Acquired Maxillary Defects

Basic differences between congenital and acquired maxillary defects

Congenital clefts are confined to the lines of union

Etiology
1. Surgical Is the main etiological factor namely resection of tumor masses 2. Disease e.g. Syphilis, osteomeylitis (rare) 3. Trauma Gun shots (suicide attempts)

Disabilities
Most of the disabilities are related to communication of the oral and nasal cavities 1. Mastication Regurgitation 2. Speech Hypernasality 3. Appearance Diplopia etc. 4. Psychological Could be worst of all

Rehabilitation
1. Surgical

2. Prosthetic

Surgical reconstruction
Is definitely the best treatment when feasible: 1. No possibility of recurrence after tumor resection 2. After trauma 3. Relatively small defects (great defects greatly complicates the surgical approach)

Prosthetic reconstruction
Is indicated in cases surgical reconstruction is not possible 1. Possibility of recurrence after tumor resection 2. Relatively large defects (great defects greatly complicates the surgical approach) 3. Large soft palate defects

Phases of prosthetic reconstruction

A. Surgical obturation Incorporated at the time of surgery or shortly thereafter 1. Immediate surgical obturation 2. Delayed surgical obturation B. Definitive obturation Incorporated 3-4 after surgery

Immediate surgical obturation

- Indicated in edentulous subjects Functions - Matrix for the surgical pack - Separates oral cavity from nasal cavity i.e. patient can speak and swallow with less difficulties - Reduces possibilities of wound contamination - Reduces psychological impact on patient

Communication between prosthodontist and surgeon

- Spare post. portion of hard palate and tuberosity to avoid loss of function of the soft palate. - Ant. Incision through a tooth socket rather than interdental ( sectioning of FPD)

Communication between prosthodontist and surgeon

- Should terminate short of skin graft-mucosal junction.

Construction of immediate surgical obturator

- Complete history, diagnosis, shade and form registration - Tooth analysis and preparation (occlusal adjustments, occlusal rest seat preparation, dimpling etc) - Modification of the stock tray - Pt seated upright in order to record the proper position of the soft palate - Irreversible hydrocolloid is the material of choice

Construction of immediate surgical obturator

- Provisional jaw relationship - Pouring the impression and cast duplication - Outline of resection marked on the cast - Cast alteration - Clasping the existing teeth - Posterior artificial teeth should not included - Waxing-up followed by processing - Drilling interproximal holes - Attaching wire loops to the fitting surface at the area that corresponds to the resected area

Incorporation of immediate surgical obturator

- Obturator picked up from an antiseptic solution - Modifying the obturator to fit the surgical defect - Avoid pressure on the skin graft mucosa junction - Block undesired undercuts with vaselinized gauze - Add tissue conditioner or compound to the fitting surface of the obturator

Incorporation of immediate surgical obturator

- Fitting surface of the obturator can be used to support the skin graft. Black gutta percha is preferred because it is less irritant than tissue conditioning materials - Donor sites of skin grafts include inner side of arm (unhairy)

Incorporation of immediate surgical obturator

- Retention could be obtained from: - Clasps - Wires ligated to teeth - In edentulous areas ligation to zygomatic arch or ant. nasal spine - Patient is 7-10 days later to -maintain hygiene underneath the prosthesis - adjust retention - Add tissue conditioner

Incorporation of immediate surgical obturator

- Adding posterior occlusal ramps - PIP to check pressure areas

Delayed surgical obturator

Indications Extensive surgical defects in edentulous subjects Procedure - Carried out 7-10 after surgery - Modification of the stock tray - Irreversible hydrocolloid is the material of choice

Delayed surgical obturator

- Block undesired undercuts with vaselinized gauze - Patients complete denture could be used for the same purpose but after modification

Definitive obturator
- Usually constructed 3-4 months after surgery - Exact timing is controlled by the following factors: - Possibilities of recurrence - Progress in the process of healing which is effected by size and whether patient received radiotherapy - Presence of teeth which greatly contributes to retention and stability - Effectiveness of the present obturator

