----)\'r- }( ',~

\~Maxillary Obturator Prosthesis Rehabilitation FollowingMaxillectomy for Ameloblastoma: Case Series of Five PatientsBen L Omondi, BOS8/Symon W Guthua, BOS, MMEDSc, COMS, FIAOMSb/Oavid 0, Awange, BOS, MMEDScc/Walter A Odhiambo, BOSd

Purpose: The purpose of this case report is to demonstrate the benefits andapplicability of appropriate maxillofacial prosthetic rehabilitation following surgicalresection of ameloblastoma of the maxilla in Kenya. Materials and Methods: Fivepatients presenting with ameloblastoma of the maxilla over 3 years were studied withrespect to histologic type, site of tumor, resultant surgical defect, and form of definitiveobturator prosthesis. Impressions were taken using irreversible hydrocolloid and pouredwith dental stone. Immediate surgical obturators were fabricated from casts using clearautopolymerizing acrylic resin. One patient had bilateral partial maxillectomy, whereasthe rest had unilateral partial maxillectomy. Immediate surgical obturators were fittedintraoperatively and held in place using Adams clasps on the remaining natural dentitionfor all patients, except the one who had undergone bilateral partial maxillectomy, whosesurgical obturator was held loosely using circumzygomatic wires. After 6 to 8 weeks,surgical obturators and packing were withdrawn, and new impressions were taken tofabricate definitive obturators. Patients were reviewed every 2 weeks for 3 months, thenonce every 3 months per year for 3 years, and thereafter once per year. Results: Theimmediate surgical obturators facilitated retention of the surgical packing, promotinghealing with minimal postsurgical infection and scar contracture formation. This ensuredthe restoration of acceptable esthetics and maintenance of oral function at a reasonablelevel during the initial postoperative period. Definitive obturators restored esthetics, oralfunction, and ability to handle secretions to a satisfactory level. Conclusion: Satisfactoryfunctional and esthetic results are achievable in patients with extensive acquiredmaxillary defects by means of obturator prostheses fabricated using readily availablematerials. Int J Prosthodont 2004; 17:464-468.

+Tutoris! Fellow, Department of Conservative and ProstheticDentistry, Faculty of Dental Sciences. University of Nairobi, Kenya"Protessor. Department of Oral and Maxillofacial Surgery/OralPatholOgy and Oral Medicine. Faculty of Dental SCiences, Universityof Nairobi, Kenya.<SemorLecturer, Department of Oral and Maxillofacial Surgery/OralPathology and Oral Medicine, Faculty of Dental Sciences, Universityof Nairobi, Kenya."Tutoris! Fellow, Department of Oral and Maxillofacial Surgery/OralPathology and Oral Medicine, Faculty of Dental Sciences, Universityof Nairobi, Kenya.

Correspondence to: Dr Ben I. Omondi, Department of Conservativeand Prosthetic Dentistry, Faculty of Dental Sciences, University ofNairobi, PO Box 19676-KNH 00202, Nairobi, Kenya. Fax: + 254-020-2723252. e-menbiomonoiayeroo.com

This article was presented at the 14th International Association forDental Research East and Southern Africa Division Conference, 30Aug-2 Sept 2000, Harare, Zimbabwe.

464 The lnrernational Journal of Prosthodontics

Society places value on facial appearance; therefore,persons who exhibit deformities and congenital or

acquired defects become socially stigmatized. Thecommon etiologies for acquired defects of the max-illofacial region are traumatic injuries and resection ofturnors.l-' The primary objective in treating tumors isto eliminate disease and improve the quality of life. Forbenign tumors such as ameloblastoma, a locally inva-sive tumor of odontogenic origin, surgical resection isthe treatment of choice.v' However, in cases of ma-lignant tumors, combined therapy to include surgery,radiotherapy, and occasionally chemotherapy is rec-ommended.

The resultant maxillary and/or soft palatal defectscreate oranasal and/or oroantral communication, withconsequent difficulties in eating, speaking, and

Omondi et al

Fig 1a Thirty-three-year -old woman with maxillary ameloblas-toma involving left side of maxilla at operation. Note the Weber-Fergusson exposure.

Fig 1c Surgical obturator in situ.

