Implant-Supported Prosthetic Rehabilitation of a Patient With Squamous Cell Carcinoma: A Case Report.

Patients who have undergone maxillary resection procedures are rehabilitated with dental obturators or microvascular reconstruction. This case report describes implant-supported prosthetic rehabilitation of a patient who underwent maxillary resection because of squamous cell carcinoma. After maxillectomy surgery, the patient was rehabilitated using a surgical obturator for 1 week, followed by an interim obturator until the surgical field was completely healed. For definitive prosthesis, different treatment options were presented from which the patient selected an implant-supported maxillofacial prosthesis and a removable mandibular partial prosthesis. Under general anesthesia, 2 zygomatic implants and 4 conventional implants to the posterior maxilla were inserted. After a healing period, the bar-retained maxillofacial prosthesis and removable mandibular partial denture were fabricated. The patient was satisfied regarding function, esthetics, speech, and swallowing. No problems, except slight discoloration of the prosthesis, were noted at the 6-month follow-up. Implant-supported maxillofacial prostheses are a valuable treatment option to improve quality of life after maxillary resection.

The effect of "xanthan gum-based fluid thickener" on hydration, swallowing functions and nutritional status in total maxillectomy patients.

PURPOSE: Swallowing functions are affected after total maxillectomy operations and adjuvant chemoradiotherapy. The purpose of our study is to assess the role of xanthan gum based thickening agents on swallowing and hydration of maxillectomy patients on a randomized controlled fashion. METHODS: 12 of the 22 patients diagnosed with maxillary carcinoma and planned to undergo total maxillectomy was identified as study group and 10 of them were identified as control group. The study group used "xantham based liquid thickener" for liquid foods up to 3 months postoperatively and the control group did not use. Dysphagia-related quality of life, bioimpedance analysis, EAT-10 scores, swallowing functions were evaluated both preoperative and postoperative period. RESULTS: The mean age of the study group was 56 ± 9.87, and 41.6% were women. The mean age of control group was 60 ± 15.63, and 50% were women. Postoperative EAT-10 scores were statistically significant higher than preoperative scores in both groups (p < 0.05). In both of the study and control groups, a statistically significant reduction in dysphagia related quality of life was detected postoperatively (p < 0.05). Intracellular water, extracellular water and total body water detected statistically significant higher in study group at postoperative month three. CONCLUSION: Swallowing functions are affected due to total maxillectomy and radiotherapy. With this study, it has been shown that, total maxillectomy and radiotherapy reduce dysphagia-related quality of life. Swallowing dysfunction and dehydration has been shown to affect total maxillectomy patients. Using of 'xanthan gum-based fluid thickener' helps to maintain intracellular water, extracellular water, and total body water.

Obturators versus flaps after maxillary oncological ablation: A systematic review and best evidence synthesis.

Maxillary defects can be resolved by prosthetic obturation, autologous tissue reconstruction, or a combination of both. However, there is still controversy in the selection of the optimal approach. Therefore, the aim of this study was to systematically review evidences comparing the performance of obturators and flaps in patients after maxillary oncological ablation. Both electronic and manual searching approaches were conducted to identify eligible evidence. Two reviewers independently assessed the risk of bias. In addition, the same reviewers independently extracted the data. Meta-analyses were performed using Revman 5.3, and best evidence synthesis was performed. Sixteen studies were included and a total of 528 participants were analyzed. All studies were assessed at low quality. Results of this meta-analysis showed weak evidence in the difference between obturators and flaps on the outcome regarding word intelligibility (P = 0.004) and masticatory efficiency (P = 0.002). However, no differences were detected regarding speech intelligibility and nasalance. All studies were compiled into the best evidence synthesis. The sum of 31 evidences was considered. Twelve evidences were evaluated at a moderate level, such as speech, mastication, pain, salivation, taste sensations, and mouth opening. Except the outcomes of word intelligibility, masticatory efficiency, and mouth pain, other moderate evidences showed no difference between obturators and flaps. In conclusion, both obturators and flaps might be effective in patients' rehabilitation functions after maxillary ablation. However, some advantages were observed when using surgical reconstruction over prosthetic rehabilitation. Additional high-quality studies are needed to provide more solid evidence before applying these results into clinical practice.

