ISSN: 2320-5407 Int. J. Adv. Res.

12(09), 1078-1083

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/19541

DOI URL: http://dx.doi.org/10.21474/IJAR01/19541

RESEARCH ARTICLE
A DISTINCTIVE APPROACH TO REHABILITATE PATIENT WITH BILATERAL MAXILLECTOMY
DEFECT BY TWO-PIECE HOLLOW OBTURATOR- CASE REPORT

Dr. Kriti Bansal1, Dr. Kumari Deepika2, Dr. Meshi Longdo3 and Dr. Rekha Gupta4
1. MDS, Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India.
2. Reader, Department of Prosthodontics, I.T.S Dental College, Ghaziabad, Uttar Pradesh, India
3. PG Student, Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India.
4. Professor and Head, Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi,
India.
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Manuscript Info Abstract
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Manuscript History An obturator is a common tool for prosthetic rehabilitation following
Received: 28 July 2024 invasive surgery, particularly in a total maxillectomy case. However,
Final Accepted: 30 August 2024 loss of teeth, palatal denture-bearing area, and vestibular retentive
Published: September 2024 undercuts leaves an inadequate anatomic base to construct the
Key words:-
Definitive Two-Piece Obturator, Magnet definitive prosthesis. This results in compromised retention and
Retained, PVC, Hollow Obturator stability. The retention problem can be resolved by fabricating an
obturator that engages remaining undercuts. But in such acquired large
defects, if all undercuts are engaged, the prosthesis may become too
heavy, non-retentive, and challenging to insert, particularly in patients
with very high and large defects. Therefore, in this case fabrication of
two-piece magnet retained hollow obturator was described to make a
prosthesis light weight with the use of thermoplastic polyvinyl chloride
sheet in first part which provides adequate retention by engaging the
desirable undercuts. The second part of the obturator was made hollow
by the use of urinary catheter that was removed easily after completion
of denture processing. After this, both the parts were attached together
with the use of magnets. This technique is economical and easy to use
to restore both function and esthetics in patients with bilateral
maxillectomy defect.

Copyright, IJAR, 2024,. All rights reserved.

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Introduction:-
COVID-19 infection had led to the widespread use of corticosteroids in India, causing increase in surge of
mucormycosis, a rare fungal infection associated with diabetes. Due to the invasive nature of mucor, extensive
maxillary defects may develop following surgical excision and debridement of the affected areas. 1Any palatal defect
no matter how minor affect speech, mastication, and esthetics. An obturator that is comfortable, restores function
and has acceptable esthetics should be provided to a patient with an acquired maxillary defect. 2 It may be necessary
for a clinician to occasionally alter or even disregard some fundamental prosthesis design principles for a patient
with a significant maxillary defect. In large defects, the obturator is stretched both horizontally and vertically to
engage the bony or soft tissue undercuts and to engage the surgical defect. 3 As a result, the obturator becomes
heavier and larger, which may make it less retentive under the effects of gravity and jeopardize its ability to perform.
Additionally, because the patient is unable to insert the obturator through a small oral opening, fabrication of such a

Corresponding Author:- Dr. Kumari Deepika 1078

Address:-Reader, Department of Prosthodontics, I.T.S Dental College, Ghaziabad,
Uttar Pradesh, India.
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large obturator may not be feasible. To overcome this problem, the prosthesis can be split into two or more pieces if
necessary. Beside this, hollow bulb obturators are created to lessen the weight of the prosthesis. Also, hollow
obturators are readily tolerated by the patient while effectively extending into the defect areas. 4 In edentulous
patients having such defects, acrylic resin prosthesis can be ineffective as no dentition is present to adequately
stabilize the acrylic prosthesis with clasp and also the aided weight of the prosthesis and effect of gravity
compromises the retention. In this case report, the rehabilitation of an edentulous patient with a total maxillectomy
defect was described in which two-piece magnet retained hollow obturator was fabricated by a simple, affordable,
and time-saving polyvinyl chloride (PVC) sheet technique that offers a precise fit and enhanced stability of the
obturator.

