Clinical amnagement of edentulous maxillectomy pt/ implant dentistry course

CLINICAL MANAGEMENT OF EDENTULOUS
MAXILLECTOMY PATIENT
2
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS
• 1] Introduction
• 2] Surgical Enhancements
• 3] Phases Of Prosthetic Restoration
 Surgical Obturator Prosthesis
 Bone Screw Retention
 Suture Retention
 Circumzygomatic Wire Retention
 Use Of The Existing Maxillary Denture
• 4] Interim Obturator Prosthesis
• 5] Definitive Obturator Prosthesis
• 6] Lid Fabrication Of Hollow Obturator Prostheses
• 7] Troubleshooting The Obturator Prosthesis
 Leakage Into The Nose
 Hypernasal Speech
• 8] Conclusion
• 9] References
• 3www.indiandentalacademy.com

G.P.T-8
• maxillofacial prosthetics : the branch of
prosthodontics concerned with the restoration
and/or replacement of the stomatognathic
and craniofacial structures with prostheses
that may or may not be removed on a regular
or elective basis
4www.indiandentalacademy.com

Introduction
• Tumors of the hard palate, maxillary sinus, and sometimes the
buccal mucosa or nasal cavity require surgery called a
maxillectomy or maxillary resection. The hard palate is the
anatomic floor of the maxillary sinus.
• Depending on the extent of the tumor, maxillary resections can
be performed that do not violate the integrity of the hard
palate. Maintaining the hard palate however, is the exception
rather than the rule.

• Violation of the hard palate creates an anatomic defect that
allows the oral cavity, maxillary sinus, nasal cavity, and
nasopharynx to become one confluent chamber.
• Lack of anatomic boundaries creates disabilities in speech and
deglutition. Air, liquids, and food bolus escape from the oral
cavity to exit the nares, making adequate oral nutrition difficult
if not impossible.
• . Speech becomes unintelligible due to hyper nasality
distorting sounds that require impounding of air within the oral
cavity.

Surgical Enhancements
• Surgical enhancements have been suggested to prepare the
defect for optimal prosthetic rehabilitation
• Some procedures offer definite advantages; others have
minimal influence on prosthetic function and primarily add a
burden of time and perhaps morbidity to the surgical
procedure,

Maintain as much hard palate as possible
• Since the edentulous patient must rely on the remnant of the
hard palate for primary retention, support, and stability the
surgeon should be encouraged to resect only enough hard
palate to allow adequate tumor margins.
• The more ipsilateral premaxillary area that can be maintained,
the more of a tripoding prosthetic effect that can be achieved
• This adds, stability to the prosthesis, and the increased surface
area will enhance retention.

Quality of retention depends on
• Muscular control.
• Size of surgical cavity
• availability of tissue undercut around the cavity
• Direct and indirect retention provided by any remaining teeth.

Skin graft the cheek flap.
• In the classic maxillectomy the cheek is elevated away from
the maxillary bones, and the pterygoid muscles and the bones
are resected.
• This leaves a denuded surface on the entire cheek flap,
remnants of the pterygoid muscle bed, and soft palate
musculature originating form the pharyngeal wall
• If this area is allowed to heal by secondary intention, the
healing time will extend many weeks with a bleeding surface.
• Eventually the surface will be covered with respiratory
epithelium migrating from the nasal cavity and nasopharynx.
• This mucosa does not serve well as prosthesis-bearing tissue
and is easily abraded.

• . Respiratory epithelium will also add to the mucous
secretions that the patient must clean from the cavity
• . A split-thickness skin graft can be placed over these denuded
surfaces at the time of tumor surgery.
• This graft will be prosthesis bearing in 10 to 14 days and after
a few weeks of maturation can be aggressively cleaned and
approximated by the prosthesis

• . Due to differential contracture of the skin graft and the
mucosa of the oral cavity, a scar band will form along the
lateral cheek at the junction of the skin graft with the
remaining buccal mucosa, and in the pterygoid muscle area.
• It has often been stated this scar band will aid retention
because it is an anatomic undercut.

• This area can be quite mobile when the patient moves the
mandible, however, and the changes in contour must be
accommodated in the obturator impression.
• constant motion of this minimal undercut in the lateral cheek
usually makes this area of little use for retention.

