BioMed CentralCases Journal
ssOpen AcceCase ReportInfluence of immediate and permanent obturators on facial contours: a case seriesSha Trkaslan*1, Timuin Baykul2, M Asm Aydn3 and M Mustafa zarslan1
Address: 1Department of Prosthodontics, Faculty of Dentistry, Sleyman Demirel University, Isparta, Turkey, 2Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Sleyman Demirel University, Isparta, Turkey and 3Department of Plastic & Reconstructive Surgery, Faculty of Medicine, Sleyman Demirel University, Isparta, Turkey
Email: Sha Trkaslan* - [email protected]; Timuin Baykul - [email protected]; M Asm Aydn - [email protected]; M Mustafa zarslan - [email protected]
* Corresponding author
AbstractIntroduction: Rehabilitation of patients after surgical removal of carcinomas in facial skeleton isone of the most difficult therapies of the stomatognathic system. Significant deformation of tissues,dysfunctions of the stomatognathic system with concurrent biological imbalance of the oral cavityenvironment frequently affect the treatment to become arduous. Scars and contraction of the oralcrevice may cause serious psychological deficiencies that are another aspect of the treatmentschedule.
Case presentation: Three Turkish patients ages 46 (male), 61 (male) and 24 (female) whoexperienced similar operations were rehabilitated with maxillary obturators. The situations wasideal for patient no 1. Patient no 2 could not receive an immediate obturator and patient no 3rejected using permanent obturator. The paper describes the advantages of a surgical obturatorwhich is constructed before operation and inserted immediately following partial maxillectomy andexpresses long term complications when neglecting the use of definite obturator prosthesis, in thelight of three cases.
Conclusion: The primary objective of oral-maxillofacial and plastic surgeons and prosthodontistswhen treating tumors is to eliminate disease and to improve the quality of life including the facialcontours which influences the psychological condition of patient. Neglecting immediate obturatorconstruction may cause serious facial appearance problems due to soft tissue contracture. Whenpermanent obturator is rejected, serious contracture of soft tissues and facial disharmony isinevitable.
IntroductionProstodontic rehabilitation of maxillectomies is the pre-ferred treatment in most centers over autogenous tissuereconstructions [1-5]. It reveals satisfactory outcomes withrespect to speech, nutrition, and facial appearance when
the cooperation of the prostodontist begins before theoperation and the long term management of the patient ismaintained carefully [3,5-9]. When the patient is referredafter the operation, optimum results may not be obtained.Thus, if the patient is lost to follow-up and comes out after
Published: 3 January 2009
Cases Journal 2009, 2:6 doi:10.1186/1757-1626-2-6
Received: 2 December 2008Accepted: 3 January 2009
This article is available from: http://www.casesjournal.com/content/2/1/6
2009 Trkaslan et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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a long period without using prosthesis, facial disfigure-ment may be seen to be so severe that resumption of pros-thetic rehabilitation may become impossible [10-14]. Theaim of this paper is to describe and illustrate the advan-tages of a surgical obturator that is constructed beforeoperation and inserted immediately following partialmaxillectomy and to express the long term complicationsof neglected use of prosthesis in the light of three cases.
Case presentationThe following case reports illustrate the benefits of obtu-rator prostheses by emphasizing the advantages of theobturator that was constructed before operation andinserted immediately following maxillary surgery. Denialof using permanent obturator is also demonstrated.
