Preoperative
and
immediate
William Carl, D.D.S.* Roswell Park Memorial Institute,
postoperative
obturators
Buffalo, N. Y.
R
esection of the maxillae usually leaves a defect which causes impairment of speech, mastication, and swallowing. Sometimes the appearance of the patient is affected. The size and location of the defect influence the degree of impairment and the degree of difficulty in prosthetic rehabilitation. Debilitation of the patient can be kept to a minimum and the recovery period considerably shortened if rehabilitation is planned prior to surgery. This approach requires the joint efforts of surgeon and prosthodontist’l 2 The purpose of a preoperatively constructed obturator is to provide a prosthesis which can be inserted, with little modification, shortly after surgery. Such a prosthesis minimizes scar contracture and disfiguration, protects the wound from debris, and allows the patient to eat normally. Most important is the ability of the patient to speak intelligibly with family and friends.” Prosthetic rehabilitation of patients with maxillary defects is divided into three phases: ( 1) taking a presurgical impression and construction of a prosthesis approximating the anticipated defect, (2) postoperative modification of the prosthesis, with extension beyond and into the defect at the time of insertion, and (3) construction of a definitive prosthesis employing all the established principles of prosthodontics. CONSTRUCTION
OF PREOPERATIVE
OBTURATORS
Preoperatively constructed prostheses usually are made of heat-cured acrylic resin. Impressions of the dental arches are made with rubber base or alginate (irreversible hydrocolloid) materials. The anticipated surgical defect should be determined as closely as possible on the master cast by the surgeon (Fig. 1) . The course of prosthetic rehabilitation depends upon the number, location, and condition of teeth present after surgery and upon the size and location of the defect. The more natural teeth that can be retained, the more effective is rehabilitation. Wrought-wire clasps processed into the heat-curing resin provide sufficient retention at this time, regardless of whether the anticipated operative area is in the midline or the lateral, posterior, or anterior palate (Fig. 2). When the patient is edentulous, the problem of retention, weight, and balance Read
before
*Department
290
the American of Dentistry
Academy and
of Maxillofacial
Maxillofacial
Prosthetics.
Prosthetics,
Lake
Geneva,
Wis.
Volume Number
36 3
Pre- and postoperative
obturators
299
Fig. 1. (A) The outline of the defect in the left posterior palate. (B) Approximate outline of the defect involving the right maxilla. (C) The outline of a midpalatal defect. (D) An outline of a malignant melanoma of the anterior palate. (E) The outline of an approximate surgical defect in the left maxilla in an edentulous patient. (F) An outline of the right posterior palatal defect in an edentulous patient. of the prosthesis becomes more difficult to manage. Existing dentures may be modified to serve as a preoperative obturator. In the absence of dentures, a muscletrimmed mucostatic impression is made, and a denture base is processed on the master cast (Fig. 3). Artificial teeth are not provided at this stage. The mucous membrane is fragile and easily traumatized by the patient’s attempts to masticate with dentures. The presence of maxillary teeth or a portion of the maxillary arch simplifies the fabrication of an obturator base which can be modified to close the defect at the time of insertion. A total bilateral maxillectomy presents a problem. Preoperative preparation consists of the fabrication of a custom-made impression tray which will fit the border tissues better than a stock tray (Fig. 4). Construction of a complete denture using the preoperative cast as a guide should be deferred. This is especially important in patients who have never worn complete dentures. In prematurely providing them with complete denture prostheses, many unrealistic expectations may be created. IMMEDIATE
POSTOPERATIVE
The preoperative prosthesis, anatomy, becomes the immediate
OBTURATORS constructed obturator.
on a cast of the patient’s
intact
oral
J. Prosthet. Dent. September,
1976
Fig. 2. (A) Wax-up of a prosthesis for the left posterior palatal defect. (B) Wax-up of a prosthesis for the right palatal defect. (C) Wax-up of a prosthesis anticipating a large anterior palatal defect. No clasps were used. At the time of insertion, retention will be provided with resilient denture lining material.
Fig. 3. (A) A modification of the patient’s complete denture for an anticipated right palatal defect. (B) The denture base is intended for use as an immediate prosthesis. No teeth are attached at this stage.
A prosthesis which is retained by natural teeth is easy to insert immediately after partial maxillary resection, but a prosthesis which has to be sutured to place after a total or nearly total maxillectomy is impractical because irrigation of the wound, essential for healing, becomes difficult if not impossible. Miglani and Drane4 regard the presence of teeth on the unoperated side a prerequisite for an immediate obturator. Many surgeons prefer to pack the surgical site with surgical gauze for a few days before a prosthesis is inserted. Most preoperatively fabricated prostheses need modifications at the time of insertion. Previously attached clasps may have to be changed because the operation was
Volume Number
Fig.
36 3
4. An
impression
tray
for
Fig. 5. (A) A malignant melanoma tion of the tumor. (C) The tissue addition of a resilient denture lining mouth.
a patient
for
Pre-
and postoperative
whom
a total
maxillectomy
obturators
301
is anticipated.
of the anterior palate. (B) The surgical defect after surface of an immediate obturator after modification material. (D) The immediate obturator is in place
resecand in the
302
J. Prosthet. September,
Carl
Fig. 6. (A) A surgical defect operatively constructed prosthesis has been placed in the mouth.
involving the middle and right has been modified for insertion.