• Many maxillofacial texts suggest that the placement of a skin
graft will decrease the contracture of the cheek flap
• . For practical purposes, one should view the skin graft as a
sound prosthetic bearing surface that will not be easily
abraded, does not secrete mucus, allows for vigorous cleaning
of the defect, and may aid in retention.

Remove the inferior turbinate
• . If the hard palate is resected to expose the nasal cavity, the
inferior turbinate is also exposed.
• If the tumor does not involve the nasal cavity, the inferior
turbinate will likely not be resected.
• Anatomically this structure is only millimeters above the cut
edge of the hard palate and covered with respiratory
epithelium.
• Maintaining the inferior turbinate will preclude extending the
medial wall of the obturator bulb into the nasal cavity

Skin graft the maxillary sinus walls.
• When tumor involves the hard palate with minimal
involvement of the maxillary sinus walls.
• The hard palate will be resected and most of the bony wall of
the sinus will remain intact.
• These walls can be prepared during surgery to allow the bony
undercuts to serve for retention or for vertical support to keep
the prosthesis from rotating into the defect during mastication

• The sinus walls are covered with respiratory mucosa, which
must be denuded and covered with a split-thickness skin graft.
• Grafting the sinus walls stops formation of polypoid tissue
and mucus generation within the sinus and allows the walls to
become load-bearing areas.

 Phases of Prosthetic Restoration

Surgical Obturator prosthesis
• Use of an immediate surgical obturator is less common for the
edentulous patient than the dentate patient because of the
seemingly invasive method of securing the prosthesis.
• Methods
• 1. palatal bone screw,
• 2.sutures into the surrounding mucosa,
• 3.andcircumzygomatic wires.

• Regardless of the method of securing the prosthesis, the
procedures needed to fabricate the surgical obturator are
identical
• Generally a auto polymerizing resin or heat cured resin is used
but not composite resins because of its brittle nature

Bone screw retention
• The palatal bone screw can be placed through a midpalate hole
predrilled through the acrylic resin baseplate in the midpalatal
at the anterior peak of the palatal vault.
• This position will allow placement of the screw into the vomer.
• The hole should be drilled from the palate to the intaglio
surface and angled posteriorly.

• . A 13 to 16 mm self-tapping screw should be used to ensure
enough length to pass through the denture and achieve
adequate bone retention.
• This bone screws are usually titanium or stainless steel and are
available in mandibular fracture armamentarium.
• A small plug of tissue conditioner or polyvinylsiloxane over
the head of the screw will keep the screw attached to the
denture in the event the patient dislodges the denture during
the postoperative period.
•

Suture retention
• In a previously irradiated patient, one might elect to use the
suture technique to avoid placing a bone screw in the
irradiated palate.
• 2-0 silk sutures can be passed through six to eight predrilled
holes in the lateral and anterior borders of the acrylic resin
baseplate.
• Each suture is secured with a knot against the denture flange in
the middle of the suture and each one tagged with a hemostat.
• The baseplate is then taken to the oral cavity and each suture
passed through the soft tissue and tied.

• It is not necessary to suture across the soft palate for adequate
retention and soft palate sutures are difficult to remove when
the patient is in the clinic
• . There will be slight prosthesis movement with this technique,
but the packing will be secured and the prosthesis will not
dislodge.

Circumzygomatic wire retention
• Wires are passed over the zygomatic arch and threaded
through two bilateral holes placed in the premolar area of the
baseplate flange.
• This technique is the most invasive and has greatest morbidity
when removing the wires in the clinical setting.
• It is not commonly used.

• The palatal bone screw offers the most stability of the three
options, The bone screw, sutures, and packing can be removed
with sedation,
• Syncopal attack is un avoidable if patient is sedated or not

Use of the existing maxillary denture
• Some texts suggest using the patient's existing denture for the
surgical obturartor and for the subsequent interim obturator
prosthesis,
•

Dis-advantages
• 1. The patient will expect it to be used throughout the entire
prosthetic period,
• 2. When the surgical defect involves approximately one half of
the hard palate, maintaining comfortable occlusion while
constantly reducing and relining the flanges of an unstable
obturator prosthesis is almost impossible.
• 3. If the maxi1lary denture is ill -fitting preoperatively, it will
be necessary to reline the denture prior to surgery

• As facial contracture occurs, the anterolateral border of the
denture will require significant reduction .
• It is not uncommon that the contracture is so great that the
anterior teeth are soon extended beyond the obturator
prosthesis periphery.
• The teeth on the surgical side often require facial reduction
and ultimate removal from the baseplate due to overextension.
• If the teeth are not reduced, the lip is too protruded and
unseats the prosthesis.