Preschool and School Phases of Postmaxillectomy Prosthetic Rehabilitation in a Child: A Clinical Report.

This report describes the postmaxillectomy prosthetic rehabilitation of a child with maxillary chondrosarcoma over an 8-year period. Specifically, it (1) describes the planning and rehabilitation procedures carried out during the period from before the operation to the time when the patient started elementary school and (2) reports the results of evaluations of the patient's oral and psychosocial function conducted during the school phase. The prosthetic treatment plan was separated into two phases (the preschool and school phases) and was started prior to surgery, when an immediate surgical obturator was designed by the surgeons. After the operation, it was considered important to provide the patient and her mother with training regarding how the defect should be cleaned, trismus prevention, and how the prosthesis should be fitted. In addition, esthetic improvements and the ability to speak clearly were also targeted during treatment planning. After surgery, obturators were fabricated in a conventional manner and fitted at the ages of 2, 4, 6, 8, and 10 years. The patient's oral function during the use of the obturators was evaluated objectively. Marked improvements in oral function were seen during both treatment phases. The patient's ability to perform psychosocial functions at school also improved during the use of the obturators.

An Alternative Prosthetic Approach for Rehabilitation of Two Edentulous Maxillectomy Patients: Clinical Report.

Obturator prosthesis is a common treatment method for maxillectomy patients for maintaining their oronasal separation and resuming their social lives. After tumor resection, the remaining anatomical structures have a significant effect on prosthesis retention. The present study describes the rehabilitation of two maxillectomy patients after cancer surgery using a prosthesis consisting of a denture and a special retentive obturator that is positioned in the anatomical undercuts of the nasal cavity. These patients have undergone total and subtotal maxillectomy surgery after the diagnosis of squamous cell carcinoma. The systemic and local health status of the total maxillectomy patient was not suitable for zygomatic implant surgery. Only one osseointegrated dental implant was placed into the left maxillary tuberosity area in the subtotal maxillectomy patient. In addition, the quality, vertical height, and horizontal width of the remaining bone structures in the maxilla limited the use of osseointegrated dental implants. Mechanical prosthesis retention was provided using a multiunit retentive mechanism composed of an orthodontic forsus fatigue resistant device (OFFRD), two Herbst appliances, and an acrylic piece associated with healthy keratinized mucosa. The OFFRD could easily apply a consistent force and push the acrylic pieces toward the retentive undercut under the control of the two Herbst appliances. Two OFFRD units in different directions were designed for the total maxillectomy patient, while only one OFFRD unit was placed on the opposite side of the osseointegrated implant in the subtotal maxillectomy patient. A sufficient retention was obtained for both patients. The patients were satisfied, and no major complications were observed in periodic controls.

[Surgical reconstruction of maxillary defects using a computer-assisted techniques].

The maxilla is the most important bony support of the mid-face skeleton and is critical for both esthetics and function. Maxillary defects, resulting from tumor resection, can cause severe functional and cosmetic deformities. Furthermore, maxillary reconstruction presents a great challenge for oral and maxillofacial surgeons. Nowadays, vascularized composite bone flap transfer has been widely used for functional maxillary reconstruction. In the last decade, we have performed a comprehensive research on functional maxillary reconstruction with free fibula flap and reported excellent functional and acceptable esthetic results. However, this experience based clinical procedure still remainssome problems in accuracy and efficiency. In recent years, computer assisted techniques are now widely used in oral and maxillofacial surgery. We have performed a series of study on maxillary reconstruction with computer assisted techniques. The computer assisted techniques used for maxillary reconstruction mainly include: (1) Three dimensional (3D) reconstruction and tumor mapping: providing a 3D view of maxillary tumor and adjacent structures and helping to make the diagnosis of maxillary tumor accurate and objective; (2) Virtual planning: simulating tumor resection and maxillectomy as well as fibula reconstruction on the computer, so that to make an ideal surgical plan; (3) 3D printing: producing a 3D stereo model for prebending individualized titanium mesh and also providing template or cutting guide for the surgery; (4) Surgical navigation: the bridge between virtual plan and real surgery, confirming the virtual plan during the surgery and guarantee the accuracy; (5) Computer assisted analyzing and evaluating: making a quantitative and objective of the final result and evaluating the outcome. We also performed a series of studies to evaluate the application of computer assisted techniques used for maxillary reconstruction, including: (1) 3D tumor mapping technique for accurate diagnosis and treatment of maxillary tumor; (2) Maxillary reconstruction with free fibula flap used computer assisted techniques; (3) Computer assisted orbital floor reconstruction after maxillectomy. The results suggested that computer assisted techniques could significantly improve the clinical outcome of maxillary reconstruction.

