Clinical Management Of Maxillary

Acquired Defects

R.Sunil
3rd MDS
 Contents

• Introduction
• Etiology
• Classification
• Management of edentulous maxillectomy patient.

• Management of dentulous maxillectomy patient.

• Conclusion
• References
 Introduction

• A rewarding area of prosthodontics is the rehabilitation

of patients with acquired maxillary defects.
• Here, the dentist contributes to all facets of patient care
from diagnosis and treatment to rehabilitation.
• In most circumstances, the prosthetic prognosis is
favorable, and patients are pleased and grateful upon
completion of rehabilitation.
 Etiology
• Most acquired maxillary defects are caused by cancer,
other causes include infection, trauma or other diseases.
 Classification by Aramany based on the
relationship of the defect to the remaining teeth

Olepu SR. et al.,Prosthetic Rehabilitation of maxillary defects:A review Int J Dent Health
Sci 2014; 1(4):632-643
 Treatment plan

Mohamed A. Aramany. Basic principles of obturator design for partially edentulous

patients. Part II: Design principles. J Prosthet Dent 2001; 86 (6): 562-568.
 Liverpool classification
• Vertical Component-
• Class 1:- Maxillectomy not causing oro-nasal fistula.
• Class 2:- Maxillectomy not involving the orbit.

• Class 3:- Maxillectomy involving the orbital adnexae with

orbital retention.
• Class 4:- Maxillectomy with orbital enucleation or
exenteration.
• Class 5:- Orbitomaxillary defect.

• Class 6:- Nasomaxillary defect.

 • Horizontal Component-
• Letter a:- Palatal defect only.
• Letter b:- Less than or equal to half of unilateral maxilla.
• Letter c:- Less than or equal to half of the bilateral
maxilla.
• Letter d-:-Greater than half of the maxillectomy.

Dr.Gupta et al,Maxillofacial defects and their classification: A reviewInt Journal

of Adv Research (2016), Vol 4, Iss 6, 109-114
 Management of edentulous
maxillectomy patient
Surgical enhancements
• Maintain as much hard palate as possible.
• Skin graft the cheek flap.
• Remove the inferior turbinate.

• Skin graft the maxillary sinus walls.

 Phases of prosthetic rehabilitation

• Surgical obturator prosthesis.

• Interim obturator prosthesis.
• Definitive obturator prosthesis
 Immediate surgical obturator
advantages
• The prosthesis provides a matrix on which the surgical
packing can be placed.
• Prosthesis reduces the oral contamination of the wound
and also protect from infection.
• The prosthesis enables the patient to speak more
effectively postoperatively by reproducing normal palatal
contours and by covering the defect
• The prosthesis permits deglutition, thus eliminating the
need for a nasogastric tube, for some or its earlier
removal for others.
• The prosthesis lessens the psychological impact of
surgery by making the postoperative course easier to
bear.
• The prosthesis may reduce the period of hospitalization.
 Principles for designing immediate
obturator
• The obturator should terminate short of the skin graft
mucosal junction initially.
• The prosthesis should be kept simple, light weight, and
inexpensive.
• The prosthesis for dentulous patients should be
perforated with a small dental bur at the interproximal
extensions to allow the prosthesis to be wired to the teeth
at the time of surgery.
• Normal palatal contours should be reproduced to
facilitate postoperative speech and deglutition.
• Posterior occlusion should not be established on the
defect side until the surgical wound is well organized.

• The surgical obturator for edentulous patients should be

fabricated much like a record base, with no replacement

teeth.
• In some patients, the existing complete or partial
prosthesis may be adapted for use as an immediate
surgical obturator. However , the buccal flange of the
denture and the posterior denture teeth on the defect
side are removed.
 Fabrication of immediate obturator

Margins outlined on Cast trimmed Final trimmed cast

presurgical cast
Tumor distorted palatal contour Tumor distorted palatal contour

Altered cast Immediate surgical obturator

Obturator wired to the alveolar ridge
Methods of retaining surgical obutrator

Bone screw retention Suture retention

Circumzygomatic wiring retention

 Delayed surgical obturator

Edentulous patient after Impression made

Cast poured
8 days of maxillectomy

Old denture modified Hollowed out to reduce the weight

Fabrication of interim obutrator
Impressions
Master Cast
Wax trial
Flasking and dewaxing giving Second
pour I
Second pour II
Packing with Second pour -II
Filling the defect with salt in polyethylene
pack
Flasked and cured hollow bulb
obturator
Obturator floating in a water bowl
Insertion
Post-insertion appearance
 Follow-up

After 3 months
After 1 month
 Second interim obturator given to the
patient with increased volume of hollow
 Advantages

BETTER POSTERIOR SEAL OF BETTER FIT OF THE

THE DEFECT PROSTHESIS
LIGHTER WEIGHT OF THE
PROSTHESIS
 Interim obturator

Immediate surgical Converted to interim

Patient 1week post op
obturator after cleaning obturator

Try in patients mouth Anterior teeth added Impression made for

revision of prosthesis
Revised prosthesis Revised prosthesis
tissue surface polished surface
Edentulous patients with total
maxillectomy defects

Preliminary impression
Definitive Obturator-impression making

Impression tray Border moulding on Border moulding on

non defect side defect side

Indentation of the scar Posterior view Cut back by 1to 2mm

Completed impression
 Permanent denture base Occlusal rim
Master cast
Teeth arrangement Denture insertion
 Partial maxillectomy treated with
implants

Three implants placed in maxilla

Preoperative view
 OPG showing implants Copings of magnetic keeper

Denture with magnets Denture inserted

 Case report

Ozaki, H., Sakurai, H., Yoshida, Y., Yamanouchi, H., & Iino, M. (2018). Oral Rehabilitation of Oral
Cancer Patients Using Zygomatic Implant-Supported Maxillary Prostheses with Magnetic
Attachment: Three Case Reports. Case Reports in Dentistry, 2018, 1–5. 
 Clinical management of dentate
maxillectomy patient
• Preoperative conditions:
• According to Desjardins(1977)
• Psychological support of the patient.
• Preoperative dental management.

