Clinical Management Of Maxillary
Acquired Defects
R.Sunil
3rd MDS
Contents
• Introduction
• Etiology
• Classification
• Management of edentulous maxillectomy patient.
• Management of dentulous maxillectomy patient.
• Conclusion
• References
Introduction
• A rewarding area of prosthodontics is the rehabilitation
of patients with acquired maxillary defects.
• Here, the dentist contributes to all facets of patient care
from diagnosis and treatment to rehabilitation.
• In most circumstances, the prosthetic prognosis is
favorable, and patients are pleased and grateful upon
completion of rehabilitation.
Etiology
• Most acquired maxillary defects are caused by cancer,
other causes include infection, trauma or other diseases.
Classification by Aramany based on the
relationship of the defect to the remaining teeth
Olepu SR. et al.,Prosthetic Rehabilitation of maxillary defects:A review Int J Dent Health
Sci 2014; 1(4):632-643
Treatment plan
Mohamed A. Aramany. Basic principles of obturator design for partially edentulous
patients. Part II: Design principles. J Prosthet Dent 2001; 86 (6): 562-568.
Liverpool classification
• Vertical Component-
• Class 1:- Maxillectomy not causing oro-nasal fistula.
• Class 2:- Maxillectomy not involving the orbit.
• Class 3:- Maxillectomy involving the orbital adnexae with
orbital retention.
• Class 4:- Maxillectomy with orbital enucleation or
exenteration.
• Class 5:- Orbitomaxillary defect.
• Class 6:- Nasomaxillary defect.
• Horizontal Component-
• Letter a:- Palatal defect only.
• Letter b:- Less than or equal to half of unilateral maxilla.
• Letter c:- Less than or equal to half of the bilateral
maxilla.
• Letter d-:-Greater than half of the maxillectomy.
Dr.Gupta et al,Maxillofacial defects and their classification: A reviewInt Journal
of Adv Research (2016), Vol 4, Iss 6, 109-114
Management of edentulous
maxillectomy patient
Surgical enhancements
• Maintain as much hard palate as possible.
• Skin graft the cheek flap.
• Remove the inferior turbinate.
• Skin graft the maxillary sinus walls.
Phases of prosthetic rehabilitation
• Surgical obturator prosthesis.
• Interim obturator prosthesis.
• Definitive obturator prosthesis
Immediate surgical obturator
advantages
• The prosthesis provides a matrix on which the surgical
packing can be placed.
• Prosthesis reduces the oral contamination of the wound
and also protect from infection.
• The prosthesis enables the patient to speak more
effectively postoperatively by reproducing normal palatal
contours and by covering the defect
• The prosthesis permits deglutition, thus eliminating the
need for a nasogastric tube, for some or its earlier
removal for others.
• The prosthesis lessens the psychological impact of
surgery by making the postoperative course easier to
bear.
• The prosthesis may reduce the period of hospitalization.
Principles for designing immediate
obturator
• The obturator should terminate short of the skin graft
mucosal junction initially.
• The prosthesis should be kept simple, light weight, and
inexpensive.
• The prosthesis for dentulous patients should be
perforated with a small dental bur at the interproximal
extensions to allow the prosthesis to be wired to the teeth
at the time of surgery.
• Normal palatal contours should be reproduced to
facilitate postoperative speech and deglutition.
• Posterior occlusion should not be established on the
defect side until the surgical wound is well organized.
• The surgical obturator for edentulous patients should be
fabricated much like a record base, with no replacement
teeth.
• In some patients, the existing complete or partial
prosthesis may be adapted for use as an immediate
surgical obturator. However , the buccal flange of the
denture and the posterior denture teeth on the defect
side are removed.
Fabrication of immediate obturator
Margins outlined on Cast trimmed Final trimmed cast
presurgical cast
Tumor distorted palatal contour Tumor distorted palatal contour
Altered cast Immediate surgical obturator
Obturator wired to the alveolar ridge
Methods of retaining surgical obutrator
Bone screw retention Suture retention
Circumzygomatic wiring retention
Delayed surgical obturator
Edentulous patient after Impression made
Cast poured
8 days of maxillectomy
Old denture modified Hollowed out to reduce the weight
Fabrication of interim obutrator
Impressions
Master Cast
Wax trial
Flasking and dewaxing giving Second
pour I
Second pour II
Packing with Second pour -II
Filling the defect with salt in polyethylene
pack
Flasked and cured hollow bulb
obturator
Obturator floating in a water bowl
Insertion
Post-insertion appearance
Follow-up
After 3 months
After 1 month
Second interim obturator given to the
patient with increased volume of hollow
Advantages
BETTER POSTERIOR SEAL OF BETTER FIT OF THE
THE DEFECT PROSTHESIS
LIGHTER WEIGHT OF THE
PROSTHESIS
Interim obturator
Immediate surgical Converted to interim
Patient 1week post op
obturator after cleaning obturator
Try in patients mouth Anterior teeth added Impression made for
revision of prosthesis
Revised prosthesis Revised prosthesis
tissue surface polished surface
Edentulous patients with total
maxillectomy defects
Preliminary impression
Definitive Obturator-impression making
Impression tray Border moulding on Border moulding on
non defect side defect side
Indentation of the scar Posterior view Cut back by 1to 2mm
Completed impression
Permanent denture base Occlusal rim
Master cast
Teeth arrangement Denture insertion
Partial maxillectomy treated with
implants
Three implants placed in maxilla
Preoperative view
OPG showing implants Copings of magnetic keeper
Denture with magnets Denture inserted
Case report
Ozaki, H., Sakurai, H., Yoshida, Y., Yamanouchi, H., & Iino, M. (2018). Oral Rehabilitation of Oral
Cancer Patients Using Zygomatic Implant-Supported Maxillary Prostheses with Magnetic
Attachment: Three Case Reports. Case Reports in Dentistry, 2018, 1–5.