Interim Obturator Prosthesis
• Chairside impression of the surgical site 5 to 10 days after
surgery :
• The baseplate used for the surgical obturator can be relined
and modified to serve as the interim prosthesis
• The baseplate can be border molded and relined on the
remaining hard palate.

• After this is accomplished and the base is stable, the periphery
of the surgical detect is impressed.
• True-soft can be placed incrementally along the periphery of
the defect.
• Using this incremental shaping method creates a hollow, light
prosthesis

Patient movements, speech, and swallowing evaluation during
border molding
• The impression, of the surgical side requires that the patient
perform exaggerated head movements turning right to left with
the head level
• and then again with the neck flexed and extended.
• The mouth should be opened and closed and the mandible
moved laterally.
• The patient should also be asked to swallow.
• The clinician should maintain control of the impression
throughout the entire procedure by manually supporting the
tray

• Swallowing and head movements should always be made with
every addition of material.
• If the clinician does not use functional border molding, the
prosthesis will be less stable and the patient will experience
tissue irritation in a short time.

• The peripheries of the bulb portion will likely be 2 to 3 cm in
height. There is no need to add material to fill the entire sinus
space; it only adds weight to the prosthesis and offers little to
the border seal.

• To achieve border seal and adequate speech restoration , the
posterior border will be extended over the cut edge of the soft
palate to extend to the posterior aspect of the defect.

• the only speech sounds that are formed when air passes
through the nasal cavity are m, n, and ng,
• When air is obstructed from passing from the vocal cords out
the nose during the m, n, and ng sounds, hyponasal speech is
evident,
• This occurs frequently during the common cold when the nasal
passages become obstructed from edema or mucus.

• Hypernasal speech occurs due to loss of air from the oral
cavity into the nasal cavity.
• In the case of the maxillectomy patient, this loss of air occurs
because of an anatomic defect in the hard palate.
• Without the obturator, the loss of air into the nasal cavity is so
great that a patient's speech is Unintelligible

• Examining the peripheral surface of the obturator bulb and
ensuring peripheral tissue contact will correct hypernasal
speech in most instances
• Final analysis for appropriate speech is to listen for distinction
between the letters m and b.

• The patient should also say the Word beat then manually
occlude the nares and again say the word beat. If there is a
difference in Sound quality between the two test words,
hypernasality remains
• If the speech is still slightly hypernasal, a slight addition of a
light or less viscous mix of material at the soft palate junction
should be attempted.

• The fit may also be tested while drinking water with the head
upright.
• The liquid should pass easily without the patient experiencing
reflux. into the nose or sinus cavity
• Patients may not be able to control liquids in the oral cavity at
the early interim phase, and drooling due to postoperative
swelling and anesthesia of the upper lip on the surgical side
from loss of the ipsilateral anterior-superior alveolar nerve is
often observed..

Insertion Of the interim prosthesis
• After the tissue conditioner impression the entire tray and
impression can be used as a wax pattern.
• It can be flasked, completely removed from the stone mold,
and the mold packed. auto polymerizing or heat-processed
resin
• prosthesis may be hollowed further to decrease weight

• The goal is to have a well fitting light weight prosthesis.
• The prosthesis should be delivered within .a few hours of
making the impression,

• The patient should be instructed not to leave the prosthesis out
for more time than is needed to clean it or the surgical site,
• At delivery of the prosthesis, the intaglio surface of the
remaining hard-palate area and cut edge of the hard-palate
area should be checked with pressure-indicating paste,

• The tissue conditioner is placed and functional impression is
made.
• Patients must regularly use a powdered adhesive to retain the
prosthesis, so changing the tissue conditioner to acrylic resin
in the interim prosthesis allows use of the adhesive on the hard
palate area.

Revisions
• Every 10 to 14 days the next 2 months, the prosthesis will
require revisions due to tissue changes will be happening in
the surgical site.

