Restoration of maxillectomy defects demand varied modifications in prosthesis fabrication, to make them lighter and well-tolerated by the patient. Literature suggests the use of various retentive aids for the construction of conventional obturator to improve retention and oral function.

2. CONTEMPORARY TREATMENT MODALITIES FOR
DEFINITIVE REHABILITATION OF ACQUIRED MAXILLARY
DEFECTS – A REVIEW
Kathleen Manuela D’souza1,*, Sapna Sada Raut Dessai2 , Elaine Savia Barretto3 , Dinesh Swamy3 , Meena Ajay Aras1
Ijohd.2020.019 2395-4914/ 2020 Innovative Publication
Nishu Priya
2nd year PGT
Department of Prosthodontics and Crown &
Bridge

3. INTRODUCTION
 Rehabilitation of acquired maxillary defects is a daunting
task.
 Spontaneous loss of teeth, distortion of intra-oral
anatomy, facial and functional impairment can negatively
affect the patient’s quality of life.
 Effective treatment modalities are necessary to promote
oral function and psychological well-being.
infections
trauma
inflammatory diseases
neoplastic diseases
Factors influencing successful rehabilitation
teeth present
size and location of the acquired defect
the quantity and integrity of the residual
maxilla
presence of retentive scar band
muscular control
nature of defect supporting structures
radiation therapy
disease recurrence
Failure to follow the necessary guidelines can lead to premature
loss of abutment teeth, chronic irritation of soft tissue and loss
of prosthesis retention.

4. 1. DEFINITIVE OBTURATOR
 Definitive obturators are usually advised in smaller maxillary defects due to the functional and aesthetic
challenges faced in larger defects.
 permit immediate restoration of function with minimal surgical intervention
 inspection of the defect area for recurrent lesions.
 facilitate oral hygiene procedures and are economical.
Disadvantages
• non-permanent closure of the oral and sinonasal
communications
• arduous placement in patients with trismus and extensive
defects
• need for frequent adjustments

5. CONVENTIONAL DEFINITIVE OBTURATOR
 Restoration of maxillectomy defects demand varied
modifications in prosthesis fabrication, to make them lighter
and well-tolerated by the patient.
 Literature suggests the use of various retentive aids for the
construction of conventional obturator to improve retention
and oral function.
Retentive aids:
• extension into nasal aperture space
• bar-clip system
• ball attachment,
• Magnets
• orthodontic wire clasps

6. • telescopic crowns
• swinglock attachment
• Spring trained obturators

7. II. IMPLANT-SUPPORTED OBTURATOR
 A significant number of patients have difficulty in retaining the obturator prosthesis
due to absence of teeth and/or extensive defect size. This necessitates the
utilization of osseointegrated dental implants as a framework for the overlying
prostheses.
 promotes increased retention of the removable prostheses
 reduction in the load placed on the vulnerable soft tissues.
 less expensive than fixed prostheses and can better compensate for any remaining
defects following soft tissue reconstruction.
Implant survival is significantly influenced by
• the experience of the surgeon,
• bone quality,
• the patients’ general and oral health personal habits
• use of hyperbaric oxygen therapy (HBO) has resulted in
improved osseointegration of implants placed in radiated
bone
Implants are contraindicated in the following
patients:
1) systemically compromised, 2) small defects with
sufficient remaining dentition, 3) recurrent disease
and 4) noncompliant.

8. CONVENTIONAL DENTAL IMPLANTS
 Implants should be placed in the residual alveolar bone
rather than the bone surrounding the defect site.
 Favorable implant positions include premaxilla, tuberosity
and posterior alveolus.
 Reduction of cantilever stresses, rigid fixation of prosthesis,
crossarch stabilization by splinting all the implants and close
adaptation with maximal lateral extension of obturator
minimizes technical and biological complications.

9. ZYGOMATIC IMPLANTS
 Zygomatic implants are used for prosthetic rehabilitation of
extensive defects, in absence of adequate maxillary alveolar bone
and in the presence of a minimum of 15 mm of zygomatic bone
support.
 Implant position and angulation should provide favorable AP
spread.
 Bilateral defects demand the placement of two zygoma implants
bilaterally.
 Unilateral defects without teeth in the unaffected side need one or
two zygoma implants in the affected side and 2 or 3 regular
dental implants with long AP spread in the unaffected side.

10. Limitations:
• unavailability of bone,
• restricted intra-operative vision,
• anatomic complexity and variability
of zygoma bone.
• overloading leverage in large
defects,
• overgrowth of local soft tissue
preventing abutment connection,
• sinus infections,
• facial pain,
• damage to surrounding structures
and positional errors
• Boyes-Varley et al. advocated immediate implantation of
zygomatic implants following ablative surgery to circumvent
the need for a vascularized flap and its associated
inconveniences.
• In addition, this protocol allows implant osseointegration prior
to postoperative radiotherapy.
• He suggested the fabrication of fixed-removable overdentures
or fixed prostheses placed over definitive cast titanium
superstructure, with and without separate obturators.

