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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 14  |  Issue : 5  |  Page : 524-528

Surgical obturator as an immediate prosthesis post hemimaxillectomy of palatal squamous cell carcinoma: A case report


1 Department of Prosthodontic, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
2 Undergraduate Student, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia

Date of Submission16-Sep-2021
Date of Decision22-Jul-2022
Date of Acceptance26-Jul-2022
Date of Web Publication31-Oct-2022

Correspondence Address:
Dr. Ratri M Sitalaksmi
Department of Prosthodontic, Faculty of Dental Medicine, Universitas Airlangga, Mayjend Prof. Dr. Moestopo 47, Surabaya
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_251_21

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  Abstract 

Surgical management of oral squamous cell carcinoma results in significant defects in the oral and maxillofacial regions. This case study aims to support the formation of an intraoral defect profile, shorten recovery time, and improve the patient’s psychological aspects by inserting a postoperative surgical obturator. A 44-years-old male presented to Dental Hospital Universitas Airlangga at the referral from General Hospital Dr. Soetomo Head and Neck Surgery Department due to recurrent palatal squamous cell carcinoma. The patient required a surgical obturator to restore anatomical defect post-hemimaxillectomy. Multidiscipline discussion forums were performed to determine the plan for tissue removal, and the prosthodontist designed the surgical obturator. The design was made utilizing the retention of the remaining 17 and 27 teeth with Adams claps. In this case, mechanical retention was achieved by a wire, which was attached to the zygoma bone. The artificial teeth were arranged in the anterior area to improve aesthetic, while in the posterior region, the artificial teeth were not used to minimize the masticatory loading. Surgical obturator improved the masticatory function and psychology of the patient.

Keywords: Carcinoma, Hemimaxilectomy, Human and Health, Maxillofacial Prosthesis, Surgical Obturator


How to cite this article:
Sitalaksmi RM, Ari MD, Mundiratri K, Sanjaya RA, Pramesti TR, Dahlan A. Surgical obturator as an immediate prosthesis post hemimaxillectomy of palatal squamous cell carcinoma: A case report. J Int Oral Health 2022;14:524-8

How to cite this URL:
Sitalaksmi RM, Ari MD, Mundiratri K, Sanjaya RA, Pramesti TR, Dahlan A. Surgical obturator as an immediate prosthesis post hemimaxillectomy of palatal squamous cell carcinoma: A case report. J Int Oral Health [serial online] 2022 [cited 2022 Dec 4];14:524-8. Available from: https://www.jioh.org/text.asp?2022/14/5/524/359963




  Introduction Top


Squamous cell carcinoma is one of the most prevalent malignancies found in the oral cavity. The incidence of oral squamous cell carcinoma (OSCC) involving the hard palate and soft palate are 50% and 70%, respectively.[1],[2] Despite advancements in combined therapy, including as surgery, chemotherapy, and radiotherapy, the 5-year survival rate of oral squamous cell carcinoma (OSCC) is still around 40%. Despite the fact that OSCC is found in a visible area of the surface mucosa, up to 50% of cases are detected late. Because speech, mastication, and swallowing are all necessary functions of the oral cavity, the treatment method for oral cavity cancer has a direct impact on the patients’ quality of life. The most effective strategy to reduce fatality rates, morbidity, and anatomical injury is through early detection and diagnosis.[3]

Surgery is one of the treatment option commonly used in patients diagnosed with this disease. Surgical treatment, in this case, involves the removal of part or all of the maxillary structure and leaves a defect that can interfere with the integrity and function of the oral cavity.[4] The management of OSCC requires multidisciplinary treatment mainly by oral and maxillofacial surgeons, head and neck specialists, and prosthodontists. Prosthodontists have a pivotal role in maxillectomy cases to assist recovery and rehabilitation of the patients by manufacturing and installing surgical obturators.[4]

A post-operative surgical obturator has to be inserted into the patients. This case study seeks to explain support the formation of an intraoral defect profile, shorten recovery time, and improve the patient’s psychological aspects by inserting a postoperative surgical. A surgical obturator can be post-operative soft tissue support and minimize tissue contraction from wound defects to positively impact patient psychology. Rehabilitation with this prosthesis that replaces the structure of the teeth and palate can help restore speech, mastication, and esthetics.[5],[6],[7],[8]


  Case Report Top


A 44-years-old male patient was referred to the Dental Hospital Universitas Airlangga by the department of Head and Neck Surgery Dr. Soetomo General Hospital due to recurrent palatal squamous cell carcinoma. The patient requires a surgical obturator to support hemimaxilectomy. Six months ago, the patient was diagnosed with localized oral squamous cell carcinoma. The diagnose showed that the patient got a partial maxillectomy performed on the maxillary anterior region. Three months recall post-surgery, the patient complained about a persistently ulcerated lesion that appeared in the maxillary mucolabial fold. Clinical examination the patient got further examination; there was recurrence and extension of the previous carcinoma. The patient was diagnosed with Oral Squamous Cell Carcinoma palatal region (T2a N0 M0). The patient had never used dentures. On examination, there were asymmetrical lips caused by a maxillectomy defect in previous surgery, causing a concave upper lip profile [Figure 1] and [Figure 2].
Figure 1: Patient profile. Front view (a) and side view (b)

