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Clinical management
of the edentulous
maxillectomy patient
Ammar G. Salem
4th year KBMS – Restorative Dentistry
Content
Introduction
Surgical enhancements
Phases of prosthetic restorative
Surgical obturator prosthesis
Interim obturator prosthesis
Definitive obturator prosthesis
Troubleshooting the obturator prosthesis
Summary
Clinical management of edentulous maxillectomy patient 2
Introduction
Violation of the hard palate creates an anatomic defect that allows the
oral cavity, maxillary sinus, nasal cavity and nasopharynx to become
one confluent chamber.
3
Introduction
The lack of boundaries creates:
- Disabilities in speech (hypernasality).
- Inadequate oral nutrition.
This makes the prosthetic intervention a necessity for the remainder of
patient’s life.
4
Surgical
enhancements
1. Maintain as much hard palate
as possible.
2. Skin graft the cheek flap.
3. Remove the inferior turbinate.
4. Skin graft the maxillary sinus
walls.
Maintain as much hard palate as
possible
- Aid in primary retention, support, and stability.
- More ipsilateral premaxillary area to maintain:
- More of tripoding prosthetic effect (stability).
- Increased surface area (retention).
- Maintaining anterior alveolus and floor of the nose  less collapse
of facial form and less postoperative contracture.
6
Skin graft of the cheek flap
At surgery time after elevating the cheek away from the maxillary
bones, this will leave a denuded surface on entire cheek flap.
This has multiple disadvantages:
- Bleeding surface extend many weeks (in case of healing by
secondary intention).
- Lately will be covered with respiratory epithelium which doesn’t
serve well for prosthetic appliance. 7
Skin graft of the cheek flap
To overcome this, a split-thickness skin graft can be placed over denuded surfaces at
the time of the surgery.
This will provide:
- Sound prosthetic bearing surface.
- Not be easily abraded.
- Does not secrete mucus.
- Allows for vigorous cleaning of the defect.
- May aid in retention. 8
Remove the inferior turbinate
Often likely not to be resected if tumor does not involve the nasal cavity.
Resecting the inferior turbinate at time of surgery will:
- Allowing extending the medial wall of the obturator bulb into the nasal
cavity  this counters the rotation of the prosthesis.
- Prevent bleeding from functional movement.
- Allows liquids to reflux into the cavity at the medial periphery of the bulb.
9
Skin graft of the maxillary sinus
walls
Preparation of the bony walls of the maxillary sinus to:
- Allow the bony undercuts to serve for retention.
- Provide vertical support to keep the prosthesis from rotating into the
defect during mastication.
Grafting sinus walls with split-thickness skin graft stops formation of
polypoid tissue and mucus generation within the sinus + allows the
walls to be stress-bearing areas. 10
Phases of
prosthetic
restoration
- Surgical obturator prosthesis.
- Interim obturator prosthesis.
- Definitive obturator prosthesis.
Surgical obturator prosthesis
• Less common used in edentulous
than dentulous because of invasive
method of securing.
• Securing methods:
• Palatal bone screw.
• Suture into surrounding mucosa.
• Circum-zygomatic wires.
Fabrication procedure
- Alginate impression with
conventional denture coverage.
- Reduce to normal contour any tumor
bulk.
- Extension to identical borders of
complete denture (to avoid
overextension).
- Use autopolymerizing resin (only
used for 10 days or less).
12
Securing methods
Bone screw
retention
- Placement into the
vomer.
- Hole predrilled through
baseplate at anterior
peak of palatal vault.
- Offer most stability.
Suture retention
- In previously irradiated
patient.
- Sutures placed at the
periphery of prosthesis.
- It will have slight
prosthesis movement.
Circum-zygomatic
wire retention
- Most invasive and has
greatest morbidity.
- Not commonly used.
13
Using existing dentures
If denture not fitting well, it need reline prior to surgery.
Patient should discontinue using lower denture.
Disadvantages:
- Obtaining comfortable occlusion, constant relining and reducing of flanges is
almost impossible.
- Postoperative facial contracture over the next weeks  significant reduction.
- Teeth of surgical side often require facial reduction/removal of baseplate.
- Need multiple appointments and more complex. 14
Interim obturator prosthesis
Impression
- 5-10 days after surgery.
- Using surgical
obturator.