Implant-supported and magnet-retained oral-nasal combination prosthesis in a patient with a total rhinectomy and partial maxillectomy due to cancer: A clinical report.

This clinical report describes the fabrication of an implant-supported and magnet-retained combination oral-nasal prosthesis for a patient with a midline midfacial defect. The patient had undergone a total rhinectomy and partial maxillectomy as part of his cancer treatment. The nasal prosthesis was retained on the face by a magnet attached to the implant-supported maxillary denture, resulting in improved appearance and the recovery of speech, mastication, and swallowing functions.

Function of obturator prosthesis after maxillectomy and prosthetic obturator rehabilitation / Função da prótese obturadora após maxilectomia e reabilitação protética obturadora

ABSTRACT INTRODUCTION: Maxillary defects are usually rehabilitated by a prosthetic obturator. OBJECTIVE: This study aimed to evaluate the functioning of obturators prosthesis in patients with unilateral defects after maxillectomy. METHODS: Of 49 patients, 28 underwent to maxillectomy as a result of tumor ablative surgery, and acquired unilateral maxillary defects. Evaluation of the function was performed by applying the Obturator Functional Scale (OFS). RESULTS: From a total of 49 patients, 28 were treated as follows: 9 with a conventional retained obturator prosthesis (COP), 11 (39%) with an enhanced retentive obturator prosthesis with stud attachment (POP) and 8 (28%) with an enhanced retentive obturator prosthesis with magnetic attachment (POM). The mean OFS score was 80. Scores on functions of speech, swallowing and chewing reached statistical significances (p < 0.05) among these three subgroups. Comparing COP and MOP groups, the scores of OFS in the domains of "Speech-ability to speak in public" and "Swallowing-leakage with liquids" were significantly higher in AOP group. Comparing COP group, the scores of OFS in "Swallowing-leakage with solid" and "Chewing/eating" domains were increased significantly (p < 0.05) both in MOP and AOP groups. CONCLUSION: Obturator prosthesis improves oral function of patients after maxillary defects; the retention of the obturator prosthesis enhanced by the addition of attachments showed more benefits in oral function.

RESUMO INTRODUÇÃO: Em geral, os defeitos da maxila são reabilitados por uma prótese obturadora. OBJETIVO: O estudo avaliou o funcionamento da prótese obturadora em pacientes com defeitos unilaterais após maxilectomia. MÉTODO: De 49 pacientes, 28 foram submetidos a maxilectomia como cirurgia de ablação tumoral e tiveram como sequela defeitos maxilares unilaterais. A avaliação do funcionamento foi efetuada pela aplicação da Escala Funcional do Obturador (EFO). RESULTADOS: De um total de 49 pacientes, 28 foram tratados da seguinte forma: nove com prótese obturadora retentiva convencional (POC), 11 (39%) com prótese obturadora retentiva com fixação por pino (POP) e oito (28%) com prótese obturadora retentiva com fixação magnética (POM). O escore médio na EFO foi de 80. Os escores para funções da fala, deglutição e mastigação alcançaram significância estatística (p < 0,05) entre os três subgrupos. Na comparação entre os grupos POC e POM, os escores da EFO nos domínios da "Fala-capacidade de discursar em público" e "Deglutição-vazamento de líquidos" foram significativamente mais altos no grupo POP. Na comparação com o grupo POC, os escores da EFO nos domínios de "Deglutição-vazamento com sólido" e "Mastigação/ingestão" estavam significativamente aumentados (p < 0,05) nos grupos POM e POP. CONCLUSÃO: A prótese obturadora melhorou o funcionamento oral de pacientes com defeitos maxilares; a retenção da prótese obturadora reforçada pela adição de dispositivos de fixação demonstrou maiores benefícios na função oral.

Prosthetic Rehabilitation of Patients After Surgical Treatment of Maxillary Tumors with Respect to Upper Airway Protection.

