Functional Rehabilitation of an Anterior Maxillary Defect

INTRODUCTION

A variety of materials and techniques have been used for the construction of prosthetic replacement of the acquired surgical defects. Most defects usually affect variety of functions, including speech, deglutition, management of oral secretions, and mastication. Maxillofacial prosthetic rehabilitation helps not only to restore oral functions and cosmetics following surgery but also the psychological well being of the patient.1,2 Thus defects of the orofacial structures must be analyzed as to the specific cause and the consequent objectives of rehabilitation.

Prosthetic rehabilitation of maxillectomy defects has been described as an alternative to surgical reconstruction to close the oral cavity. The primary goal of prosthetic rehabilitation is closure of the maxillectomy defect and separation of the oral cavity from the sino-nasal cavities.3 Creating facial prostheses to restore midfacial defects involves many challenges, including the achievement of proper retention and marginal fit. Because the quality of life of a patient with an unrehabilitated facial deformity is significantly compromised, facial prosthetic rehabilitation is often selected as the treatment of choice.4

CASE REPORT

A 36 year old male patient reported to the Palika Health Complex, Dharam Marg, New Delhi Municipal Council complaining of difficulty in chewing and deglutition and whistling in voice while speaking. The patient’s medical history revealed that he had undergone surgical resection for a cystic lesion in the left anterior maxilla about one year ago and had the problem since then. He also complained of partially masticated food going into the defect which was very difficult to take out and caused a lot of pain and halitosis.

On clinical examination an oval defect was seen measuring approximately 4 x 2 cm. Its lateral border extended 3 mm beyond maxillary frenum on the right side to mesial aspect of maxillary left incisor on the left side (Fig.1). There were signs of healthy mucosal tissue at the borders of the defect (Fig.2). The patient had not been advised for any obturator prosthesis post surgery.

It was planned to fabricate a maxillary obturator prosthesis which would have a dual function of acting as a barrier against food and liquid from entering the defect during mastication and deglutition as well as escape of air and better phonetics. This would be connected to a palatal plate with the assistance of clasps for better retention.

CLINICAL PROCEDURE

1. An upper maxillary tray was selected, the extensions of which covered all the maxillary teeth and vestibule. The anterior tray extensions were extended with modeling wax from mesial aspect of left canine to mesial extension of right first molar.
2. Two gauze rolls were placed onto the defect before taking the impression such that alginate should not enter the undercut of the defect.
3. Alginate was mixed as per manufacturers recommendation and tray filled with material. This was carried into the patient’s mouth and impression was taken.
4. The tray was carefully removed after setting and the impression was inspected for any defects (Fig.3 & Fig.4).
5. The cast was poured in type Type III gypsum (Dental stone) and base was fabricated. The alginate was removed from the defect in the cast and it was filled with Type II gypsum (Dental Plaster) (Fig.5).
6. Bilateral clasps were fabricated on the interdental spaces between second premolar and molar on the maxillary cast.
7. After doing the wax-up, the prosthesis was conventionally cured with heat-cured polymerizing acrylic resin.
8. The assembly was then deflaxed and was finished and polished (Fig.6 & Fig.7).
9. This was tried in the patient’s mouth and necessary adjustments were made. The assembly fitted in such a way that the metal clasps did not hinder the occlusion bilaterally (Fig.8, Fig.9, Fig.10 & Fig.11).

Fig.1 & Fig.2 – Defect in the anterior maxilla

Fig.3 & Fig.4 – Alginate impression of the defect in anterior maxilla

Fig.5 – Defect filled with Type II gypsum (Dental Plaster)	Fig.6 & Fig.7 – Final prosthesis finished & polished

Fig.8 & Fig.9 – Final prosthesis in the mouth

Fig.10 & Fig.11 – Before treatment & After treatment

DISCUSSION

Maxillary defects are created by surgical treatment of benign or malignant neoplasms, congenital malformation and by trauma. The size and location of the defects influence the degree of impairment and difficulty in prosthetic rehabilitation. The obturator prosthesis is used to restore masticatory function and improve speech, deglutition and cosmetics for maxillary defect patients. Neglecting timely prosthodontic cooperation may cause inappropriate facial contour which is almost impossible to reconstruct. In the absence of immediate covering of the defect, soft tissues remain unsupported and collapse dramatically and aesthetic and/or possible psychological problems may occur. There is also complaint of partially masticated food going into the defect which was very difficult to take out and causes a lot of pain and halitosis. This also causes negative influence on psychology. Defect of such a magnitude usually leave the patient with a psychological barrier due to speech and deglutition problems. The prosthesis helped the patient to improve on the above said difficulties. Speech is improved as well as exploration of the defect by the tongue is prevented. Despite its advantages, however, prostheses has its own drawbacks, including the need for manual dexterity to maintain the prosthetic, the difficulty of obtaining perfecily leak-tight separation of the oral cavity from the nasal cavity and sinuses, the problem .depending on the amount of tissue resected-with long-term retention, constant irritation, and, of greatest importance, decreased patient satisfaction.5

CONCLUSION

Fabrication of prostheses does not require any special ability. To fabricate a prostheses, extension into a defect or an arbitrary extension of a prosthesis into a defect is required. Fabrication of the maxillofacial prosthesis depends on the application of basic prosthodontic principles that are used in the treatment of patients without maxillary defects. Some principles must be modified because of the defect, the character and position of the remaining structures. The defect, in conjunction with the remaining structures, must be used to provide support, retention, and stability of a prosthesis. Acceptable prosthodontic care for the patient with the acquired maxillary defect should include cautious prosthesis design combined with routine maintenance care to provide comfort, function, cosmetics, and minimal change to the compromised remaining structures.6,7

BIBLIOGRAPHY