• Patients should be advised that adjustments are needed if pain
or bleeding occurs or if the prosthesis will not seat. However,
they should be reassured that increased hypernasality and nasal
reflux is primarily a nuisance; there will be no physical or
medical complications .

• The prosthesis should be evaluated to determine if the
prosthesis will seat completely and not move with jaw and
head movements.
• If movement of the mandible creates movement of the
prosthesis after border reduction, more material should be
reduced in the overextended areas.
• Some visits may require removal of considerable bulk of
existing material due to tissue contraction

• When the' surgical site becomes more stable, then fewer major
adjustments needed

• DEFINITIVE OBTURATOR PROSTHESIS

Preliminary impression
• The preliminary impression should offer maximum extension
within the surgical site.
• When maxillary surgical cavity is, large, regardless of the
tissue or bony undercuts within the cavity, it is not necessary
to block the cavity with gauze prior to the impression.
• Blocking of the defect adds time and patient discomfort, and
the material often shifts during the impression,

• It is important to block palatal fistulas that open into intact
maxillary sinus or nasal cavities.
• Impression material can mushroom into the intact cavities and
tear from the impression during removal of the tray.
• This is most likely to occur with alginate impression materials

Final impression
• The custom acrylic resin tray should extend 2 to 3 mm into the
cavity.
• It should extend beyond the scar band and superior to the cut
edge of the hard and soft palates, leaving space for 5 to 8 mm
of compound to add to the surgical site.
• There may be cast undercuts within the surgical cavities which
must be blocked out

• The remaining palate should be impressed first. The borders
and cut edge of the palate should be border molded and then
impressed with a definitive impression material.
• Performing this initial step creates a stable tray for the addition
of the cavity impression Compound ,this should be added
incrementally to the periphery of the surgical side

• The cavity is convex from inferior to superior. At the height of
the convexity, the cavity walls begin to turn toward the center
of the cavity.
• At this point the superior aspect of the prosthesis bulb should
terminate. Superior extension beyond the greatest convexity
adds weight to the prosthesis but adds no retention.

• It should be border moulded with impression wax with
incremental addition.
• A posterior palatal seal can also be placed.

Jaw relationship records
• Maxillectomy patients have loss of facial contour on the
surgical side proportional to the amount of bone that is
resected
• Infrastructure maxillectomies have minimal facial
disfigurement.

• if the floor of the orbit is resected, the globe is also displaced.
• Often the maxillary resection crosses the midline, and if the
nasal spine is resected, the nose· is unsupported There is a
desire to use the obturator prosthesis to support the facial
tissues.
• Unfortunately these tissues are fibrotic and can only be
minimally displaced by the prosthesis border.
• Trying to push the contracted tissues into their preoperative
position can cause overextension of the prosthesis borders.
• This creates considerable dislodging force on the prosthesis

• Attempting to maintain the dentition in its normal position will
cause dislodging forces.
• Normal prosthetic landmarks cannot be used to position the
dentition.
• Processed record bases are ideal for jaw relationship records
for the maxillofacial prosthetic patient. Because of the missing
structures and unusual reconstructions, prosthetic retention and
stability are greatly compromised.

• Blocking out routine undercuts and the undercuts within the
surgical area adds to the instability of the conventional record
base.
• Blocking out these undercuts will result in a trial base that
does not extend to the periphery or the defect
• This trial base makes no Contact with the surgical side of the
face.
• There will be no retention of the prosthesis except for the
adhesive on the hard palate.
• The prosthesis will fall into the oral cavity when attempting to
establish the occlusal plane and rotate into the defect when
attempting the centric relation record.

• Without maximum extension of the record one cannot
determine the optimal position of the teeth to support the lip
and cheek.
• It is quite common that retention becomes worse as the wax
rim is added in its preoperative position
• A Compromise must be reached between tissue support and
prosthesis retention.