As a consequence of surgical treatment of maxillary tumors, a connection between oral and nasal cavities is formed, which leads to serious functional disorders, manifested by inability to normally ingest food, proper speech articulation, and to respiratory route disorders and upper airway inflammation. These morphological and functional disorders are intensified by adjunctive radio- or chemotherapy. The aim of this paper is to present different possible methods of rehabilitation, including application of interim obturators and individually planned prosthetic restorations to improve respiratory efficiency in patients after extensive maxillary resections. In the course of prosthetic treatment, cooperation with the laryngologist to consider every aspect of chronic paranasal sinusitis, accompanied by concurrent inflammation of oral, nasal, or laryngeal mucous membranes, was of paramount importance. Based on the quality of life questionnaire, used in this study, evident improvement in the masticatory efficiency, speech articulation, and respiration was observed. Particularly good effects were obtained in edentulous patients, in whom implant-prosthetic treatment was possible to apply. Comprehensive and multidisciplinary care of postoperative patients greatly contributes to their better quality of life and facilitates their return to prior living conditions, as well as to occupational and family lives.

Function of obturator prosthesis after maxillectomy and prosthetic obturator rehabilitation.

INTRODUCTION: Maxillary defects are usually rehabilitated by a prosthetic obturator. OBJECTIVE: This study aimed to evaluate the functioning of obturators prosthesis in patients with unilateral defects after maxillectomy. METHODS: Of 49 patients, 28 underwent to maxillectomy as a result of tumor ablative surgery, and acquired unilateral maxillary defects. Evaluation of the function was performed by applying the Obturator Functional Scale (OFS). RESULTS: From a total of 49 patients, 28 were treated as follows: 9 with a conventional retained obturator prosthesis (COP), 11 (39%) with an enhanced retentive obturator prosthesis with stud attachment (POP) and 8 (28%) with an enhanced retentive obturator prosthesis with magnetic attachment (POM). The mean OFS score was 80. Scores on functions of speech, swallowing and chewing reached statistical significances (p<0.05) among these three subgroups. Comparing COP and MOP groups, the scores of OFS in the domains of "Speech-ability to speak in public" and "Swallowing-leakage with liquids" were significantly higher in AOP group. Comparing COP group, the scores of OFS in "Swallowing-leakage with solid" and "Chewing/eating" domains were increased significantly (p<0.05) both in MOP and AOP groups. CONCLUSION: Obturator prosthesis improves oral function of patients after maxillary defects; the retention of the obturator prosthesis enhanced by the addition of attachments showed more benefits in oral function.

Evaluation of Highly Porous Dental Implants in Postablative Oral and Maxillofacial Cancer Patients: A Prospective Pilot Clinical Case Series Report.

PURPOSE: The aim of this study was to evaluate the clinical efficacy of new porous tantalum trabecular metal (PTTM)-enhanced titanium dental implants used for the prosthodontic rehabilitation of postablative cancer patients. First-year interim results of a prospective clinical case series are presented. MATERIALS AND METHODS: A total of 25 PTTM-enhanced titanium implants were placed in both maxillas and mandibles of 6 patients, who met specific inclusion criteria. Resonance frequency analysis was conducted, and implant stability was recorded in Implant Stability Quotient (ISQ) values at implant placement and after 2, 4, 6, and 12 months of functional loading. Bone levels were calculated by digitally measuring the distance from the implant shoulder to the first bone-to-implant on periapical radiographs taken at surgery and after 2, 4, 6, and 12 months of functioning. RESULTS: Cumulative implant survival was 100% (n = 25/25). At implant placement and the 2-, 4-, 6- and 12-month monitoring appointments, mean ISQ values were 72.14 ± 5.61 (range = 50-81), 64.39 ± 8.12 (range = 44-74), 74.26 ± 7.14 (range = 44-74), 76.84 ± 7.65 (range = 60-83), and 78.13 ± 4.14 (range = 64-84), respectively, and mean crestal marginal bone loss was 0.19 ± 0.25, 0.22 ± 0.4, 0.3 ± 0.46, and 0.57 ± 0.62 mm, respectively. CONCLUSIONS: PTTM-enhanced dental implants were clinically effective in the prosthetic rehabilitation of postoncological patients. Larger long-term follow-up studies will help to evaluate clinical efficacy of PTTM dental implants.