• Preoperative impressions.
• Suggestions for the surgeon.
 Psychological support of the patient

• Include their available positive role models and their

spirituality.
• Reframing an event and search for positive aspects in
relation to patient’s strengths and abilities to face serious
problems.
• Positive outcomes of the treatment can be achieved through
this attitude and victims will see them as capable human

beings.
 Preoperative dental management

• Treating active dental disease before the surgery reduces

the risk of emergency dental problems in post surgical
healing.
• The tooth that are treated preoperatively has a high
chance of survival and can act as abutments for the
prosthesis.
• As a general rule, all maxillary teeth that can be
maintained should be saved.
 Pre surgical impressions

• It is recommended that two casts should be made before

the surgery.
• One is kept as a permanent record and the other is used
for fabrication of surgical obturator.
 Suggestions for the surgeon

Classic hemimaxillectomy Conservative approach

midline resection increases retention
Maxillectomy preserving Interproximal socket
posterior alveolus reduction preserving the
bone and the tooth.
 Definitive obturator design principles

• Maximum distribution of support for the obturator by rests.

• Retention of the obturator should be gained form the
remaining teeth preserved and from the defect site.
• Clasp should be placed close to the defect. Additional
clasp should be placed far from the first clap to create a
more favourable fulcrum.
• Resistance form can be achieved by adding guide planes
on the palatal surface on the non defect side teeth.
 Definite obturator fabrication

Introral defect of the palate Primary impression

Primary cast Metal framework of the obturator

 Pickup impression Teeth arrangement

After dewaxing Final prosthesis Prosthesis in situ

Singh, M., Limbu, I. K., Parajuli, P. K., & Singh, R. K. Definitive Obturator Fabrication for
Partial Maxillectomy Patient. Case Reports in Dentistry, 2020
 Hemi maxillectomy case

4.0 cm x 4.50 cm
 Maximum
Intercuspation

Right MIP Left

 Sectioned stock
Tray

Positioning of Impression Making

Tray
Putty & Light
Body
Impression

Master Cast
 Wax - Up

Permanent Base

Pick Up Impression

Working Cast
 Face – Bow Transfer

Bite frok
 Articulation

Maxillary and Mandibular casts articulated

Wax Try – in

Flasking

Lost Salt Technique

 Digital work flow

Before treatment Digital impression using IOS

Design of the metal frame Printed resin pattern

 Framework on polyurethane model Functional impression using metal framework

Waxed denture on altered cast Final prosthesis

Park et al, Fabricating a maxillary obturator using an Intraoral digital

impression: A case history report  Int J Prosthodont2017;30:266-68
 Trouble shooting

• Leakage into nose: continued fibrosis in the tissues

bordering the prosthesis is the cause.
• Triad reline material can be used to close the defect.
• The material is coated with the manufacturer’s air barrier
coating and cured in the system’s curing unit.
• Hypernasal speech: Occurs due to patient’s soft palate
and pharyngeal closure mechanism are not functional.
• This condition is seen when a portion of the soft palate is
removed during the surgery.
• Relining the prosthesis periphery will not alter the
hypernasal speech.
• A pharyngeal bulb will help to reduce this hypernasal
speech.
 Maintenance of obturator

• Prosthesis should be evaluated for pressure spots using

PIP paste.
• Bulb portion is checked by using tissue conditioner of
different color.
• Patients should wear the interim obturator during the
night time to manage the secretions.
• Diet also should be modified when there is large defect .
• Adhesives can be used to increase retention and
adaptation to the obturator.
• Patient visit should be scheduled after 24 hours for any
modification.
• Any modifications required can be done with in 2 to 3
days.
• If secretions are leaking into oral cavity, relining of the
obturator is required.
 Conclusion

• Prosthodontic rehabilitation of maxillectomy patients is a

lengthy and involved process.
• If proper attention and detailed treatment plan is
involved, it can be the most satisfying procedures in all
of Prosthodontics.
 References

• Olepu SR. et al.,Prosthetic Rehabilitation of maxillary

defects:A review Int J Dent Health Sci 2014; 1(4):632-643.
• Dr.Gupta et al,Maxillofacial defects and their classification:
A reviewInt Journal of Adv Research (2016), Vol 4, Iss 6,
109-114.
• Park et al, Fabricating a maxillary obturator using an
Intraoral digital impression: A case history report  Int J
Prosthodont2017;30:266-68
• Aramany, M. A.: Basic principles of obturator design for
partially edentulous. Part I: Classification. J Prosthet Dent
40:554-7, 1978.
• Desjardins R. early rehabilitative management of the
maxillectomy patient J Prosthet Dent 1977; 38:311.
• Singh, M., Limbu, I. K., Parajuli, P. K., & Singh, R.
K. Definitive Obturator Fabrication for Partial Maxillectomy
Patient. Case Reports in Dentistry, 2020,
• Mohamed A. Aramany. Basic principles of obturator design for
partially edentulous patients. Part II: Design principles. J Prosthet
Dent 2001; 86 (6): 562-568.

• Ozaki, H., Sakurai, H., Yoshida, Y., Yamanouchi, H., & Iino, M. Oral

Rehabilitation of Oral Cancer Patients Using Zygomatic Implant-

Supported Maxillary Prostheses with Magnetic Attachment: Three

Case Reports. Case Reports in Dentistry, 2018, 1–5.