experiences of the patient.

9.

IO. Il.

12.

Verge TJ, Chapman RJ: Maximizing support for maxillary defects. J PKOSTHE?. DENT 45:179, 1981. Hahn GW: A comfortable silicone bulb obturamr with or without dentures. J PROSTHLT DENT 28:X13, 197X. Wood RH, Carl W: Hollow silicone obturators for patients after total maxilleccomy. J PROSTHET DENT 38:64X, 1977. Laney WR: Restoration of acquired oral and paraoral defects. In: Laney WR, Gibilisco JA: Diagnosis and Treatment in Prosthodontics. Philadelphia, 1983, Lea & Febiger, chap 15. pp 377-446. Desjardins RP: Obturator design for acquired maxillary defectc. J PKOXTHET DENT 39:424, 1978. Zarb GA. Bergman B, Clayton JA, Mackay HF: Prosthodontic Treatment for Partially Edentulous Patients. St. Louis, 1978, CL’ hlosby c:o. hlajid AA, Weinberg B, Chalian \‘A: Speech inrelllgibility following prosthetic obturation of surgically acquired maxillary defects. J PRC>STIIF;~ DENT 32:87. 1974. Aramany LlA, Draw JB: Etlect of nasal extension sections on the voice quality of acquired cleft palate patients. J ~‘R~sTHE.I DENT 27:194, 1972. Kipfmueller LJ, Lang BR: Presurgical maxillary prosthesis: An analysis of speech intelligibility. J PROS~IIET DENT 28:620. 1972. Cores JE: Lung Function, ed 4. Oxford. 1979, Blackwell Scientific Publications. Ullah hll, Cuddihy V, Saunders KB, Addis GJ: How many blows really make an FEV,, FVC. or PEFR? Thorax 3&l 13, 1983. American ‘l‘horacic Society Statement. Snowbird workshop on standardization of spirometry. i\m Rev Respir Dis 119:831, 1979

\Ve we indebted 10 Dr. H. Nunnerley, Consultant Radiologist, King’s College Hospital for her special advice and help. Clinical assistance was provided by Messrs. D. Davis, J. Rogers, and R. Welfare, Lecturers in Prosthetic Dentistry. Illustrations were pro-

Modification prostheses

of surgical

Rhonda

F. Jacob, D.D.S.,

University

of Texas,

M.

M.S.,*

D. Anderson

obturators

Jack W. Martin, Hospital

and Tumor

D.D.S., Institute,

A

M.S.,* Houston,

to interim and Gordon

E. King,

D.D.S.**

Tex.

fter consultation with the surgeon regarding the anticipated surgical margins of a maxillary defect,

immediate surgical obturators are made on a presurgical diagnostic cast. Immediate surgical obturator prostheses

*Assistant Clinical

**Chairman, Department of Dental (Maxillofacial); Professor of Clinical of Dental Oncology.

THE

JOURNAL

Dental Dental

Oncologist Oncology,

OF PROSTHETIC

(Maxillofacial); Assistant Professor Department of Dental Oncology. DENTISTRY

of

Oncology; Dental Oncologist Dental Oncology, Department

93

Fig. 1. Intraoral extension

view of obturator prosthesis into maxillectomy defect.

prior

to

Fig. 3. Soft denture band by utility wax.

lining

material

Larried

Fig. 4. Final interim

Fig. 2. Utility

rope wax placed

at border

impression of maxillectomy obturator fabrication.

over scar

defect

hiJ

of obturator

extension.

are generally made of acrylic resin with wrought wire clasps. Modification of the cast prior to obturator fabrication usually entails removal of the teeth on the cast where surgery is to be performed. At the time of surgery, discrepanciesin the fit of the surgical prosthesis are compensatedby a bolus material packed into the maxillary defect. The simple prosthesis allows the patient to take oral nourishment immediately postoperatively.’

When the surgical obturator prosthesis and bolus packing are removed, corrections in the obturator contours are needed.The most common changeis increased extension of the prosthesisposteriorly and posterolaterally. After 4 to 6 weeks of healing, the extension of the prosthesisagain requires major modifications. Usually healing is sufficient at this time to gain support from the scar band at the skin-grafted margins. An impression technique that usesutility rope wax and an intermediate soft-denture lining material (Tru-soft, Harry J. Bosworth Co., Skokie, Ill.) for modification of an acrylic 94

resin surgical obturator to engage the maxillectomy defect scar band is described.

