prosthodontic rehabilitation of oral cavity post ablative surgery

1. ROLE OF PROSTHODONTIC REHABILITATION
AFTER SURGERY OF ORAL AND MAXILLARY
SINUS TUMORS
PRESENTED BY: DR MONALISA BANERJEE
FHNO FELLOW, KCHRC, MUNI SEVA ASHRAM,GORAJ
MENTORS:DR RAJESH A KANTHARIA,DR.SHEHNAZ KANTHARIA

2. CONTENTS
 INTRODUCTION
 CLASSIFICATION OF MAXILLOFACIAL DEFECTS
 PRE-SURGICAL CONSIDERATION OF PATIENTS FOR MAXILLOFACIAL PROSTHESIS
 MAXILLARY DEFECTS CLASSIFICATION AND PROSTHESIS
 PROSTHESIS FOR VELOPHARYNGEAL INSUFFICIENCY
 MANDIBULAR DEFECT CLASSIFICATION AND PROSTHESIS
 RECENT ADVANCES
 CLINICAL CASE SCENARIOS
 CONCLUSION

3. INTRODUCTION
 Surgical removal of tumors of the oral and maxillofacial region contributes to numerous morphological and
functional disturbances in the stomatognathic system, which greatly affect to the functional and psycological
well being of the patients.
 In the midface , surgical resection usually creates a communication between oral, nasal and sinus cavities by
breaking the continuity of the dental arch, alveolar ridges, parts of the hard and soft palate, and may
sometimes include the zygomatic bone and the orbit.
 Disturbances within the lower part of the face after tumor resection of the mandible and soft tissues of this
region may lead to disarticulation of the TMJ and development of post operative scarring and adhesion of the
soft tissues leading to speech defects, shallow vestibules, microstomia.
The role of prosthetic treatment is to use optimal procedures leading to restoration
of the morphological and functional defects.

4. CLASSIFICATION OF MAXILLOFACIAL DEFECTS
 Can be divided into 4 groups:
 1) Defects after surgery of the midface
 2) Defects after surgery of the lower part of the face
 3)Defects with mixed postsurgical losses , in both the maxilla and mandible
 4)Defects with losses of the face tissues and those after surgery in other locations of the head and neck
region.

5. PRE-SURGICAL CONSIDERATION OF PATIENTS REQUIRING
MAXILLOFACIAL PROSTHESIS
 The assembly of a treatment team consisting of the head and neck surgeon,radiation and medical
oncologists, oral and maxillofacial surgeon, speech therapist, nutritional specialist along with the
maxillofacial prosthodontist is an essential strategy in patient counselling and forming a treatment plan.
 History of a patient should be obtained.
 Intra and extra-oral examination of a patient should be done.
 Consult with patient and discuss anticipated post surgical impairment and manner of prosthesis
management.
 Plan subsequent prosthetic treatment based on records(diagnostic casts and radiographs)
 Surgical site preparation if required to optimize prosthetic management.
 .

6. MAXILLA

7. MAXILLECTOMY DEFECTS
 Defects can cause disruption of articulation and airflow during speech production and also nasal reflux
during deglutition.
 These changes require the fabrication of prosthesis and also sometimes repeated prosthesis adjustments
to confirm to the soft tissue changes.
 In such situation an obturator is designed to close the opening between the residual hard and / or soft
palate and the nasal cavity or sinuses.
 The prosthesis provided for these patients are called as OBTURATORS

8. Aramany’s Classification for Maxillectomy Defects:-

9. OBTURATOR
 DEFINITION (GPT 9)
 obturare - close or to shut off.
 1. A maxillofacial prosthesis used to close a congenital or
acquired tissue opening, primarily of the hard palate and/or
contiguous alveolar/soft tissue structures
 2. That component of a prosthesis that fits into and closes a
defect within the oral cavity or other body defect;