11. PTERYGOID IMPLANTS
 These implants are anchored in the pterygoid plate
through the maxillary tuberosity.
 They follow an oblique mesiocranial direction and end
either in the pterygoid or scaphoid fossa of the
sphenoid bone.
 The success rate of pterygoid implants has been
recorded to be 97.05% at one year follow-up.
 However, surgical complications have been reported,
such as, trismus, misplacement of implant and bleeding.
• Placement under local anesthesia
• Good anchorage due to appropriate density of
bone
• Tuberosity rests against the denser mass of
cortical bone formed by pyramidal process of
palatine bone and pterygoid process of sphenoid
bone.

12. CAD/CAM TECHNOLOGY IN MANAGEMENT OF ACQUIRED
MAXILLARY DEFECTS
 promotes better presurgical preparation
 decreases intraoperative time,
 increases accuracy of reconstruction
 produces superior outcomes especially in cases
with limited visibility and anatomic complexity.
Digitally
scanning,
surveying and
designing the
framework on the
master cast using
model scanner
and computer
software
CAM technology can
be used to
manufacture a resin
positive mould
representing the
defect shape, which
can aid in final
impression
procedures for the
obturator.

13. SURGICAL RECONSTRUCTION
 It requires proper patient selection based on the patient’s medical condition, tolerance to donor site
morbidity, ability to undergo multiple revision surgeries and economic status.
The goals of surgical reconstruction include:
1. immediate single-stage closure of the defect,
2. preserve normal speech, swallowing and velopharyngeal function,
3. obliterate postoperative dead space,
4. minimize the inconveniences of removable obturators,
5. provide support for facial soft tissue and orbital contents and
6. create a stable pre-prosthetic framework for implant reconstruction and/or obturator fabrication.
the prime disadvantage of surgical reconstruction is that it does not allow direct inspection of the resection cavity,
in case of postoperative recurrence.

14. Small localized defects involving posterior maxilla and palate
are usually restored with local flaps and regional pedicled flaps with
or without free bone grafts, such as, buccal pad of fat,temporalis
myofacial, Sternocleidomastoid , and Pectoralis Major flap.
Larger maxillary defects require either free vascularized soft
tissue flaps combined with free bone grafts or vascularized
osteomyocutaneous flaps (free bone flaps) followed by implant
placement.
Flaps are unable to provide bony support for facial
structures and implant placement. Therefore, these
flaps are usually used in combination with non-
vascularized bone grafts or titanium mesh.
Tissue prefabrication
technique

15. Prosthetic rehabilitation following surgical
reconstruction
Retention may be
compromised due to the bulk
and mobility of the flap tissue.
Growth of hair and excessive
flap thickness may interfere
with the fabrication
procedures of the prosthesis
planning the
prosthodontic
rehabilitation of the
patient prior to
surgery
bone augmentation
procedures
additional soft-tissue
surgery

16. BONE TISSUE ENGINEERING FOR MAXILLECTOMY DEFECTS
 Tissue engineering involves regeneration of new tissue with biologic mediators.
 Recent research has reported the use of stem cells, growth factors and a synthetic scaffold as alternative
method for defect repair, in an attempt to alleviate the disadvantages encountered with surgical
reconstruction.
 The accessibility of equipment and expertise for stem cell harvesting and culturing is limited and a long delay is
associated with the completion of the reconstruction. Thus, further research is necessary, before bone tissue
engineering can be effectively applied in a clinical setting.

17. RELATED ARTICLES
1

18. PROSTHODONTIC REHABILITATION OF MAXILLARY
DEFECT IN A PATIENT WITH MUCORMYCOSIS
SATYA PRAKASH M, ASHOK V, NESAPPAN T ET AL. PROSTHODONTIC REHABILITATION OF MAXILLARY DEFECT IN A
PATIENT WITH MUCORMYCOSIS. J EVOLUTION MED DENT SCI 2020;9(42):3163- 3166, DOI: 10.14260/JEMDS/2020/692

19. CASE REPORT
 A 26-year-old male patient reported to the Department of Prosthodontics, Saveetha Dental College &
Hospital, Chennai, with a chief complaint of difficulty in chewing and unaesthetic appearance for the past 16
months.
 History: Medical examination revealed that the patient had a history of kidney failure and got transplanted six
years before. He had a history of mucormycosis and got treated 16 months before where partial
maxillectomy was done.
 On oral examination, in maxilla the teeth present are 16,17,26,27 and in mandible all teeth are present
without any infection.

21. APPROACH
 On radiographic evaluation, a thin bone is present in maxilla, bilaterally up to 2nd premolar region.
Based on diagnosis, implant prosthesis was ruled out due to the immune status and the bone quantity of
the patient. A removable prosthesis with a cast partial denture was planned with porcelain fused metal
surveyed crowns in relation to 16, 17, 26, 27.