- Using varied viscosity
monomer and polymer
manually shaped and
placed incrementally
along periphery of
defect.
- The entire defect
shouldn’t be impressed
at once.
Patient movement, speech, and swallowing
evaluation during border molding
- Exaggerated head movements turning right to left with
head level, neck flexed, and extended.
- Open and close mouth, move mandible laterally.
- No need to fill entire sinus space, only 2-3cm in height.
- If periphery lowered to make contact with cut edge of
soft palate, the prosthesis will be overextended and
become irritating a few days after the clinical visit
because that injured soft palate junction will contract
and elevate back to the level of the hard palate very
rapidly over next 2 weeks.
15
Interim obturator prosthesis
speech
- Sounds formed when
air passes through the
nasal cavity m, n, ng.
- When air is obstructed
from passing out the
nose m and ng sounds
become hyponasal (like
common cold).
- Hypernasality is when
air loss from oral into
nasal cavity.
- Distinct between m and
b sounds.
- If b is clear and distinct
 no air escaped.
- If b not distinguished
from m, then air
escapes.
- Saying word beat, then
occlude nares
manually and say it
again.
- Drinking water with
head upright to check
reflux of water into
nose or sinus.
- Inability to control
liquids and drooling is
due to postoperative
swelling and
anesthesia
16
17
Insertion of interim
Prosthesis must be hollowed to decrease weight.
It should be delivered within few hours due to rapid change in shape because of
tissue edema.
The patient is instructed to keep the prosthesis and only take it out for cleaning it and
the surgical site.
Regular use of denture adhesive.
Instruct the patient that head upright position will decrease leakage of liquids through
the nose. 18
Revisions of interim
Every 10-14 days over the next 2 months.
Adjustments needed if pain or bleeding occurs.
Reassure patient regarding increased hypernasality and nasal reflux.
Tissue conditioning material will harden between visits and need reducing (at
least 5mm) and resurfacing.
If movement of mandible creates movement of prosthesis reduction of
overextended areas. 19
Definitive
obturator
prosthesis
- Preliminary impression.
- Final impression.
- Jaw relationship records.
- Insertion.
- Instructions.
- Lid fabrication of hollow.
Preliminary impression
- Offer max. extension
within surgical site.
- Not necessary to block
out with gauze.
- Prudent to block out
palatal fistulas that
open into intact
maxillary sinus/nasal
cavity.
- Stock edentulous tray
serve enough,
- Support surgical side
with compound or wax.
21
Final impression
- Custom tray should
extend 2-3 cm into
cavity.
- Should extend beyond
scar band and superior
to the cut edge of the
hard and soft palates
leaving 5-8mm space
for compound.
- First impress the
remaining palate with
incremental addition of
compound to the
periphery of surgical
site.
- With every increment
should be head
movements and
swallowing.
- Cavity is convex from
inferior to superior.
5/16/2023 
 22
- Superior extension
beyond the greatest
convexity adds weight
to prosthesis.
- Exception in remaining
bony walls of maxillary
sinus where they are
resurfaced and split-
thickness skin grafted.
Final impression
- After using compound,
an impression wax is
placed over the
compound surface.
- Surgical side dipped
into hot water bath and
placed in the mouth
and border molded.
5/16/2023 23
Jaw relationship records
- Tissues that are fibrotic can only
minimally displaced by the
prosthetic borders.
- With more aggressive resection,
crossing the anterior midline,
tooth position and flange of
prosthesis should bee palatally
placed due to tissue collapse.
- Scar and suture line of the lip
change the normal drape of lip
and should accommodate with
occlusion and teeth position.
- Normal prosthetic landmarks
cannot be used to place dentition.
- Processed record bases are ideal
for jaw record.
- Modify wax rim to re-establish
occlusion.
- Recreate palatal contour on
surgical side to identical of
contours on remaining hard
palate.
- Routine denture appointment is
progressed.
5/16/2023 PRESENTATION TITLE 24
Jaw relationship records
- Improve lip closure by
buccolingual tooth position rather
than decrease in VDO.
- Processed base for lower arch is
needed to manually stabilize the
maxillary prosthesis during
centric relation record.
- Using adhesive is needed in
records.
- Sometimes it is necessary to
reduce the width of the occlusal
table on the surgical side to allow
for tongue space.
- Clinician may place a lid on the
obturator or bulb open for several
days.