• The wax up of the processed obturator base can be solid in the
area of the bulb and hollowed before jaw relationship records.
• The bulb can be processed hollow by waxing the external
periphery of the bulb portion several millimeters thick and
pouring a stone core through the back of the master cast or
creating a stone core in the cope of the cast, in which case
there will be a hole in the palate after processing

• The jaw relationship appointment should progress as a routine
denture appointment.
• At the try-in appointment, all records are verified
• For the patient edentulous in both arches, a cuspless tooth
allows freedom to create a negative horizontal overlap on the
surgical side of the arch without having to create it on the
nonsurgical side

• The final palatal contours should be evaluated at the try-in
appointment. It is likely that the contours are not symmetric
because they were created arbitrarily on the surgical side
• The vault may be too high or too flat.
• Finally, pressure indicating paste can be streaked across the
palate from right to left. ‘
• Seat the prosthesis and have the patient swallow and count.
• Where the tongue makes contact with the palate, the contact
can be read in the pressure-indicating paste.
• Heavy areas should be reduced and the entire palate checked
again.
• Wax may need to be added in the palate where there is no
contact.

• If the patient lisps, air is escaping laterally from the tongue.
• Because the teeth are positioned palatally due to facial
contracture, they may impinge on the tongue
• Prosthesis can be processed at a lower temperature than that
used to process the base.
• The clinical significant of the distortion created with multiple
processing of the resin is negligible

• The clinician may place a lid on the obturator prosthesis or
may insert the prosthesis with the bulb open for several days
until 'all of the adjustments are performed.

Insertion
• At insertion, the prosthesis should be evaluated for pressure
areas as described for interim prostheses, including pressure-
indicating paste for the residual palate

Instructions
• Patients should continue to wear the maxillary prosthesis or
the interim prosthesis at night because sinus secretions and
saliva cannot be managed at night without it.
• If the prosthesis is removed overnight, the soft tissue periphery
of the surgical site will change due to tissue edema,
• and patients will report that it often requires an hour of
wearing the prosthesis in the morning before it fully seats into
position

• Mastication is also often difficult for patients with large
surgical defects and must be accomplished on the nonsurgery
side of the arch.

Lid fabrication of hollow obturator prostheses
• It will difficult for the patient to clean the inside area if the
bulb is left open and if it is not smooth
• Placing a lid on the bulb allows hollowing of the alveolar area
and into any unusual lateral undercuts

Other methods

• TROUBLESHOOTING THE OBTURATOR
PROSTHESIS

Leakage into the Nose
• Many patients eventually complain of nasal reflux and
hypernasal speech caused by escape of air.
• This may occur several months or even a few years after
insertion of the prosthesis.
• In most cases, continued fibrosis in the tissues bordering the
prosthesis is the cause.

• The prosthesis should be disclosed with a tissue-conditioning
material, and the patient should perform functional movement.
• If swallowing and speech improve, the disclosing material
should be evaluated for the area where the tissue conditioner is
thickest.
• The speech can be tested by evaluating the m and b sounds and
the word. beat as described previously,

• The tissue condition material should be checked to see where
this reline is required and this conditioning material is replaced
with reline material later.

Hypernasal Speech
• Patients may complain of hypernasal speech at follow-up visits
• This is because of the continued fibrosis through years and the
dysfunctions of the soft palate and pharyngeal closure
mechanism.
• For this a pharyngeal obturator must be constructed where a
small amount of soft palate is also resected
• . Some patients are unable to seat the prosthesis because of
its unusual path of insertion.
• If this procedure is unsuccessful, the hyper nasal speech
cannot be prosthetically corrected

conclusion
• The edentulous obturator patient has greater
problems in retention, speech and mastication
than the conventional maxillary denture patient
• . Finally, no matter what additional retentive
elements may be employed sound prosthodontic
principles of using bony undercuts achieving
maximum tissue coverage without overextension,
and placing the dentition in harmony with the
functional tissue are paramount for prosthetic
success when treating the edentulous
maxillectomy patient.

• NEED IS MOTHER OF ALL INVENTIONS

References
• 1] CHELIAN, multi disciplinary practice
• 2] JOHN BUMER maxillo facial rehabilitation
• 3] THOMAS. D .TAYLOR . clinical maxillo facial
prosthetics
• 4] Paprocki Gj, Jocob RF, Kramer DC, seal
integrity of hollow- bulb obturator. Int j
prosthodont 1990,-3,- 457

References
• 1] CHELIAN, multi disciplinary practice
• 2] JOHN BUMER maxillo facial rehabilitation
• 3] THOMAS. D .TAYLOR . clinical maxillo facial
prosthetics
• 4] Paprocki Gj, Jocob RF, Kramer DC, seal
integrity of hollow- bulb obturator. Int j
prosthodont 1990,-3,- 457
98
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