22. Primary casts

23. Border molding Secondary impression After abutment prepration

24. Crowns leaving
rest seat for
the direct
retainer
Cast partial
denture
framework
Wax trial
prosthesi
s

25. Intraoral view

26. The natural teeth
have to be preserved
as much as possible.
Bone
support
s the
soft
tissue.
reduced soft tissue support- psychological
trauma
reduces the alveolar bone resorption
gives retention, stability and support to the
prosthesis
DISCUSSION
Tooth supported prosthesis will be the best option since it gives proprioception. If the abutment teeth are less in
number or the condition of the abutment teeth to withstand force is less, tooth supported over dentures can be
an option.
In the present case, clasps engaging the abutment teeth offer additional prosthetic retention.
A good prosthesis not only rehabilitates the patient’s lost function and aesthetics but also gives confidence and
comfort in society.

27. RELATED ARTICLES
II

28. A PRACTICAL APPROACH TO OROFACIAL REHABILITATION IN A
PATIENT AFTER INFERIOR MAXILLECTOMY AND RHINECTOMY WITH
MONO FRAMEWORK CONSTRUCTION SUPPORTED ON A
ZYGOMATIC IMPLANT PLACED IN THE GLABELLA: A CASE REPORT
GAUR ET AL. MAXILLOFACIAL PLASTIC AND RECONSTRUCTIVE SURGERY (2021) 43:25

29. CASE REPORT
 A 48-year-old man was referred to the maxillofacial clinic of Mannan
Hospital, Chennai, India, with a severe face deformation and difficulty
in chewing with restricted mouth opening.
 He had undergone anterior segmental maxillectomy along with right
antrostomy and complete rhinectomy 4 years back as a treatment for
oral squamous cell carcinoma. The post-surgical defect was closed
after mobilizing the pectoralis major myocutaneous flap (PMMC).
 After the surgery patient did not undergo any additional radio- or
chemotherapy.

30.  Complaints: A broad nasal opening led to
anterior facial deformity. Moreover, hyper-
nasal tone, abnormal breathing pattern,
inability to masticate, and speak properly
 Extraorally, as of the bulky skin island and the
flap, the base for the nasal epithesis was
devoid of supporting nasal and alveolar bone.
Anteriorly, the resection included septum, the
nasal piriformis, and support of the alar base.

31. Intraorally, all the upper incisors up to premolars were missing bilaterally, as well as lower left
molars. There was excess bulk of the PMMC flap on the right side and restricted mouth opening
and constricted right corner of the mouth.

32. APPROACH
 Because of the patient’s fear of additional surgeries, hard tissue augmentations like fibula or iliac crest bone
graft were not performed. One of the consequences of this decision was the lack of stable bone in the front
of the maxillae for the implant placement.
 To solve these problems, additional zygomatic implant engaging glabella/floor of the frontal sinus was
chosen in order to anchor the implant in the native bone which, together with the pterygoid implants, would
allow to create enough support for the implant-retained prosthesis with nasal epithesis. This solution was
offered to the patient as one of the possible treatment options, which the patient readily accepted and
agreed to.
 Prior to implant placement, all the remaining teeth were extracted due to their questionable periodontal
support.
 In the mandible, three implants were placed in order to replace the left molar.

34. Glabella
osteotomy
Implant procedure Metal try in

40. One year follow up

41. DISCUSSION
 Rehabilitating resection cases with dental implants is a tedious and challenging task.
 Zygomatic bone engagement is one of the most evidence-based techniques when restoring the resected
or atrophic cases.

42.  One of the principles of single-piece implants placement is to place them in different directions and at
different angles; thus, when splinted, they would resist the lateral forces.
 Most studies present the construction of the nasal craniofacial prosthesis framework by zygomatic and
small glabella implants combined with the support from the piriform aperture engaging the nasal floor
or the nasomaxillary buttress. In this case, there was no nasal base and the lateral wall bone which could
be used for implant anchorage. Thus, the prosthetic idea was to make margins over the mobile soft
tissue.
 Main limitation of this type of treatment is difficulty in zygomatic, tubero-pterygoid, and glabella
osteotomy and implant placement especially without anatomical landmarks.
 Properly executed treatment improved the esthetics, speech, masticatory function, muscle support, and
overall quality of life.

43. CONCLUSION
 Subtotal maxillectomy defects represent a complex challenge for the maxillofacial prosthodontist and
patients. The key factor in prosthetic rehabilitation of maxillectomy patients is the separation of the oral
and nasal cavities. Prosthetic success of a maxillary obturator is directly related to support, retention, and
stability of the prosthesis.
 Recent developments in rehabilitative techniques for acquired maxillary defects has ensued
improvements in the quality of life. Reconstructive and rehabilitative techniques involving
osseointegration, microvascular free tissue transfer and CAD/CAM technology have resulted in improved
functional and aesthetic outcomes.