5/16/2023 PRESENTATION TITLE 25
5/16/2023 PRESENTATION TITLE 26
5/16/2023 PRESENTATION TITLE 27
Insertion and instructions
Evaluated for pressure areas.
Bulb portion checked for functional pressure with tissue conditioning
material of contrast color.
Continue to wear interim at night (manage sinus secretions and
saliva).
mastication for large defects is difficult and patient should know diet
limitations and require denture adhesive.
28
Troubleshooting the obturator
prosthesis: leakage into the
nose
Evaluated by m and b sounds.
Complained of nasal reflux.
Caused by escape of air (it is predictable) mostly due to continued
fibrosis in the tissues bordering the prosthesis.
Using tissue conditioning material added and check swallowing and
speech if improved.
29
Troubleshooting the obturator
prosthesis: leakage into the
nose
Checking the thickest conditioning material area.
2-3mm thick material are targeted for reline in the periphery of the
bulb.
30
Troubleshooting the obturator
prosthesis: hypernasal speech
May be caused by other issues especially if sealing of periphery of
prosthesis is adequate.
It can be caused by dysfunctional soft palate and pharyngeal closure
which occur postoperatively in cases when a portion of soft palate is
also resected due to lesion.
In this situation the pharyngeal obturator is optimal for correction of speech.
31
Summary
- Edentulous obturators offer greater challenge for retention, speech and
mastication rather than conventional denture of dentate condition.
- No matter how many additional retentive elements are employed, sound
prosthodontic principles of using bony undercuts, achieving maximum
coverage without overextension and placing dentition in harmony with the
functional tissue are paramount for success of prosthesis in edentulous
patient.
5/16/2023 PRESENTATION TITLE 32
Thank you

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Clinical management of the edentulous maxillectomy patient.pptx

  • 1. Clinical management of the edentulous maxillectomy patient Ammar G. Salem 4th year KBMS – Restorative Dentistry
  • 2. Content Introduction Surgical enhancements Phases of prosthetic restorative Surgical obturator prosthesis Interim obturator prosthesis Definitive obturator prosthesis Troubleshooting the obturator prosthesis Summary Clinical management of edentulous maxillectomy patient 2
  • 3. Introduction Violation of the hard palate creates an anatomic defect that allows the oral cavity, maxillary sinus, nasal cavity and nasopharynx to become one confluent chamber. 3
  • 4. Introduction The lack of boundaries creates: - Disabilities in speech (hypernasality). - Inadequate oral nutrition. This makes the prosthetic intervention a necessity for the remainder of patient’s life. 4
  • 5. Surgical enhancements 1. Maintain as much hard palate as possible. 2. Skin graft the cheek flap. 3. Remove the inferior turbinate. 4. Skin graft the maxillary sinus walls.
  • 6. Maintain as much hard palate as possible - Aid in primary retention, support, and stability. - More ipsilateral premaxillary area to maintain: - More of tripoding prosthetic effect (stability). - Increased surface area (retention). - Maintaining anterior alveolus and floor of the nose  less collapse of facial form and less postoperative contracture. 6
  • 7. Skin graft of the cheek flap At surgery time after elevating the cheek away from the maxillary bones, this will leave a denuded surface on entire cheek flap. This has multiple disadvantages: - Bleeding surface extend many weeks (in case of healing by secondary intention). - Lately will be covered with respiratory epithelium which doesn’t serve well for prosthetic appliance. 7
  • 8. Skin graft of the cheek flap To overcome this, a split-thickness skin graft can be placed over denuded surfaces at the time of the surgery. This will provide: - Sound prosthetic bearing surface. - Not be easily abraded. - Does not secrete mucus. - Allows for vigorous cleaning of the defect. - May aid in retention. 8
  • 9. Remove the inferior turbinate Often likely not to be resected if tumor does not involve the nasal cavity. Resecting the inferior turbinate at time of surgery will: - Allowing extending the medial wall of the obturator bulb into the nasal cavity  this counters the rotation of the prosthesis. - Prevent bleeding from functional movement. - Allows liquids to reflux into the cavity at the medial periphery of the bulb. 9
  • 10. Skin graft of the maxillary sinus walls Preparation of the bony walls of the maxillary sinus to: - Allow the bony undercuts to serve for retention. - Provide vertical support to keep the prosthesis from rotating into the defect during mastication. Grafting sinus walls with split-thickness skin graft stops formation of polypoid tissue and mucus generation within the sinus + allows the walls to be stress-bearing areas. 10
  • 11. Phases of prosthetic restoration - Surgical obturator prosthesis. - Interim obturator prosthesis. - Definitive obturator prosthesis.