10. CLASSIFICATION
OF OBTURATORS
10

11. CLASSIFICATION (BEUMER, CURTIS)
11
• A. Based on phase of treatment –
• 1. Surgical obturators
• 2. Interim obturators
• 3. Definitive obturators –
• a. closed hollow bulb (one piece/two piece)
• b. open bulb
• B. Based on material used –
• 1. Metal obturator
• 2. Silicone obturator
• 3. Resin obturator
• C. Based on area of restoration –
• 1. Meatal obturator
• 2. Palatal obturator

12. 1. SURGICAL OBTURATOR
12
• A temporary maxillofacial prosthesis inserted during or immediately following surgical or traumatic loss
of a portion or all of one or both maxillae and contiguous alveolar structures. – (GPT - 9)
• It is of two types –
1. Immediate surgical obturator (inserted during surgery)
2. Delayed surgical obturator (inserted 7-10 days after surgery)

13. A. IMMEDIATE SURGICAL OBTURATOR
13
 Less commonly used because of invasive method of securing the prosthesis.
 Fabrication procedure:
• An alginate impression of maxilla  Casts are retrieved.
• Surgical outline is marked on the cast and any tumor bulk present is reduced to normal contour;
• Prosthesis can be fabricated with auto polymerizing or heat polymerizing resin.
• Heat processed is not needed since it is only for 7-10 days.
• Composite resins are convenient but quite brittle (fracture with placement of wires or screws).

14. Appadurai ET AL - surgical retention for immediate obturator in maxillectomy patients. Indian journal of dental research. 2019 jan 1;30(1):133. 14

15. A. IMMEDIATE SURGICAL OBTURATOR
15
• A clear acrylic plate is fabricated and inserted after surgery.
• Dentulous patient  retention is obtained with simple clasps.
• Edentulous patient  wired into alveolar ridge & zygomatic arch.
• The obturator is retained for 7-10 days post surgically.
• Replaced with an interim or definitive obturator after complete healing.

16. Farias a,et al - A simplified technique to make an immediate surgical obturator for a maxillectomy patient. Journal of interdisciplinary dentistry. 2013
may 1;3(2):125.
16

17. B. DELAYED SURGICAL OBTURATOR
17
• Given 7-10 days post surgically.
• Treatment of choice in edentulous patients with extensive defect.
• An impression is made after the packing is removed.
• The procedure must be carefully done when the area is raw and tender. Prosthesis is made as described
previously.
• As healing progresses, posterior occlusal ramps are established since posterior occlusion helps the
patient retain the prosthesis in position.

18. B. DELAYED SURGICAL OBTURATOR
18
• Diagnostic casts are made prior to surgery. Post surgically, the surgeon outlines the surgical margins on
the cast. Prosthesis is made and on the day the packing is removed, the prosthesis is delivered and
adjustments are made.
• After initial healing and removal of the pack the immediate obturator is usually discarded and replaced by
transitional prosthesis having a definite bulbous extension and occasionally artificial anterior teeth.

19. 19
B. DELAYED SURGICAL OBTURATOR
Intraoral view of the defect 1 week after surgery.
Immediate Surgical Obturator. Alginate Impression.
Maxillary cast.
Modelling wax adapted in the defect for the
fabrication of open lid obturator.

20. 20
B. DELAYED SURGICAL OBTURATOR
Open Lid Delayed Surgical Obturator. Relined with tissue conditioning material.
Intraoral View of the Defect
after 2 months.
Intraoral- Delayed Surgical Obturator.

21. 2. INTERIM OBTURATOR
21
• A prosthesis that is made several weeks or months following
surgical resection of a portion of one or both maxillae. It
frequently includes replacement of teeth in defect area. It
replaces the surgical obturator that is placed immediately
following the resection and may be subsequently replaced
with a definitive obturator. – (GPT-9)
Open Lid Interim Obturator.
Intraoral View of Interim Obturator.