Fig 1d (right) Five-day postoperative appearance. Note thereasonable facial appearance despite postoperative edema.

breathinq+'' The effect is diminished quality of life andhence lowered self-esteem. Therefore, the restorationand/or replacement of lost stomatognathic apparatusand associated facial structures by appropriate artifi-cial substitutes is advocated, especially for large max-illary defects secondary to tumor resection? A multi-disciplinary medical team comprising the maxillofacialsurgeon, prosthodontist, oncolog ist/radiotherapist,speech therapist, and maxillofacial prosthesis techni-cian isessential in the management of such patients.5.7.s

The useof magnets and osseointegrated implants toprovide retention does enhance support and improve

Fig 1b Resected tumor.

stability of the obturator prosthesis? This is thought tosignificantly improve mastication and efficiency ofspeech and deqlutition." The high cost of implants,coupled with the fact that Kenya lacks trained person-nel to place the implants, meant that the only option torehabilitate these patients was to use prostheses madeentirely of acrylic resin.

This study demonstrates the benefits and applica-tion of maxillary obturator prosthetic rehabilitationusing readily available materials in a society wheremost of the population is in the low socioeconomicbracket.

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Volume 17. Number 4.2004 465

Obturator Rehabilitation for Ameloblastoma Resection

Materials and Methods

Fivepatients presenting with maxillary ameloblastomaat the University of Nairobi Dental Hospital from 1997to 1999were studied with regard to histologic type, siteof tumor, resultant surgical defect. and form of defin-itive obturator prosthesis used. After comprehensivepreoperative assessment and counseling of the pa-tients, impressions were taken using irreversible hy-drocolloid material (Blue Print, Dentsply). The impres-sions were then poured with dental stone to makecasts, from which the surgical obturators were madeusing clear autopolymerizing acrylic resin (Dentsply).

One patient had bilateral partial maxillectomy,whereas the rest had unilateral partial maxillectomy. Inall cases, a Weber-Fergusson incision was employedto expose the tumor. Some of the treatment proceduresfor one of the patients are presented in Fig 1.A surgi-cal packing of zinc oxide iodoform paraffin paste (ZIPP)in sterile gauzewas used. The surgical obturators werefitted intraoperatively and held in position using Adamsclasps on the remaining natural dentition for all pa-tients, except the one who had undergone bilateralpartial maxillectomy, whose surgical obturator washeld loosely using circumzygomatic wires. This en-sured ease of changing the surgical packing for thispatient.

Patientswere reviewed every 2 weeks for change ofthe surgical packing for 6 to 8weeks. After consultationwith the attending surgeon, the surgical obturators andsurgical packing were withdrawn. This was done underlocal anesthesia (Lignospan, Septodont) for the patientwhose surgical obturator was held in place using cir-cumzygomatic wires. Normal saline was used to cleanthe defect, after which new impressions were takenusing irreversible hydrocolloid material. These werepoured with dental stone, from which casts were ob-tained. From these, special trays were made to obtainsecondary impressions using irreversible hydrocolloidmaterial. These were poured with dental stone to pro-duce the working casts.Jaw relation records were done,and the casts were mounted on average value articu-lators. Denture teeth (Acrotone) were waxed in. Theprostheses were tried in the patients to verify the oc-clusion with the mandibular teeth. The definitive pros-theses were processed using pink heat-cured acrylicresin (Dentsply), then finished and polished in the cus-tomary manner. Wire clasp retainers on the remainingnatural dentition were used to retain the prosthesis forthose who had undergone unilateral partial maxillec-tomy.The patient who had bilateral partial maxillectomyhad palatal fenestrations following healing (Figs2a and2b).Thesewere engaged to enhance the retention of thedefinitive prosthesis, which was fabricated as a closed-hollow obturator prosthesis to reduce weight and a

466 The International Journal of Prosthodontics

complete denture design since hewas completely eden-tulous in both jaws (Fig 2c).

At delivery, patients were instructed in the care anduse of the obturators. No adhesive was used in thesecases.They were reviewed every 2weeks for easing ofany pressure spots for 3 months. Once stable, the re-view visits were reduced to once every 3 months for 3years; patients were subsequently seen once per yearas a follow-up.

Results

Five patients (three men, two women) presented withameloblastoma of the maxilla during the study period.Histopathologic reports revealed that two patients hada follicular type, whereas two others had a mixed fol-licular and plexiform pattern. The fifth patient showedhistologic features consistent with the unicystic variantof the disease (Table 1).

The surgical obturators provided a matrix on whichthe surgical packing was placed.They also reduced oralcontamination of the wound and therefore reduced theincidence of local infection during the immediate post-surgical period. The surgical obturator provided an ar-tificial palate, ensuring restoration of oral function, es-pecially speech and deglutition, thereby eliminatingthe need for nasogastric tube feeding. Tissue collapseabout the defect was overcome with the use of the sur-gical obturators, which ensured the restoration of thefacial contour to a reasonable level (Fig 1d).