  • 12. Surgical obturator prosthesis • Less common used in edentulous than dentulous because of invasive method of securing. • Securing methods: • Palatal bone screw. • Suture into surrounding mucosa. • Circum-zygomatic wires. Fabrication procedure - Alginate impression with conventional denture coverage. - Reduce to normal contour any tumor bulk. - Extension to identical borders of complete denture (to avoid overextension). - Use autopolymerizing resin (only used for 10 days or less). 12
  • 13. Securing methods Bone screw retention - Placement into the vomer. - Hole predrilled through baseplate at anterior peak of palatal vault. - Offer most stability. Suture retention - In previously irradiated patient. - Sutures placed at the periphery of prosthesis. - It will have slight prosthesis movement. Circum-zygomatic wire retention - Most invasive and has greatest morbidity. - Not commonly used. 13
  • 14. Using existing dentures If denture not fitting well, it need reline prior to surgery. Patient should discontinue using lower denture. Disadvantages: - Obtaining comfortable occlusion, constant relining and reducing of flanges is almost impossible. - Postoperative facial contracture over the next weeks  significant reduction. - Teeth of surgical side often require facial reduction/removal of baseplate. - Need multiple appointments and more complex. 14
  • 15. Interim obturator prosthesis Impression - 5-10 days after surgery. - Using surgical obturator. - Using varied viscosity monomer and polymer manually shaped and placed incrementally along periphery of defect. - The entire defect shouldn’t be impressed at once. Patient movement, speech, and swallowing evaluation during border molding - Exaggerated head movements turning right to left with head level, neck flexed, and extended. - Open and close mouth, move mandible laterally. - No need to fill entire sinus space, only 2-3cm in height. - If periphery lowered to make contact with cut edge of soft palate, the prosthesis will be overextended and become irritating a few days after the clinical visit because that injured soft palate junction will contract and elevate back to the level of the hard palate very rapidly over next 2 weeks. 15
  • 16. Interim obturator prosthesis speech - Sounds formed when air passes through the nasal cavity m, n, ng. - When air is obstructed from passing out the nose m and ng sounds become hyponasal (like common cold). - Hypernasality is when air loss from oral into nasal cavity. - Distinct between m and b sounds. - If b is clear and distinct  no air escaped. - If b not distinguished from m, then air escapes. - Saying word beat, then occlude nares manually and say it again. - Drinking water with head upright to check reflux of water into nose or sinus. - Inability to control liquids and drooling is due to postoperative swelling and anesthesia 16
  • 17. 17
  • 18. Insertion of interim Prosthesis must be hollowed to decrease weight. It should be delivered within few hours due to rapid change in shape because of tissue edema. The patient is instructed to keep the prosthesis and only take it out for cleaning it and the surgical site. Regular use of denture adhesive. Instruct the patient that head upright position will decrease leakage of liquids through the nose. 18
  • 19. Revisions of interim Every 10-14 days over the next 2 months. Adjustments needed if pain or bleeding occurs. Reassure patient regarding increased hypernasality and nasal reflux. Tissue conditioning material will harden between visits and need reducing (at least 5mm) and resurfacing. If movement of mandible creates movement of prosthesis reduction of overextended areas. 19
  • 20. Definitive obturator prosthesis - Preliminary impression. - Final impression. - Jaw relationship records. - Insertion. - Instructions. - Lid fabrication of hollow.
  • 21. Preliminary impression - Offer max. extension within surgical site. - Not necessary to block out with gauze. - Prudent to block out palatal fistulas that open into intact maxillary sinus/nasal cavity. - Stock edentulous tray serve enough, - Support surgical side with compound or wax. 21
  • 22. Final impression - Custom tray should extend 2-3 cm into cavity. - Should extend beyond scar band and superior to the cut edge of the hard and soft palates leaving 5-8mm space for compound. - First impress the remaining palate with incremental addition of compound to the periphery of surgical site. - With every increment should be head movements and swallowing. - Cavity is convex from inferior to superior. 5/16/2023 22 - Superior extension beyond the greatest convexity adds weight to prosthesis. - Exception in remaining bony walls of maxillary sinus where they are resurfaced and split- thickness skin grafted.