22. 2. INTERIM OBTURATOR
22
• Baseplate used for surgical obturator can be border molded and relined on remaining hard palate.
• The prosthesis is seated with each increment of material and impression is made to capture a few mm at a
time. This incremental shaping creates a hollow, light prosthesis.
• Technique:
• Patient movements, speech and swallowing are evaluated during border molding :
• Exaggerated head movements, turning right to left with neck flexed and extended.
• The mouth should be opened and closed, mandible moved laterally and asked to swallow.
• Peripheries of bulb portion will be 2-3 cm in height.

23. 2. INTERIM OBTURATOR
• Hypernasal speech occurs due to loss of air form oral cavity into nasal cavity. As the prosthesis periphery is
sealed, air loss will diminish and speech becomes normal.
• Insertion: After impression is made with a reliner, it is then flasked and the prosthesis is fabricated.
• Given on same day otherwise tissue edema will occur and the defect will change rapidly after removal of the
packing.
• Delivery should include a functional impression with tissue conditioner since it allows better assessment of
functional movement.
• Requires several revisions after surgery. Over extensions may occur due to tissue changes and will require
correction.
23

24. 3. DEFINITIVE OBTURATOR
24
• A prosthesis that artificially replaces part or all of the maxilla and the associated teeth lost due to
surgery or trauma. (GPT – 9)
• Fabricated 6-12 months post surgery.
• Timings will depend on the defect size, healing prognosis, tumor control, the effectiveness of the present
obturator and the presence/absence of the teeth.

25. DEFINITIVE OBTURATOR
• Indicated after surgical site is healed and dimensionally stable and the patient is
prepared physically and emotionally for restorative care.
• Reasons for new prosthesis:
• Periodic addition of interim lining material increases the bulk and weight, and this
temporary material may become rough and unhygienic.
• If anterior teeth are resected, addition can be of psychological benefit.
• If retention and stability are inadequate, occlusal contact on the defect side may
result in improvement.
25

26. 26
3. DEFINITIVE OBTURATOR
The resected hard palate, alveolar
bone, teeth, and soft tissue on the right
side.
Heat-processed hollow bulb
obturator.
Closely adapted obturator.

27. PRINCIPLES OF DESIGN OF
OBTURATOR
• The need for a rigid major connector;
• Guide planes and other components that facilitate stability and bracing;
• A design that maximizes support;
• Rests that place supporting forces along the long axis of the abutment tooth;
• Direct retainers that are passive at rest and provide adequate resistance to
dislodgment without overloading the abutment teeth;
• Control of the occlusal plane that opposes the defect, especially when it involves
natural teeth.
27
Rahn AO - Prosthodontic principles in the framework design of maxillary obturator prostheses. J prosthet dent 1989;62(2):205-12.

28. Principles of design (aramany 1978) 28
PRINCIPLES OF DESIGN (ARAMANY 1978) –
• Class I: Resection is along midline.
• A. Linear design: when there are no anterior teeth or they are not used and all posterior
teeth are in straight line. Support is form posterior teeth and palatal tissue.
• B. Tripodal design: when anterior teeth are used for support and retention

29. CLASS 1 DESIGN - TRIPODAL
• Direct retention – labial surface of the
anterior teeth with an I-bar on the central
incisor.
• Posterior retention is placed on the buccal
surface of the molars and bracing is
located palatally.
• Indirect retention – canine rest/distal
surface of the first premolar in a tripodal
design.
29
Principles of design (aramany 1978)

30. CLASS 1 DESIGN – LINEAR
• Linear design  when anterior teeth absent or cannot
be used. The remaining posterior teeth are usually in a
relatively straight line.
• Support : Remaining posterior teeth and the palatal
tissues.
• The palate becomes more important in the linear design
because the use of leverage to resist vertical dislodging
forces is decreased.
• Retention : buccal surfaces of the premolars and the
palatal surfaces of the molars.
• Stability : palatal surfaces of the premolars and buccal
surfaces of the molars.
•
30
Principles of design (aramany 1978)