Case Report:-
A 79-year-old male patient was referred from the ENT department for the fabrication of a delayed surgical obturator
for closure of his palatal defect after undergoing surgery for sino-nasal mucormycosis. He had a history of covid -
19, steroids use, and diabetes since10-12 years. Extra-oral examination revealed reduced labial fullness and
depressed mid-face due to loss of support. There was an adequate mouth opening. Intraoral examination revealed
completely edentulous arches with a total maxillectomy defect and intact orbital contents (Fig. 1A, B). A big
communication was present between nasal and oral cavity with retained turbinates. The patient was having difficulty
in mastication, speech, and deglutition. In the absence of any anatomical features like hard palate and teeth for
retention and support of conventional prosthesis, it was decided to retain the delayed surgical obturator utilizing
extra oral customized headgear and face bow assembly to address his functional needs. After 2 weeks, it was found
that the patient was not comfortable and it does not serve the purpose well. After that vacuum pressed thermoplastic
polyvinyl chloride (PVC) sheet was used as an interim obturator to close the defect and the patient was found it very
comfortable, retentive with improved function. After 3 months, as the defect was very high and complex to insert a
one-piece obturator, so two-piece magnet retained definitive obturator was decided to fabricate. First part was the
same PVC sheet used for closing the defect in interim obturator and second part fabricated in conventional manner
as complete denture. Both the bulb and shim portion in two-piece to be made hollow to reduce the weight of the
prosthesis.

Procedure
1. A primary impression of maxillary and mandibular arch was made with irreversible hydrocolloid material
(Zelgan, Dentsply) by blocking out the severe undercuts and poured with type IV gypsum product (Kalabhai
labstone) for working model.
2. A 3mm thick thermoplastic PVC sheet (Huaer and OEM Dental Vacuum forming sheet) was heated and pressed
to model defect using vacuum machine (Biostar, Scheu-dental) (Fig. 2A). The margins of the PVC sheet were
trimmed and finished to check in patient’s mouth for retention.
3. After that condensation silicone putty (Zhermack Dental) adapted into the defect area over PVC sheet to create
palatal contour. Acrylic shim was fabricated using auto polymerizing acrylic (Pyrax) over the putty (Fig. 2A, B).
4. Then acrylic shim separated to remove the putty for hollowing. Acrylic shim was joined to the underlying PVC
sheet using auto-polymerizing acrylic to form palatal contour and hollow bulb portion of the obturator (Fig. 2 C, D).
This assembly made the first part of obturator. Silicone point was used to trim and polish the adhesive component.
5. Magnetic attachments (Neodymium –Iron- Boron magnets; 8mm diameter and 3 mm height; Dental custom
magnets) were then incorporated to the oral side of first part of obturator in tripod manner using auto-polymerizing
acrylic resin (Fig. 3A) and an over impression was taken to obtain stone model cast.
6. Record base was made over this second cast and magnets were attached to similar sites opposing the magnets in
the first part of obturator (Fig. 3B). Over that occlusal rim was fabricated and tentative jaw relation was recorded,
after that try in and evaluation for esthetics and phonetics was done in conventional method.
7. Both maxillary (second part) and mandibular denture was then processed in conventional manner with hollowing
of maxillary denture using urinary catheter that was removed easily by making access hole in thin area of denture
(Fig. 4 A-C).
8. After that auto-polymerizing acrylic was used to close the access hole to achieve water tight seal.
9. After finishing and polishing of dentures, magnets were reattached to maxillary denture in similar position as in
first part of obturator with the same orientation.
After occlusal adjustments, two-piece maxillary obturator and mandibular complete denture was delivered
and phonetics was assessed (Fig. 5A-D).
10. The effect on the facial profile with and without prosthesis can be seen in Figure 6 A-D.

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The instructions were given to the patient regarding its use and maintenance. The follow-up was done at every week
for the first month followed by monthly follow-up upto 6 months. The patient was found very comfortable in using
the obturator and hygiene was well maintained. The phonetics was also improved with time.