  • 23. Final impression - After using compound, an impression wax is placed over the compound surface. - Surgical side dipped into hot water bath and placed in the mouth and border molded. 5/16/2023 23
  • 24. Jaw relationship records - Tissues that are fibrotic can only minimally displaced by the prosthetic borders. - With more aggressive resection, crossing the anterior midline, tooth position and flange of prosthesis should bee palatally placed due to tissue collapse. - Scar and suture line of the lip change the normal drape of lip and should accommodate with occlusion and teeth position. - Normal prosthetic landmarks cannot be used to place dentition. - Processed record bases are ideal for jaw record. - Modify wax rim to re-establish occlusion. - Recreate palatal contour on surgical side to identical of contours on remaining hard palate. - Routine denture appointment is progressed. 5/16/2023 PRESENTATION TITLE 24
  • 25. Jaw relationship records - Improve lip closure by buccolingual tooth position rather than decrease in VDO. - Processed base for lower arch is needed to manually stabilize the maxillary prosthesis during centric relation record. - Using adhesive is needed in records. - Sometimes it is necessary to reduce the width of the occlusal table on the surgical side to allow for tongue space. - Clinician may place a lid on the obturator or bulb open for several days. 5/16/2023 PRESENTATION TITLE 25
  • 28. Insertion and instructions Evaluated for pressure areas. Bulb portion checked for functional pressure with tissue conditioning material of contrast color. Continue to wear interim at night (manage sinus secretions and saliva). mastication for large defects is difficult and patient should know diet limitations and require denture adhesive. 28
  • 29. Troubleshooting the obturator prosthesis: leakage into the nose Evaluated by m and b sounds. Complained of nasal reflux. Caused by escape of air (it is predictable) mostly due to continued fibrosis in the tissues bordering the prosthesis. Using tissue conditioning material added and check swallowing and speech if improved. 29
  • 30. Troubleshooting the obturator prosthesis: leakage into the nose Checking the thickest conditioning material area. 2-3mm thick material are targeted for reline in the periphery of the bulb. 30
  • 31. Troubleshooting the obturator prosthesis: hypernasal speech May be caused by other issues especially if sealing of periphery of prosthesis is adequate. It can be caused by dysfunctional soft palate and pharyngeal closure which occur postoperatively in cases when a portion of soft palate is also resected due to lesion. In this situation the pharyngeal obturator is optimal for correction of speech. 31
  • 32. Summary - Edentulous obturators offer greater challenge for retention, speech and mastication rather than conventional denture of dentate condition. - No matter how many additional retentive elements are employed, sound prosthodontic principles of using bony undercuts, achieving maximum coverage without overextension and placing dentition in harmony with the functional tissue are paramount for success of prosthesis in edentulous patient. 5/16/2023 PRESENTATION TITLE 32

Editor's Notes

  1. Avoid surgical peripheries in soft palate and pterygoid area, surgical packing will close any discrepancies.
  2. Means baseplate+dentition
  3. Excess cut away by scissor. Continue until defect is sealed. Decreased opening + at once it wipes the material away + difficult to carry material into anatomic undercuts at one time.
  4. Check with pressure indicating paste Bulb portion is disclosed with light body tissue conditioning material of contrast color. Follow up in 24 hrs.
  5. For radiated patients it may take several months. Complete stable area may be 6-12 months.
  6. Using gauze add time, patient discomfort, material often shifts during impression (under-extended) Material can tear inside intact cavity, Block out with piece of cotton or gauze tied with floss. Require 60-100 mL custom nozzle to inject alginate. Using alginate with greater viscosity (no need for wax or inject)
  7. Registering the lateral and posterior walls of sinus aid in resisting the swallowing and mastication displacement forces.
  8. To try to push the contracted tissue lead to overextension and considerable dislodging forces. Attempt to maintain dentition in its place will dislodge. Processed base will reveal optimal retention before teeth added.
  9. Soft tissue will change and require an hour of wearing id left overnight.
  10. Soft tissue will change and require an hour of wearing id left overnight.
  11. Soft tissue will change and require an hour of wearing id left overnight.
  12. Soft tissue will change and require an hour of wearing id left overnight.