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Figure 2: Patient clinical photo. Right view (a), front view (b), left view (c), Maxillary occlusal view (d) and Mandibular occlusal view (e)

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  Case Management Top


In the first stage of treatment, a thorough discussion of the treatment plan was conducted, and the patient’s informed consent was acquired. Subsequently, anatomical impressions of the maxilla and mandible were taken using a stock tray with irreversible hydrocolloid (alginate), and the positive impressions were made with type III plaster (dental stone). The next step was mounting the study model to the articulator, and a complete treatment plan and surgical obturator design were established [Figure 3]a, b, and c.
Figure 3: Study model left view (a), front view (b) and right view (c) design of the surgical obturator (d)

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The study model was utilized to fabricate the surgical obturator [[Figure 3d]]. Adam’s clasp was used as retentive components, and artificial teeth were arranged in the anterior region to improve the patient’s aesthetic. The posterior region was left edentulous to minimize masticatory loading. The finishing stage of the wax-up was conducted and then continued by the acrylic packing stage. After the fabrication of the surgical obturator was completed, we made several retention holes on the entire surface edge of the obturator [Figure 4] and [Figure 5].
Figure 4: Arrangement the artificial teeth occlusal view (a), front view (b), right view (c) and left view (d)

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Figure 5: Surgical obturator after polishing

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A day before surgery, the obturator was disinfected by an antiseptic solution. The surgery was performed by a head and neck surgeon Dr. Soetomo General Hospital, Surabaya [Figure 6], [Figure 7], and [Figure 8]. After the surgical procedure was finished, the surgical obturator was adjusted to the patient. Adam’s clasp was placed on teeth 17 and 27 and fixated to the right and left zygomatic bone using wires as presented in [Figure 9]. Extraoral and intraoral suturing were done on the entire retention hole of the surgical obturator using a simple interrupted suture technique. The occlusion evaluation was done, and no occlusal adjustment is needed [Figure 10].
Figure 6: Try in the surgical obturator on patient

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Figure 7: Wire placement on the edge of the surgical obturator

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Figure 8: Fixation on the anterior region to get occlusion and stability of the surgical obturator

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Figure 9: Fixation on lef and right zygoma

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Figure 10: Insertion of surgical obturator extra oral (a) and intraoral (b and c)

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After the surgery, the patient was instructed to maintain the hygiene of the surgical wound and only to consume liquid diet. On the first control (three days’ post-surgery), the patient complained of moderate discomfort in the operated area. The intraoral examination showed redness (+), bleeding (-), swelling (+), debris (+) in the operated area. We irrigated the area using 3% H2O2 and clean the surgical obturator. In the second control (ten days after the surgery), patients complained of minor discomfort in the operated area, and intraoral examination shows improvement of clinical symptoms, redness (-), bleeding (-), swelling (-), debris (+). We instructed the patient to consume a soft diet and visit for evaluation one month after the second control for the interim obturator planning.


  Discussion Top


The design of the surgical obturator utilized the 17 and 27 teeth as abutment with Adam’s clasp and retentive component. Retention using a wrought-wire clasp has long been used as a type of retention in the manufacture of surgical obturators.[9],[10] In this case, mechanical retention in the form of a zygoma-attached wire is also used. A similar case has also been carried out by Appadurai et al. (2019), which shows one of the relatively easy ways to obtain retention in maxillectomy cases where retention to the dentition is challenging.[11]

The surgical obturator design involves the arrangement of anterior artificial teeth, while in the posterior region, the surgical obturator design is only a plate without artificial teeth. The arrangement of artificial teeth in the anterior region supported the aesthetic function of the prosthesis used by the patient. Some authors also recommend that in the manufacture of surgical obturators, the posterior part should be freed from occlusal contacts and only functioned to close the defect and form a palatal. This design is continued until the surgical wound has healed and is ready for an interim obturator.[12],[13]

An interim obturator can be made 4 to 6 weeks after insertion of the surgical obturator.[12] Following the instructions carried out at the second control, an evaluation will be carried out one month after the second control and assess the readiness of the defect tissue to receive the interim obturator. An interim obturator can be made to prepare healthy tissue that can receive complete stomatognathic function through definitive obturator prosthesis.[14],[15],[16],[17] In surgical obturators, education to maintaining oral hygiene is essential to support the healing process and tissue regeneration after surgery. This treatment aims to avoid local infections that can hinder the healing process. In the end, prostheses on maxillofacial defects significantly impact the patient’s quality of life when he returns to the social environment and increases the patient’s confidence.

This case will get a lot of research, but there are some conclusions that can be relied on right away for postoperative surgical obturator was effective for supporting the formation of an intraoral defect profile and shorten recovery time. The issue of surgical management OSCC is an intriguing one which could be usefully explored in further research.


  Conclusion Top


The study contributes to our understanding of surgical management of OSCC by postoporeative surgical obturator insertion. The surgical obturator can shorten the recovery time in 7 weeks. Interim obturator can be made to prepare healthy tissue that can receive complete stomatognathic function through definitive obturator prosthesis. The prostheses on maxillofacial defects significantly impact the patient’s quality of life when the patient returns to the social environment and increases the patient’s confidence The issue of surgical management OSCC is an intriguing one which could be usefully explored in further research.