31. CLASS 2 DESIGN
• CIass II: Unilateral defect, anterior teeth on contralateral side
are retained.
• Recommended design - Tripodal.
• Retention - buccally on all abutment teeth.
• Indirect retention - located on opposite side of defect.
• Primary support - tooth nearest the defect as well as the most
posterior molar on the opposite side and remaining palate.
• Guiding planes - located proximally - on the distal of the anterior
tooth and the distal of the molar.
31
Principles of design (aramany 1978)

32. CLASS 3 DESIGN
• Design – quadrilateral, simple and
effective.
• Support - widely distributed on both
premolars and molars.
• Retention - buccal surfaces and
stabilization from the palatal
surfaces.
32
Principles of design (aramany 1978)

33. CLASS 4 DESIGN
• Design - linear.
• Support – centrally on all remaining
teeth.
• Retention - mesially on premolars and
palatally on the molars.
• Stabilization - palatal on the premolars
and buccal on the molars.
33
Principles of design (aramany 1978)

34. CLASS 5 DESIGN
• Design - Tripodal
• Splinting of at least two terminal abutment
teeth on each side is suggested.
• I-bar clasps are placed bilaterally on the
buccal surface of the most distal teeth.
• Stabilization and support - palatal surfaces.
34
Principles of design (aramany 1978)

35. CLASS 6 DESIGN
• Design – Quadrilateral
• Two anterior teeth are splinted bilaterally and connected by a transverse
splint bar.
• Support – From remaining teeth.
35
Principles of design (aramany 1978)

36. IDEAL CHARECTERISTICS OF THE
MATERIAL USED

37. CLASSIFICATION OF MATERIALS USED
 1. Impression phase materials
• Reversible hydrocolloid
• Irreversible hydrocolloid
• Elastomeric materials
• Tissue conditioners
 2. Modelling phase materials
• Modelling clay – water based clay (stone like substance after becoming hard)
• Plastolene – modelling clay with oil base
• Waxes

38.  3. Fabrication phase materials
• Rigid i. Denture bases - metallic - non metallic
ii. Teeth - porcelain - acrylic - composite
iii. Wires - Orthodontic hard round stainless steel wire - nickel titanium wire
• Flexible
i. Acrylic copolymer or PMMA (palamed polyderm)
ii. Vinyl polymer and copolymers (mediplast, realistic) Polyurethane elastomers
– HTV Silicones , foaming silicon

39. PROSTHESIS FOR VELOPHARYNGEAL INSUFFICIENCY
 Speech bulb prosthesis and Palatal lift prosthesis
 These are prosthesis that are functionally shaped to the velopharyngeal musculature to restore
or compensate for areas of the soft palate that are deficient because of surgery or congenital
anomaly.
:
T he pa la tal pa r t ,w hich p rov id e
sta bi li t y a nd an cho r age fo r
retention .
T he p ala ta l e x ten si on w hic h
crosses the residual soft palate
T he pha r yn gea l pa r t w hi ch f il ls t he
v elop ha r yng eal pa rt d ur in g
muscular function

40. Meatus obturator
 It is designed to close the posterior nasal conchae.
 A drawback to this prosthesis is making the patient’s voice hyponasal,which can be altered by creating
holes in the prosthesis.

41. SPEECH AIDS IN PARTIAL GLOSSECTOMY DEFECTS CLOSED
PRIMARILY
 If a part of tongue is lost ,the ability of the tongue to reach the palate for appropriate speech and
swallowing is compromised.
 The contour of palate can be augmented by a prosthesis to fill the space so that a food bolus can be
more easily moved posteriorly into the oropharynx.

42. Palatal speech aid. Partial glossectomy defect that was closed
primarily.The tongue elevation was deficient.
THICK MIX OF PROVISIONAL DENTURE RELINE MATERIAL
ADDED TO THE PALATAL VAULT AREA.
Processed palatal portion hollowed to reduce the weight.