Rehabilitation of maxillectomy defects with obturator prostheses fabricated using computer-aided design and rapid prototyping: a pilot study.

PURPOSE: To establish an alternative method to design and fabricate an obturator prosthesis within the maxillectomy defect using a computer-aided design (CAD) and rapid prototyping (RP) technique and to evaluate the functional results of this technique. MATERIALS AND METHODS: Eleven patients with acquired maxillary defects resulting from head and neck cancers were treated using a protocol based on three-dimensional (3D) reconstruction, CAD, and RP technologies to fabricate obturator prostheses. To evaluate the quality of the obturator prostheses and the patients' satisfaction, the Obturator Functioning Scale (OFS) of the Memorial Sloan-Kettering Cancer Center was applied. RESULTS: Each patient received an individualized obturator that exactly matched the static shape and fit of the defect. Clinical modifications were required to improve border contours. The patients showed good results in all fields of functional outcomes and social acceptance. The OFS scores were comparable with those reported in other studies using traditional maxillectomy impression methods. CONCLUSIONS: This study combined CAD with RP technology to explore an alternative and feasible method for manufacturing individualized obturators for patients after maxillary resection. It has shown significant clinical value, especially for use in developing countries.

Comparison of obturator prosthesis fabricated using different techniques and its effect on the management of a hemipalatomaxillectomy patient.

Odontogenic tumours involving the maxilla or mandible are usually treated with surgical resection. To prevent recurrence, extensive surgical intervention might be carried out leaving the patient with anatomical defects. However, rehabilitation of such patients with an obturator can improve function, facial form and social acceptance. In this case, we have evaluated the different designs and techniques of fabrication of an obturator prosthesis used for the rehabilitation of a hemipalatomaxillectomy patient. A 40-year-old man presented with a loose fitting obturator prosthesis. He had undergone hemipalatomaxillectomy for the treatment of an ameloblastoma 2 years earlier and had been using an obturator prosthesis since then. Hollow-bulb obturator prostheses were fabricated using two different methods, the lost salt and open lid techniques. The obturator prosthesis fabricated with the lost salt technique weighed less than the patient's old obturator. But the obturator fabricated using the open lid technique did not only considerably reduce the weight of the prosthesis but also improved health, function, aesthetics, phonetics and quality of life in this hemipalatomaxillectomy patient.

Measurement of voice onset time in maxillectomy patients.

Objective speech evaluation using acoustic measurement is needed for the proper rehabilitation of maxillectomy patients. For digital evaluation of consonants, measurement of voice onset time is one option. However, voice onset time has not been measured in maxillectomy patients as their consonant sound spectra exhibit unique characteristics that make the measurement of voice onset time challenging. In this study, we established criteria for measuring voice onset time in maxillectomy patients for objective speech evaluation. We examined voice onset time for /ka/ and /ta/ in 13 maxillectomy patients by calculating the number of valid measurements of voice onset time out of three trials for each syllable. Wilcoxon's signed rank test showed that voice onset time measurements were more successful for /ka/ and /ta/ when a prosthesis was used (Z = -2.232, P = 0.026 and Z = -2.401, P = 0.016, resp.) than when a prosthesis was not used. These results indicate a prosthesis affected voice onset measurement in these patients. Although more research in this area is needed, measurement of voice onset time has the potential to be used to evaluate consonant production in maxillectomy patients wearing a prosthesis.

Fabrication of an immediate surgical obturator for a patient with resection of the maxillary antrum and bony orbital floor.

An immediate surgical obturator is necessary for maxillectomy procedures to minimize functional disabilities in speech, swallowing, and egress of food and liquid into the surgical defect. Sometimes the extent of the tumor may be such that it may even require the removal of the maxillary sinus along with resection of the orbital floor. The resected orbital floor can be surgically reconstructed with autogenous soft and/or hard tissues or with alloplastic materials. This clinical report highlights one such situation where the surgical resection of the maxilla and the orbital floor were rehabilitated with an immediate surgical obturator extending to the orbital floor to support the visual apparatus.

One step polymerizing technique for fabricating a hollow obturator.