Fig. 7. (A) Left maxillary defect after removal of gauze denture lining material has been added to the denture base.
pack
anterior (C) The
and
Dent. 19X
palates. (B) A preimmediate prosthesis
irrigation.
(B) Resilient
more extensive than initially anticipated. The borders may need reduction or extension, and the material which obturates the defect must be added to the prosthesis. Resilient self-curing resin (Coe-soft*) is suitable for this purpose (Figs. 5 to 7). Excess resin is trimmed with a sharp hot scalpel. Tissue changes during the immediate postoperative period require that additional material be added until the defect is healed. TOTAL
BILATERAL
MAXILLECTOMY
Patients who are experienced denture wearers adjust to immediate obturation better than those who have never worn a removable prosthesis. Immediate obturation for patients who have experienced partial maxillary resection is relatively simple in comparison to that for the patient with bilateral total maxillectomy (Fig. 8). Because the extent of the defect cannot be accurately predicted before surgery, the only preparation that can be made is the fabrication of a custom-made impression tray from the preoperative cast. Extension of the tray with a long handle facilitates im“Coe
Manufacturing
Company,
Chicago,
Ill.
Pre-
Fig.
8. A surgical
Fig.
9. The
defect
involving
the entire
long handle
facilitates
insertion
Fig.
10. An impression
of a defect
left
hard
obturators
303
palate.
of the tray
by total
and postoperative
for the impression.
maxillectomy
made
in irreversible
hydrocolloid.
pressionmaking due to the contraction of the upper lip. Fortunately, in patients who have had total bilateral maxillectomies, the soft palate, or a good portion of it, remains intact. At the time of the first change of the surgical packing, the impression tray is trimmed and adjusted for easeof insertion (Fig. 9). It is also perforated for retention of the impression material. The surgical site is irrigated and cleaned of all mucus, and an impression of the total defect is made in alginate (irreversible hydrocolloid) (Fig. 10). Sometimes the oral stoma is constricted, and additional amounts of irreversible hydrocolloid may have to be injected with a syringe through an opening in the center of the tray and through the initial layer of the impression material. Retention of additional irreversible hydrocolloid is achieved by creating undercuts in the hardened impressionand by applying adhesive. The cast is poured, and a maxillary base, simulating palatal contour, is waxed over the space to be obturated. For closure of the mold, a lid is made. An estimated amount of medical-grade Silastic 382” or Silastic 399” is catalyzed and introduced *Dow
Corning
Corp.,
Midland,
Mich.
304
J. Prosthet. September,
Carl
Dent. 1976
Fig. 11. (A) The completed mold for fabrication of a hollow obturator. (‘B) The closed mold after introduction of catalyzed Silastic is rotated until the material is cured. (C) The mold is separated after curing of the Silastic. (D) The completed hollow obturator is ready for insertion.
into the mold, which is closed and rotated until the material has cured. The resulting obturator is lightweight and flexible (Fig. 11) . This initial prosthesis is easily tolerated, restores intelligible speech, and allows for the rernoval of the nasogastric feeding tube. The flexibility of the prosthesis provides for comfortable insertion over sensitive tissues and into undercuts (Fig. 12). The hollow Silastic obturator has the advantage of being easily constructed without the disadvantages of the spongy, disposable, silicone rubber obturator described by Toremalm,5 which in a short time becomes saturated with oral fluids. As the wound heals and the defect changes dimension, new impressions are made and new obturators constructed.
SUM MARY The prostheses and the distinction
described between
evolve from preoperative to immediate to transitional, them is not clearly defined. How long the temporary
Volume 36 Number
Pre-
3
Fig. 12. (A) The obturator is in place in the mouth.
can be collapsed
with
and postoperative
moderate
pressure.
(B)
obturators
The
hollow
305
obturator
stage should be maintained depends upon the rapidity of healing of the defect and the judgment of the prosthodontist. Usually, healing is complete 3 to 6 months following surgery, and a definitive obturator may then be constructed.G,7 Construction, modification, and insertion of preoperative and immediate postoperative obturators for patients after partial and total maxillectomies were discussed. The purpose of an immediate obturator is to shorten the recovery period of the patient and restore speech,deglutition, and appearance as soonas possibleafter surgery. References 1. 2. 3. 4. 5. 6. 7.
Bruno, S. A.: Prosthetic Treatment of Maxillofacial Patients, J. PROSTHET. DENT. 17: 497508, 1967. Lang, B. R., and Bruce, R. A.: Presurgical Maxillectomy Prosthesis, J. PROSTHET. DENT. 17: 613-619, 1967. Zarb, G. A,: The Maxillary Resection and Its Prosthetic Replacement, J. PROSTHET. DENT. 18: 268-281, 1967. Prosthesis and Its Role as a Healing Art, Miglani, D. C., and Drane, J. B.: Maxillofacial J. PKOSTHET. DENT. 9: 159-168, 1959. Toremalm, N. G.: A Disposable Obturator for Maxillary Defects, J. PK~STHET. DENT. 29: 94-96, 1973. Riley, C.: Maxillofacial Prosthetic Rehabilitation of Postoperative Cancer Patients, J. PROSTHET. DENT. 20: 352-360, 1968. Robinson, J. E.: Prosthetic Treatment After Surgical Removal of the Maxilla and Floor of the Orbit, J. PROSTHET. DENT. 13: 178-184, 1963. 666 ELM BUFFALO,
ST. N. Y. 14263