The definitive obturator prostheses restored the pa-tients' ability to feed and swallow to a reasonable level.Intelligible speech was achievable with the definitiveprostheses. Speech intelligibility was assessed by ask-ing the patients to repeatedly utter theword "Mombasa."The patients' ability to handle oral secretions was sig-nificantly improved with the use of the obturator pros-theses. Acceptable esthetic results were also achieved(Figs 2d and 2e). This had a positive psycholoqic effecton the patients, thereby enhancing their self-esteempostsurgically.

Discussion

Prosthetic rehabilitation is the treatment of choice forpatients with large defects of the maxillary complex fol-lowing surgical resection of tumors? The prosthesismay be needed for various reasons, namely as a sup-port for surgery, as a vehicle for radiotherapy, or for pro-tection from radiation and an adjunct to rehabilitationmedicine for training and stimulation of the defectiveneuromuscular palatopharyngeal structures.'>

The tolerance and retention of obturator prosthesesare improved if the defect is lined with a split-thicknessskin graft? However, this is not recommended if there

COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO. INC.

Omondi et al

Fig 2c Definitive obturator prosthesis.

Fig 2a (left) Sixty-year-old edentulous man with ameloblas-toma involving both maxillae.

Fig 2b (be/ow) Intraoral view 2 months postoperative andafter removal of surgical obturator and packing shown in Fig 2a.Note fenestrations on superior aspect of defect.

Fig 2d (lett) Three months after prosthodontic rehabilitation.Note the satisfactory facial appearance.

Fig 2e (be/ow) Intraoral view of obturator prosthesis andmandibular complete denture in occlusion. ~

COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO. INC.

Volume 17. Number 4. 2004 467

Obturator Rehabilitation for Ameloblastoma Resection

Table 1 Summary of Patient Data

Patient Gender Age (y) Histology Site Proced u rei defect

1 M 40 Follicular Rig ht maxi lIa Partialmaxillectomy (R)2 F 33 Follicular Left maxilla Partialmaxillectomy (L)3 M 45 Mixed follicular Right maxilla Partial maxillectomy (R)

and plexiform4 F 60 Mixed follicular Left maxilla Partial maxillectomy (L)

and plexiform5 M 60 Unicystic Both maxillae Bilateral partial maxillectomy

is a likelihood of recurrence. In this study, mucosa wasleft to granulate and epithelialize because of the po-tential of the tumor to recur. The retention of the pros-thesis was enhanced by engaging the palatal fenes-trations for the patient who underwent bilateral partialmaxillectomy. This was confirmed by the degree of re-sistence to dislodgment when the prosthesis waspulled downward. For those who had unilateral partialmaxillectomy, retention was enhanced by use of wireclasps on the remaining natural dentition. In all cases,the obturator portion of the prostheses was madesmooth to reduce the possibility of trauma to the mu-cosa and therefore improve tolerance of the prosthe-sis. The weight of the prosthesis is reduced if it is fab-ricated as a closed-hollow obturator prosthesis,"

Prosthetic rehabilitation of patients with acquiredsurgical defects of the maxilla is usually done in threephases.1•7,10,11 First is the surgical obturation phase, theprimary objective of which is to restore and maintainoral functions at reasonable levels during the immedi-ate postoperative period. Interim obturation is the sec-ond phase, and its objective is to provide the patientwith a comfortable and functional prosthesis until heal-ing is complete. The interim obturator is usually fabri-cated 2 to 6 weeks postsurqlcal.P:" After the surgicalsite has healed well, the third phase of prosthodontictreatment is done. This involves the fabrication of a de-finitive obturator prosthesis and is usually undertaken3 to 6 months after surgery.

Because of the inability of the patients to meet thecost of fabrication, the interim obturation phase was notundertaken in this study. Six to 8 weeks after surgery,definitive obturator prostheses were fabricated andfitted. The results so far are encouraging. The remov-able nature of the prostheses allows for inspection ofthe surgical site to check for evidence of recurrence ofthe disease. Ameloblastoma is reported to have a re-currence rate of 17% to 40%.3.4

Despite using obturator prostheses fabricated usingacrylic resin, the patients have reported satisfactionwith regard to their ability to swallow, masticate, andproduce intelligible speech. These claims have been

confirmed by close relatives who have been with thepatients from the time of surgery through the prostheticrehabilitation phase of treatment. Satisfactory func-tional and esthetic results can be achieved in patientswith extensive maxillectomy defects by means of ob-turator prostheses fabricated using readily availablematerials following ablative surgery.

Acknowledgment

The authors would like to thank Miss Carolyne Imbayi for typing themanuscript.

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