Case 146-year old male patient presented to his local dentistcomplaining of pain and swelling associated with hisupper teeth. Routine dental diagnostic procedures andperiapical radiographs failed to determine the origin ofswelling and he was referred to the department of Oral &Maxillofacial Surgery at Suleyman Demirel University,Faculty of Dentistry. A firm swelling was seen to involveon the left side of the maxillae. An incisional biopsy wasperformed and this revealed the mass to be a SquamousCell Carcinoma (SCC). The decision following the consul-tation was to resect the tumor and to obturate the defectwith an immediate prosthesis. The patient was informedabout the treatment procedure and the immediate obtura-tion which would minimize the alteration of his appear-ance. Prior to surgery impressions of the maxilla andmandible were obtained and the cast models wereattached to a semiadjustable articulator. The predictedexcision was performed on the maxillary model. Animmediate obturator with 1 cm extension into theresected side was constructed with adams retention claspon the right second molar teeth in the preserved side.Under general anesthesia the left side of the maxillae wasresected together with the lower third of the nasal septum.After the removal of the tumor, tissue conditioning mate-rial was placed over the extension of the immediate obtu-rator to fit the surgical defect accurately and to support thedefect area and split-skin grafts (Fig. 1). Greater retentionand stability was achieved with peridental ligatures. Thepatient demonstrated good postoperative progress and 10days after the surgery the immediate prosthesis was subse-quently replaced by an interim obturator (Fig. 2) whichwas then replaced with a definitive prosthesis after threemonths (Fig. 3). Little soft tissue collapse was observed inthe medial part of the zygoma as the region failed to sup-port the lateral extension of the permanent obturator. Theproblem was tolerated by the patient and he has been sat-isfied with his appearance (Fig. 4) as well as the functions.
Case 261 years old male patient was sent to the department ofMaxillofacial Surgery with the suspicion of a malign neo-plasm in the left side of maxillae due to causeless mobilityof left molar teeth and swelling. The biopsy revealed aSquamous Cell Carcinoma (SCC) and hemimaxillectomywas planned for the patient. The patient preferred toreceive the surgical operation and adjuvant radiotherapyin a different city where his children lived. The patientreturned for prosthetic rehabilitation after 3 months. Thehistory revealed that he has used neither an immediatenor an interim prosthesis. A definitive prosthesis was con-structed following an interim obturator for 3 weeksperiod. The adversely contracted soft tissues did not per-mit an ideal prosthetic rehabilitation (Fig. 5).
Case 324 years old female patient was referred with a swellinglocalized on her left cheek (Fig. 6). The biopsy revealed an
Immediate obturator with Adams retention claspFigure 1Immediate obturator with Adams retention clasp.
Intraoral view of interim obturatorFigure 2Intraoral view of interim obturator.
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Adenoid Cystic Carcinoma (ACC) and total maxillectomywas performed. Spiessl type surgical obturator was con-structed on cast models obtained prior to surgery utilizingpolymethyl metacrilate resin material with loops insertedfor perizygomatic and transmaxillary ligature (Fig. 7). Oncompletion of surgery the prepared obturator was relinedwith tissue conditioning material to supply maximumadaptation. The prosthesis was held in position withtransmaxillary and circumzygomatic ligatures. Nonasogastric tubing was required as oral feeding was imme-diately feasible. The obturator was removed 10 days post-operatively and first impression was obtained for the
model that will be used to fabricate an individual impres-sion tray. Definitive impression was obtained for transi-tional obturator but she insistently refused to continueprosthetic reconstruction. Many attempts to reach andpersuade her for completing the procedure were of no use.A Serious deformity was seen 5 years after surgery (Fig. 8)when she returned requesting some restoration of herfacial appearance. As she was found to have lung metas-tases, neither a surgical procedure nor a prosthetic rehabil-itation could be planned.
DiscussionNeglecting timely prosthodontic cooperation may causeinappropriate facial contour which is almost impossibleto reconstruct [3,9,14]. In the reported cases, bothpatients have experienced similar surgical operations. Nocomplication experienced in patient no 1, but patient no2 did not have the opportunity to receive immediate obtu-rator where patient no 3 rejected to continue the treat-ment procedure for the construction of definite obturator.In the absence of immediate obturation, soft tissuesremain unsupported and collapse dramatically and aes-thetic and/or possible psychological problems may occur. Patient no 3 did not have the chance to use immedi-ate obturator during the construction of the interim obtu-rator since a spiessl type immediate obturator can not bereinserted once removed from the defect