PURPOSE: Although a closed hollow obturator is often applied to post maxillectomy patients, it has a few problems such as complexity of fabrication and water leakage to inside. A one step curing technique to fabricate a closed hollow obturator by constructing a small hollow bulb made by two thermoplastic resin sheets is described in the present report. METHODS: In the one step curing technique, after dewaxing the wax denture fabricated conventionally, one size smaller hollow body was fabricated with two thermoplastic resin sheets and set into the investment mold as a core. Then the circumferential part of obturator was cured by the pour type resin. This technique was used to fabricate an obturator prosthesis in a 60-year-old post-maxillectomy patient. The weight of this obturator was well controlled and the definitive prosthesis weighed 22 g. At a one year follow-up, the obturator fared well without any water leakage or breakage. CONCLUSIONS: This technique allows the fabricator to control the thickness and weight of the obturator by the amount of relief provided by the hollow bulb. It also rectifies the disadvantages of the closed hollow obturator such as water leakage and complexity of fabrication.

Management of the maxillary cancer patient--what the general dentist should know.

BACKGROUND: Maxillary defects are created following surgical treatment of patients with benign and malignant neoplasms, trauma or congenital defects. The size of these defects influences the degree of debilitation. CASE DESCRIPTION: This patient lacks the conventional support, stability and retention when fabrication of the prosthesis is planned. The prosthesis that is used to close this palatal defect is called the hollow bulb obturator. CLINICAL OUTCOMES: It improves speech, deglutition, esthetics and function for the patient.

Clinical effectiveness and influential factors of maxillary rehabilitation with zygomatic implant following tumor resection.

OBJECTIVE: To evaluate the clinical effectiveness and influential factors of maxillary rehabilitation with zygomatic implant and prosthesis after tumor resection. METHODS: Thirty-six patients with maxillary defects were collected prospectively in this study and received zygomatic implant and prosthesis for maxillary rehabilitation in the Department of Stomatology of the Municipal Hospital, Taizhou, Zhejiang, China from March 2007 to May 2010. The speech intelligibility (SI) and masticatory efficiency of pre-rehabilitation and post-rehabilitation at one, 6, 12, and 24 months were measured. The relationships between the following factors (oro-nasal communication, hard-palate resection, soft-palate resection, retention teeth) and SI value were analyzed. The relationships between the following factors (oro-nasal communication, retention teeth, the extent of maxillary defect, tumor recurrence) and absorbance value were analyzed. RESULTS: The SI values and absorbance values of post-rehabilitation at one, 6, 12, and 24 months were higher than that of pre-rehabilitation values (p<0.05). Linear regression analysis revealed that oro-nasal communication had a highly significant influence on the SI value of pre-rehabilitation (p<0.05), while soft-palate resection had a highly significant influence on that of post-rehabilitation (p<0.05). Oro-nasal communication had a highly significant influence on the absorbance value of pre-rehabilitation (p<0.05), while maxillary defect had a highly significant influence on that of post-rehabilitation (p<0.05). CONCLUSION: Zygomatic implant and prosthesis improved the near and long-term effectiveness of phonetic and masticatory function, and elevated life quality of patients with maxillary tumor resection. Zygomatic implant and prosthesis are an effective rehabilitation remedy for maxillary defects resulting from tumor resection.

Zygoma reconstruction.

Ideal reconstruction of the zygoma position is essential in restoring facial width, projection, and symmetry. Reconstruction should be focused on the zygoma's 4 articulations and restoring the vertical and horizontal pillars of the facial skeleton. This article describes the applied surgical anatomy as it relates to zygomatic deformities, surgical approaches, and reconstruction. The basis for diagnosing and classifying zygoma deformities as they relate to severity of injury and associated displacement, comminution, and comorbidities is also discussed. Traditional and contemporary concepts in posttraumatic, postablative, and esthetic reconstruction are also described.

Maxillary reconstruction.

Postablative maxillary defects present a wide range of functional and esthetic challenges. Several classification schemes have added clarity to the subject, but the surgeon must maintain a clear vision of the defect and appreciate its reconstructive implications. Local tissue flaps remain valuable tools in the reconstruction of small isolated defects of the posterior maxilla and palate; however, microvascular free flaps have eclipsed prosthetic obturators as the mainstay of therapy in advanced postablative defects of the maxilla. Many excellent microvascular options exist and the overall objectives remain to preserve oral function in accordance with the needs of the patient.