43. MANDIBLE

44. INTRODUCTION
 Mandible is a single bone that creates:
Peripheral boundaries of the floor of the mouth
Facial form
Speech
Swallowing
Mastication
Respiration
Disruption of the mandible has the potential to disrupt any of these.
 Mandibular reconstruction revolutionized by microvascular and plating techniques.
 Prosthetics mainly restore occlusion and occlusal surface.
 Implants able to restore high degree of function.

45. BASED ON AMOUNT OF RESSECTION(LANEY)
CONTINUITY DEFECT (MARGINAL
RESECTION)
DISCONTINUITY DEFECT (SEGMENTAL
RESECTION)
 Inferior border and its continuity preserved
 - No deviation
 - Less facial disfigurement
 - Occlusion rarely changed
 - Can be :- anterior defect
 posterior defect
 - Complete segment
 - from alveolar crest to inferior border removed
 - Mandible deviates to resected side
 - Marked facial disfigurement
 - Occlusion altered
 - Can be :- lateral discontinuity defect
midline discontinuity defect

46. I) Mandibular guide flange prosthesis
 Used as a training device till inter occlusal position can be
attained.
 Due to strong lateral forces, palatal retainer provided to resist
palatal movement of maxillary teeth.
 Best positioned in 2nd premolar – 1st molar area.
 If used indefinitely constant monitoring required.
 Permits only vertical movements of mandible.

47. II)Maxillary inclined plane prosthesis
 Used as training device.
 An acrylic resin ramp is given on the palatal incline of the
non-affected side.
 The mandibular fragment is guided to a position of
acceptable occlusion through the path of this ramp.

48. SEVERITY OF MANDIBULAR DEVIATION DID NOT
PERMIT ESTABLISHMENT OF APPROPRIATE
MAXILLOMANDIBULAR RELATIONSHIPS WITH
GUIDANCE RAMP.
 When palatal prosthesis was formulated
and delivered mandibular teeth still
occluded lingual to desired position.

49.  As scar contracture loosened occlusal index was adjusted so patient
achieved adequate interocclusal relationship.

50. III) Implant retained prosthesis:
 Prostheses retained and supported by osseointegrated implants placed in the anterior region of the
mandible, in combination with the remaining posterior teeth, enable most anterior resection patients
to masticate effectively.
 Most of these patients possess good tongue function, but the lack of support anteriorly impairs
effective incision and mastication of the food bolus. Osseointegrated implants provide this support.

51. ADVANCES IN MAXILLOFACIAL PROSTHESIS
 Over the years computer aided design/computer aided manufacturing(CAD -CAM)
technology has revolutionarized the clinical practices.
 CAD/CAM supplemented with 3D bioprinting has increased the consistency and efficacy of
fabricating prosthesis.
 The protocol for craniofacial prosthesis design includes data capture and patient specific
design on a virtual platform, followed by fabrication and placement of prosthesis
Courtesy:3D Incredible: Additive manufacturing in

52. MAANDIBULAR 3D PRINTED IMPLANT

53. MAXILLARY 3D PRINTED IMPLANT
Courtesy:3D Incredible: Additive manufacturing in India

54. CLINICAL
PHOTOGRAPHS

55. PHARYNGEAL OBTURATOR

56. DEFINITIVE OBTURATOR

57. Mr. Kantibhai Patel
INTERIM OBTURATOR

58. INTERIM OBTURATOR

59. MANDIBULAR GUIDE FLANGE PROSTHESIS

60. SPEECH BULB PROSTHESIS

61. CONCLUSION
 Rehabilitation of post surgical defects after surgical removal of maxillofacial tumors require a multi-
deciplinary approach
 It is a challenging task to rehabilitate such defects due to unpredictable nature of defects, compromised
surrounding soft tissues and bone condition and reduced accessibility, more so in post radiation patients.
 Over the years, development of latest technologies and newer techniques in prosthodontic rehabilitation
has proved to be beneficial in improving the overall quality of life.
 Developing patient centred rehabilitation models, proposing evidence based guidelines through co -
ordinated efforts of interdisciplinary teams should be on the agenda to achieve long term success rates.

62. THANK YOU