Discussion:-
There was increased surge in the number of cases of mucormycosis during the COVID-19 pandemic. The extensive
maxillary defects resulting from surgical debridement of necrotic tissues leave the patient with problems like
difficulty in swallowing, mastication, and speech.5 Obturator forms a seal between the oral and nasal cavity and
helps in improving speech and swallowing. In total maxillectomy cases, due to absence of adequate hard and soft
tissues for retention, it becomes very challenging for maxillofacial prosthodontist to rehabilitate such defects. In this
case report the patient had very large and high defect with complex undercuts and retained turbinates. Acrylic resin
prosthesis can irritate the sensitive turbinates and also becomes heavy due to its weight and effect of gravity which
can compromise the retention of obturator. Also, it made difficult to insert the prosthesis in one piece through small
oral opening. In such patients, obturator made with PVC sheet could be an effective solution in the early
postoperative period as well as for definitive rehabilitation. PVC sheet show better adaptation and good stability by
engaging the undercuts in the periphery of the defect, light in weight, monomer-free and non –porous in nature when
compared to acrylic.6 Patients are able to maintain a hygienic wound site due to the simplicity of insertion and
removal, which allowed for easier surveillance.
Similar techniques have been used earlier that shows the utilization of thermoplastic sheets for the
fabrication of obturator for sub-total and total maxillectomies and it has been found very effective in improving the
function.7-9 In this case, PVC was used for first part to engage the undercuts and heat cure acrylic for second part in
conventional manner. Magnets were used to join the two-piece obturator. Magnets have been used earlier for the
fabrication of two-piece obturator.10,11 The uniqueness of this clinical report were the materials and methods used
here for the fabrication of the obturator and for the hollowing of the prosthesis. The technique used here is simple
and easy to apply and economical to the patient who could not afford the treatment cost of patient specific implant
retained prosthesis that would be best for such patients. After the follow up of 6 months, the PVC sheet becomes
somewhat rigid and friable. Distortion of the prosthesis might be there that can be avoided by proper handling of the
prosthesis. Also, it can be re-fabricated easily by replacing the first part of the obturator (PVC sheet) and re-
attaching it to the second part of obturator with the help of magnets. The limitation of this type of prosthesis is
decrease masticatory efficiency due to the missing hard base.

Figures

Fig. 1:- (A) Bilateral maxillectomy defect (B) Completely edentulous mandibular arch.

A
B

Fig. 2:- Steps for the fabrication of first part of hollow obturator (A) Splint sheet adapted over primary cast (B)
Putty adapted in defect area for hollowing (C) Putty removed to attach acrylic shim to underlying PVC sheet (D)
Hollowed first part of obturator

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A
B

C D

Fig. 3:- (A) Magnets attached (B) First part of obturator in mouth.

A B

Fig. 4:- Sequence of processing of second part of obturator (A) Flasking followed by dewaxing of second part of
obturator (B) Hollowed using urinary catheter before packing heat cure acrylic (C) Processed denture showing
catheter.

A B

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Fig. 5:- Definitive prosthesis (A) Two parts of obturator (B) Finished maxillary and mandibular denture (C) Two-
piece magnet retained obturator (D) Definitive obturator delivered to the patient.

A B

C D

Fig. 6:- (A) and (B) Pre and post-operative frontal view (C) and (D) Pre and post-operative lateral view

A B

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C D

Conclusion:-
This article describes a simple technique to rehabilitate an edentulous patient having total maxillectomy defect with
the use of two-piece magnet retained obturator by utilsing PVC sheet in first part of obturator and heat cure acrylic
resin in second part. Different hollowing techniques were used in both parts of the obturator to make the prosthesis
light weight. Advantages to the technique described in the present case are reduced chairside and laboratory time
and economical to the patient which can be a significant consideration for the patient who had already undergone
extensive medical and surgical treatment and who can not afford implant retained prosthesis that is the best
treatment option in such cases.

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