Clinical management of dentate
maxillectomy patient
• Preoperative conditions:
• According to Desjardins(1977)
• Psychological support of the patient.
• Preoperative dental management.
• Preoperative impressions.
• Suggestions for the surgeon.
Psychological support of the patient
• Include their available positive role models and their
spirituality.
• Reframing an event and search for positive aspects in
relation to patient’s strengths and abilities to face serious
problems.
• Positive outcomes of the treatment can be achieved through
this attitude and victims will see them as capable human
beings.
Preoperative dental management
• Treating active dental disease before the surgery reduces
the risk of emergency dental problems in post surgical
healing.
• The tooth that are treated preoperatively has a high
chance of survival and can act as abutments for the
prosthesis.
• As a general rule, all maxillary teeth that can be
maintained should be saved.
Pre surgical impressions
• It is recommended that two casts should be made before
the surgery.
• One is kept as a permanent record and the other is used
for fabrication of surgical obturator.
Suggestions for the surgeon
Classic hemimaxillectomy Conservative approach
midline resection increases retention
Maxillectomy preserving Interproximal socket
posterior alveolus reduction preserving the
bone and the tooth.
Definitive obturator design principles
• Maximum distribution of support for the obturator by rests.
• Retention of the obturator should be gained form the
remaining teeth preserved and from the defect site.
• Clasp should be placed close to the defect. Additional
clasp should be placed far from the first clap to create a
more favourable fulcrum.
• Resistance form can be achieved by adding guide planes
on the palatal surface on the non defect side teeth.
Definite obturator fabrication
Introral defect of the palate Primary impression
Primary cast Metal framework of the obturator
Pickup impression Teeth arrangement
After dewaxing Final prosthesis Prosthesis in situ
Singh, M., Limbu, I. K., Parajuli, P. K., & Singh, R. K. Definitive Obturator Fabrication for
Partial Maxillectomy Patient. Case Reports in Dentistry, 2020
Hemi maxillectomy case
4.0 cm x 4.50 cm
Maximum
Intercuspation
Right MIP Left
Sectioned stock
Tray
Positioning of Impression Making
Tray
Putty & Light
Body
Impression
Master Cast
Wax - Up
Permanent Base
Pick Up Impression
Working Cast
Face – Bow Transfer
Bite frok
Articulation
Maxillary and Mandibular casts articulated
Wax Try – in
Flasking
Lost Salt Technique
Digital work flow
Before treatment Digital impression using IOS
Design of the metal frame Printed resin pattern
Framework on polyurethane model Functional impression using metal framework
Waxed denture on altered cast Final prosthesis
Park et al, Fabricating a maxillary obturator using an Intraoral digital
impression: A case history report Int J Prosthodont2017;30:266-68
Trouble shooting
• Leakage into nose: continued fibrosis in the tissues
bordering the prosthesis is the cause.
• Triad reline material can be used to close the defect.
• The material is coated with the manufacturer’s air barrier
coating and cured in the system’s curing unit.
• Hypernasal speech: Occurs due to patient’s soft palate
and pharyngeal closure mechanism are not functional.
• This condition is seen when a portion of the soft palate is
removed during the surgery.
• Relining the prosthesis periphery will not alter the
hypernasal speech.
• A pharyngeal bulb will help to reduce this hypernasal
speech.
Maintenance of obturator
• Prosthesis should be evaluated for pressure spots using
PIP paste.
• Bulb portion is checked by using tissue conditioner of
different color.
• Patients should wear the interim obturator during the
night time to manage the secretions.
• Diet also should be modified when there is large defect .
• Adhesives can be used to increase retention and
adaptation to the obturator.
• Patient visit should be scheduled after 24 hours for any
modification.
• Any modifications required can be done with in 2 to 3
days.
• If secretions are leaking into oral cavity, relining of the
obturator is required.
Conclusion
• Prosthodontic rehabilitation of maxillectomy patients is a
lengthy and involved process.
• If proper attention and detailed treatment plan is
involved, it can be the most satisfying procedures in all
of Prosthodontics.
References
• Olepu SR. et al.,Prosthetic Rehabilitation of maxillary
defects:A review Int J Dent Health Sci 2014; 1(4):632-643.
• Dr.Gupta et al,Maxillofacial defects and their classification:
A reviewInt Journal of Adv Research (2016), Vol 4, Iss 6,
109-114.
• Park et al, Fabricating a maxillary obturator using an
Intraoral digital impression: A case history report Int J
Prosthodont2017;30:266-68
• Aramany, M. A.: Basic principles of obturator design for
partially edentulous. Part I: Classification. J Prosthet Dent
40:554-7, 1978.
• Desjardins R. early rehabilitative management of the
maxillectomy patient J Prosthet Dent 1977; 38:311.
• Singh, M., Limbu, I. K., Parajuli, P. K., & Singh, R.
K. Definitive Obturator Fabrication for Partial Maxillectomy
Patient. Case Reports in Dentistry, 2020,
• Mohamed A. Aramany. Basic principles of obturator design for
partially edentulous patients. Part II: Design principles. J Prosthet
Dent 2001; 86 (6): 562-568.
• Ozaki, H., Sakurai, H., Yoshida, Y., Yamanouchi, H., & Iino, M. Oral
Rehabilitation of Oral Cancer Patients Using Zygomatic Implant-
Supported Maxillary Prostheses with Magnetic Attachment: Three
Case Reports. Case Reports in Dentistry, 2018, 1–5.
