Abstract
After ablative surgery, especially a total maxillectomy, an obturator is commonly used as a method of reconstruction. However, the loss of a palatal denture-bearing area and vestibular retentive undercuts leaves an anatomically deficient base on which to construct the definitive prosthesis. As a result, retention and stability is compromised. A solution to the retention problem is to construct an obturator that engages undercuts and scar bands. Engagement of all undercuts can lead to a prosthesis that is too cumbersome and difficult to insert, especially in a patient with scars after radiation. In this article, a technique for creating a 2-piece magnetic obturator that engages the nasal scar band is described.
The goal of maxillofacial prosthetics is to restore function and esthetics to patients with maxillofacial defects. Some maxillary defects are a result of the surgical treatment of neoplasms. Any palatal defects, no matter how small, can cause difficulties in speech, mastication, and esthetics. Obturators aid in recreating facial esthetics by physically supporting the cheeks and lips. Ideally, a patient with an acquired maxillary defect should be provided with an obturator that is comfortable, restores speech and mastication, and has acceptable esthetics. For a patient with a maxillary defect, the clinician occasionally needs to modify or even violate some of the basic principles of prosthesis design. If the patient has a large defect, fabricating an adequately large obturator may not be possible because the patient is unable to insert the obturator through a small oral opening. If necessary, the prosthesis can be divided into 2 or more parts.
In designing a sectional prosthesis, function and the convenience of insertion and removal of a large prosthesis needs to be considered. The location of the contacting surfaces of the prosthesis sections should be determined by considering ease of fabrication and insertion. The defect undercut should not prevent the insertion of any section. Also, the division of the prosthesis into 2 parts should not compromise esthetics. Sectional prostheses may also be considered for patients with severe alveolar undercuts that prevent insertion and removal. A maxillofacial prosthesis should have a straightforward design and be easily manipulated by the patient.
Clinical report
A 67-year-old man with a history of a moderately differentiated invasive squamous cell carcinoma (SCC) of the nasal cavity involving the left maxillary sinus and soft palate is presented. He reported being a former smoker: 2 packs per day for 50 years (100 pack years). In October 2011, a clinical examination revealed a 3-cm exophytic lesion involving the hard palate that extended into the nasal cavity and involved the anterior and inferior nasal septum. A biopsy the next month showed moderately differentiated squamous cell carcinoma. A subsequent positron emission tomography (PET) scan revealed a hypermetabolic mass centered along the anterior hard palate and extending cephalad to the inferior nasal septum with no hypermetabolic activity in the neck or chest. In February 2012, the patient completed 37 fractions of radiation at an outside hospital (6700 cGy).
In October 2012, the patient complained of persistent drainage from the nasal cavity, pain in the maxillary gingiva, and a foul smell, crusting, and occasional blood from the nasal cavity. A biopsy was performed and was positive for invasive and in situ SCC, moderately differentiated. In November 2012, a computed tomography (CT) scan showed a 9-mm nodule along the inferior nasal septum. The following month, the patient underwent a total maxillectomy. When this patient presented to our practice in July 2014, he had difficulty with speech and deglutition. His remaining tuberosities consisted of soft tissue only and were incapable of supporting his current obturator prosthesis. The prosthesis was lacking in retention and stability ( Fig. 1 ).
The patient’s maxillary defect included a scar band behind his nose that, if engaged, conflicted with the path of insertion and withdrawal. A 2-piece sectional prosthesis was designed ( Fig. 2 ). First, an impression was made with a combination of polyvinyl siloxane impression material (Henry Schein) and irreversible hydrocolloid (Jeltrate; Dentsply Sirona). The 2 parts of this impression were made separately. The polyvinyl siloxane was placed in the anterior undercut and, once polymerized, was trimmed, keyed, and replaced in position. The irreversible hydrocolloid impression was then made, and the 2 sections were luted together with baseplate wax ( Fig. 3 ). The impression was then poured in Type III gypsum (Denstone Labstone Golden; Kulzer GmbH) ( Fig. 4 ).
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