Prosthetic Rehabilitation of Maxillectomy Defects, with Single-Piece Open-Hollow Bulb Definitive Obturator

Abstract

Patients who undergo surgical resection of the maxillo-mandibular structures as a result of trauma, infection or malignancy, suffer from psycho-social setbacks which has a profound impact on their over-all quality of life. 1,2 These defects, especially those following maxillectomy, result in oroantral communication, facial deformation, impaired speech and difficulty in deglutition. For the rehabilitation of patients with such defects, surgical and prosthetic treatment options are available. As, not all patients can be successfully rehabilitated with reconstructive surgeries due to postoperative complications like graft rejection, the extent of the surgical defect and high psychological impact factor associated with repeated surgeries, prosthetic rehabilitation proves to be an alternative treatment option. The prosthetic rehabilitation of such patients is challenging as it requires restoration of the lost form, function and aesthetics, under constantly changing state of post-surgical intraoral tissues, with limited mouth opening. The maxillofacial prosthesis designed to close congenital or an acquired tissue opening, primarily of the hard palate, is known as an obturator. 3 The obturator has two functional components, one seals the surgical defect and the other replaces the lost dentoalveolarstructures.4-7 The design of an obturator may vary depending on the extent of the defect, remnant dentoalveolar complex, soft tissue undercuts and existent muscle physiology.8,9 Among the two designs, solid and hollow, hollow obturators are widely used. The bulb portion of the hollow obturator, which accommodates the surgical defect, can be open or closed9,10and its selection depends on the prosthodontist’s clinical decision-making skills and the ease of fabrication. In this article we have discussed the rehabilitated patients with single-piece, openhollow bulb definitive obturator. Patients undergo extensive maxillary surgical resections due to aggressive lesions like malignancies and deep fungal infections. Prosthetic rehabilitation of such patients with an obturator becomes of paramount importance as it separates the oropharynx from the nasopharynx, reduces the risk of recurrent infections, replaces lost dentoalveolar structures, permits intelligible speech, reinstates mastication and deglutition, restores facial contour and patient’s self-esteem. The bulb portion of the obturator extends into the defect and accommodates it, forming a hermetic seal. In this clinical report, we highlight the success of prosthetic rehabilitation of maxillectomy patients using single-piece, open-hollow bulb definitive obturator. The meticulous follow-up carried out reveals the success of the prosthesis and adds practice-based evidence to the maxillectomy rehabilitation outcome.

The rising challenge of mucormycosis for maxillofacial prosthodontists in the Covid-19 pandemic: A literature review

“…As confirmed by the majority of reports in this review [16,[19][20][21][22]25,31,32,34,39], weight reduction is critically important when the prosthesis is suspended without much remnant bone and tooth support. As a result, in such cases, a hollow bulb design should be used [17,23,24,27,32,36,[39][40][41][42]. A lighter obturator improves suspension cantilever mechanics, prevents overstressing of the remaining supporting structures, and increases retention [44].…”

“…Large-sized maxillectomy defects often result after surgical treatment of mucormycosis, and the duration of healing in such defects is determined not only by the aggressive nature of the lesion, but also by the postoperative care [39]. As confirmed by the majority of reports in this review [16,[19][20][21][22]25,31,32,34,39], weight reduction is critically important when the prosthesis is suspended without much remnant bone and tooth support. As a result, in such cases, a hollow bulb design should be used [17,23,24,27,32,36,[39][40][41][42].…”

“…The details on the sites of the defect and types of prosthetic treatment provided are summarized in Table 1. A total of 30 articles [13,14,[23][24][25][26][27][28][29][30][31][32]15,[33][34][35][36][37][38][39][40][41][42][16][17][18][19][20][21][22] on prosthetic rehabilitation in the orofacial region after surgical treatment of mucormycosis published during the 12-year study period were reviewed. Of the 30 articles, 19 reported mucormycosis in diabetic patients, 2 described mucormycosis specifically as a post-COVID 19 complication, and 25 were reports from India.…”

“…A lighter obturator improves suspension cantilever mechanics, prevents overstressing of the remaining supporting structures, and increases retention [44]. The open-hollow bulb design is also preferred over the closed-bulb design because it is lighter in weight, easier to fabricate, and produces noticeably better articulation [39]. However, it should be used when the weight of the prosthesis is a major concern [39], and only with regular follow-up because the open design tends to accumulate mucous secretions, which can be a source of infection [32].…”

“…The open-hollow bulb design is also preferred over the closed-bulb design because it is lighter in weight, easier to fabricate, and produces noticeably better articulation [39]. However, it should be used when the weight of the prosthesis is a major concern [39], and only with regular follow-up because the open design tends to accumulate mucous secretions, which can be a source of infection [32]. Remote implant-bone anchorage using pterygoid, zygomatic, and nazalus implants was also reported to be a more effective solution than conventional implants in improving prosthesis retention and support [42].…”