IMPRESSION

PROCEDURES

The borders of the obturator are relieved to allow the mandible to move freely without impingement on the obturator prosthesis. A groove is cut into the tissue surface of the obturator prosthesis.atthe junction of the surgical defect and the remaining hard palate. This serves as a finish line for trimming excessimpression material. Utility rope wax is placedaround the border oi the obturator extension so that the.superior height of thP wax is above the scar band (Figs. 1 and 2). The intermediate denture-lining material is mixed to a workable consistencyand placed along the rope wax. The obturator is inserted in the mouth, and the material is border molded. After the lining material hasset, excess material is removed (Fig. 3). Additional lining material is placedaround the border of the defect until the surface of the scar band and the medial wall of the remaining palate are evident in the impression.The internal aspect JULY

1985

VOLUME

54

NUMBER

1

SURGICAL

OBTURATOR

FOR

INTERIM

PROSTHESIS

of the obturator extension is not covered (Fig. 4). The obturator prosthesis is flasked as if it were a removable partial denture, with the clasps and nondefect portion of the obturator covered with stone in the initial Basking stage.

DISCUSSION The advantage of using the intermediate soft denture liner as the impression material is that the patient can wear the obturator with the lining material until the dentist has the opportunity to process the modification into acrylic resin. The utility wax can be removed after the impression procedure to leave the soft lining material to support itself. This part of the lining material can be stabilized by adding more lining material to the internal extension of the prosthesis. The use of utility or baseplate wax to extend the obturator at the initial removal of the packing bolus is also effective. The advantage of utility wax is the support provided to the intermediate soft liner. When the wax is removed the obturator can be worn for several days while healing progresses.

Modified

stock-eye

S. Taicher, D.M.D.,* M. Sela, D.M.D.****

D.M.D.,

TECHNIQUE 1. To use this technique routinely, maintain a large selection of prefabricated eyes. The Monoplex System (American Optical Corp., Southbridge, Mass.) offers a variety of kits that adequately match iris and scleral colors of most patients. If iris sizes and pupil diameters

*Senior Lecturer, Maxillofacial Prosthetic Unit. **Fellow, Maxillofacial Prosthetic Unit. ***Chief Technician, Maxillofacial Prosthetic Unit ****Lecturer, Maxillofacial Prosthetic Unit. OF PROSTHETIC

1.

Birnbach maxillary

S: Immediate surgical sectional stent prosthesis resection. J PROSTHET DENT 39:447, 1978.

for

&pm requesl5 lo: DR. RHONLIA F. JACOB UNIVERSIW OF TEXAS h,f. D. ANIIERSON H~SIWAL ANII TUMOR INSTW ‘I t DEPARTMEW 0~ DENTAL ONCOLOGY, Box 9 6723 BERTNER ALE. HOUSTON, TX 77030

I. Tubiana,***

and

School of Dental Medicine, Jerusalem, Israel

M

JOURNAL

REFERENCE

M.D.S.,**

alignancy, infection, and trauma may lead to enucleation or eviseration of the eye.‘,* Although customized prostheses offer excellent esthetics,‘z4 most ocular prostheses can be made from a prefabricated artificial eye.* This article describes a technique for modification of prefabricated artificial eyes to achieve ideal fit and esthetics.

THE

A technique for modification of an immediate surgical obturator prosthesis to an interim obturator prosthesis has been discussed. The method described allows the intermediate soft denture lining material to function as an impression material or become an integral part of the interim obturator prosthesis. Patient acceptance and clinical ease of manipulation have made the use of the lining material and the technique described the standard procedure at this institution.

ocular prosthesis

H. M. Steinberg,

Hebrew University-Hadassah

CONCLUSION

DENTISTRY

are not acceptable, a standard artificial eye technique should be used. 2. Add an acrylic stem to the midpoint of the pupil on the artificial eye selected by the clinician and the patient (Fig. 1). The stem is approximately 1 cm long and 3 to 4 mm wide and is attached with autopolymerizing resin (Paladur, Kulzer Co., Bad Hamburg, West Germany). The stem must be centered in the superior-inferior and medial-lateral axes. 3. Reduce’ the posterior and lateral borders of the eye to allow freedom from impingement on the tissue bed when the surrounding structures are at rest. Carefully reduce the medial and inferior borders to the estimated final lengths, because modifications in these areas may require scleral-colored acrylic resins for maximum esthetics. 4. Paint an alginate adhesive (Schein’s tray adhesive, Henry Schein Inc., Port Wash, N.Y.) on the posterior, lateral, and slightly over the anterior corners of the stock eye. 95