Design features of definitive obturators

-Movement of the

obturator - Is affected by: a. Size of the defect b. Number of missing teeth

Design features of definitive obturators

-Movement of the obturator c. Distribution of missing teeth - Both tissue-ward and tissueaway movements are expected and unless properly controlled could be extensive

Design features of definitive obturators

- Tissue changes - Could extend for a long period - Results in tissue contracture especially in the absence of a skin graft - Is more pronounced in patients receiving radiotherapy - Acrylic resin is the material of choice to facilitate rebasing and relining

Design features of definitive obturators

- Covering prosthesis - Main objective is to separate oral and nasal cavities - Contours of the defect are usually not extensively movable

Design features of definitive obturators

- Extension into the defect - Extension in the defect should be minimally without compromising retention, stability and peripheral seal.

Design features of definitive obturators

- Extension into the defect - Need for extension into the defect is controlled by: a. Size of the defect b. Nature and configuration of the remaining supporting structures

Design features of definitive obturators

- Extension into the defect - Extension superiorly along the nasal septum is not recommended because pseudostrafied columnar epithelium offers little mechanical advantage

Design features of definitive obturators

- Extension into the defect - Lateral extension is recommended especially when a skin graft is used - Posterior undercuts related to the soft palate are favorable - Anterior undercuts are usually not engaged

Design features of definitive obturators

- Presence of teeth - Is crucial in improving prognosis

Design features of definitive obturators

- Weight - Hollow design is recommended - Controversy exists as to whether to use a. open or b. closed designs

Definitive obturators in edentulous subjects

- Lack of teeth greatly worsens the prognosis especially in large defects - Implants improve prognosis - Hyperbaric oxygen improves prognosis of implants in irradiated subjects - Axis of rotation depends on the location and configuration of the defect - Increased engagement of the defect is important to improve retention and stability

Definitive obturators in edentulous subjects

- Square and ovoid arches provide a better configuration of the palatal shelf compared to tapered arches - Sparing part of the posterior maxilla improves prognosis - Proper extension in the sulci of the intact side is important - Engagement of the lateral scar band - Engaging favorable undercuts - Resilient materials

Technique of construction of definitive obturators

Primary impression - Tray modification - Blocking unfavorable undercuts - Applying adhesive to the tray - Irreversible hydrocolloids is the material of choice

Technique of construction of definitive obturators

Secondary impression - Special tray is constructed on blocked-out model - Border molding - Rubber base is the material of choice (alginate is the cheap alternative) - Tissue conditioner on the surgical obturator is an alternative

Technique of construction of definitive obturators

Jaw relation registration - Record bases or the definitive obturator base can be used in this step - Superior displacement should be minimized - Metallic oxide impression paste and plaster of Paris are better than wax for jaw relation registration - VDO could be reduced especially in cases of bruxism

Technique of construction of definitive obturators

- Occlusal schemes - Non anatomic teeth are prefered - Try in - Processing - Mostly acrylic resin - Soft liners could be used in selected cases - Polished fitting surface at the side of the defect

Definitive obturators in dentulous subjects

- Cases of total unilateral maxillectomy should be treated as an extensive Kennedy class II partial edentulous case

Retention of definitive obturators

- Clasping - Buccal retaining flanges - Swing-lock design - Undercuts in the defect - Implants - Magnets - Adhesives - Intermaxillary springs (obsolete)

Definitive obturators in dentulous subjects

- Guide planes and a precisely controlled path of insertion is of prime importance - Multiple extensive occlusal rests - Mostly rigid major connectors are employed - The tooth adjacent to the anterior margin of the defect should be used for support and retention - Due to lack of cross arch retention and stabilization, such RPD could sometimes be viewed as unilateral RPD. Double retention double bracing is sometimes indicated

Definitive obturators in dentulous subjects

- Existing teeth controls the location of the fulcrum line - Metal framework is used in making the impression implementing the altered cast technique - The prognosis of the obturator improves as the margin of resection moves posteriorly

Hollowing the obturator bulb

- Cellophane bag containing sand - Lid made of acrylic resin