Acknowledgement

The authors would like to thank the Faculty of Dental Medicine, Universitas Airlangga, Surabaya.

Financial support and sponsorship

None to declare.

Conflict of interest

There are no conflicts of interest.

Author contribution

Study conception, design, definition of intellectual content, literature search, clinical studies (RMS, MDAA, KM, RAAS, TRP, AD); Experimental studies, data acquisition, data analysis, statistical analysis (RAAS, TRP, AD); Manuscript preparation, editing, review, and guarantor (RMS, MDAA, KM).

Ethical policy and institutional review board statement

Not applicable.

Patient decaration of consent

The authors certify that the patient(s) has/have consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Data availability statement

Not applicable.



 
  References Top

1.
Abu Rass NAA, Surougi ER, Baheydarah SM, Baroom AH, ALGhamdi H, AlTuwayjiri HK, et al. Neoplasms of the palate: A review. Egypt J Hosp Med 2018;70:1393-400.  Back to cited text no. 1
    
2.
Massano J, Regateiro FS, Januário G, Ferreira A Oral squamous cell carcinoma: Review of prognostic and predictive factors. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:67-76.  Back to cited text no. 2
    
3.
Kim E, Chung M, Jeong H-S, Baek C-H, Cho J Histological features of differentiated dysplasia in the oral mucosa: A review of oral invasive squamous cell carcinoma cases diagnosed with benign or low-grade dysplasia on previous biopsies. Hum Pathol 2022;126:45-54.  Back to cited text no. 3
    
4.
Lee OH, Cho U, An JS, Cho JH Prognostic significance of the metastatic lingual lymph node in oral tongue and floor of mouth squamous cell carcinoma. J Oral Maxillofac Surg 2022;80:553-8.  Back to cited text no. 4
    
5.
Dalkiz M, Dalkiz AS The effect of immediate obturator reconstruction after radical maxillary resections on speech and other functions. Dent J 2018;6:22.  Back to cited text no. 5
    
6.
Pisulkar S, Pakhan AJ, Godbole SR Psychological considerations in patients with maxillofacial defects: A literature review. J Adv Stud 2020;1:57-60.  Back to cited text no. 6
    
7.
Patil P. Surgical obturator duplicating original tissue-form restores esthetics and function in oral cancer. World J Stomatol 2013;2:97-102.  Back to cited text no. 7
    
8.
Phasuk K, Haug SP Maxillofacial prosthetics. Oral Maxillofac Surg Clin North Am 2018;30:487-97.  Back to cited text no. 8
    
9.
Raja HZ, Saleem MN Gaining retention, support and stability of a maxillary obturator. J Coll Physicians Surg Pak 2011;21:311-4.  Back to cited text no. 9
    
10.
Chen C, Ren W, Gao L, Cheng Z, Zhang L, Li S, et al. Function of obturator prosthesis after maxillectomy and prosthetic obturator rehabilitation. Braz J Otorhinolaryngol 2016;82:177-83.  Back to cited text no. 10
    
11.
Appadurai R, Lingeshwar D, Dilshad B, Maria S Surgical retention for immediate obturator in maxillectomy patients. Indian J Dent Res 2019;30:133-4.  Back to cited text no. 11
    
12.
Beumer III J, Marunick MT, Esposito SJ Maxillofacial Rehabilitation: Prosthodontic and Surgical Management of Cancer-Related, Acquired, and Congenital Defects of the Head and Neck. 3rd ed. Hanover Park, IL: CBS; 2011. p. 468.  Back to cited text no. 12
    
13.
Kamiyanagi A, Sumita Y, Hattori M, Otomaru T, Murase M, Haraguchi M, et al. Clinical survey about immediate surgical obturator at the clinic for maxillofacial prosthetics tokyo medical and dental university. J Prosthodont Res 2020;64:237-8.  Back to cited text no. 13
    
14.
Dholam KP, Bachher G, Gurav SV Changes in the quality of life and acoustic speech parameters of patients in various stages of prosthetic rehabilitation with an obturator after maxillectomy. J Prosthet Dent 2020;123:355-63.  Back to cited text no. 14
    
15.
Mukeshsoni, Jain DD Interim obturator rehabilitation of a maxillary defect - Case report. IOSR J Dent Med Sci 2015;14(2 Ver. VII):1-3.  Back to cited text no. 15
    
16.
Ding L, Chen X, Zhang J, Wang R, Wu G Digital fabrication of a maxillary obturator prosthesis by using a 3-dimensionally printed polyetheretherketone framework. J Prosthet Dent 2021; S0022-3913(21)00209-2:1-4.  Back to cited text no. 16
    
17.
Jamayet NB, Farook TH, AL-Oulabi A, Johari Y, Patil PG Digital workflow and virtual validation of a 3D-printed definitive hollow obturator for a large palatal defect. J Prosthet Dent 2021;S0022-3913(21)00489-3:1-7.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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