A preplanned surgical obturator prosthesis for alternative resection lines inthe anterior region

Mark Penn, DMD,a Yoav Grossmann, DMD,b and Arie Shifman, DMDc

Chaim Sheba Medical Center, Tel-Hashomer; and School of Dental Medicine, Tel AvivUniversity, Tel Aviv, Israel

A technique is described that enables adaptation of a surgical obturator to accommodate anterior teeththat may or may not be resected with the lesion at surgery. This is designed and fabricated by placingadditional clasps on the teeth in question and providing for a clasp on one of the anterior teeth thatcan be determined at the time of surgery, thereby allowing anterior retention of the obturator immedi-ately postoperatively. This technique is cost-effective and useful, especially if no prosthodontist is avail-able at the time of surgery to perform obturator modifications. (J Prosthet Dent 2003;90:510-3.)

Surgical obturators for patients requiring a maxillec-tomy offer distinct advantages regarding immediate re-habilitation of facial contours, speech, and swallowing.1

In the dentate patient, surgical obturator designs mayvary from a prosthesis using an acrylic resin record basebearing no teeth,1 with or without wrought-wireclasps,2 to a clasped acrylic resin prosthesis that restoresthe dental arch form.3 It is recommended that posteriorocclusal contacts not be established on the resected sideuntil the surgical wound is healed.4,5

Despite modern imaging technologies, there still re-mains some uncertainty in predicting the exact extent ofthe surgical resection. Therefore, the prosthodontistmust be prepared to modify the obturator immediatelypostoperatively. The modification results from a need toaccommodate the teeth that are not resected but havebeen removed from the cast during obturator fabrica-tion.4 Huryn1 suggested modifying the obturator with abur in the operating room. Arcuri and Taylor4 outlined2 approaches, conservative and radical, regardless of thedefinitive lines of resection for designing a surgical ob-turator for the dentulous patient. When the obturator isfabricated according to the most conservative line ofresection, a surgical dressing may be needed to adapt theobturator to larger resections. On the other hand, fab-ricating the obturator for most extreme surgical resec-tion may require adaptation of the obturator to smallerresections by removing the unnecessary portion.4

Beumer et al5 recommended fabricating 2 or more pros-theses presurgically in order to be prepared for mosteventualities.

This article describes a technique for fabricating asurgical obturator prosthesis that efficiently allows adap-tation to the postsurgical resection lines, thereby allow-ing for more anterior teeth than presurgically planned tobe preserved in a dentate maxillectomy patient.

TECHNIQUE

1. Prior to surgery (Fig. 1), make impressions of bothdental arches with irreversible hydrocolloid impres-sion (Blueprint; Dentsply Caulk, Milford, Del). Pourthe impressions with dental stone (Yellow Stone;Whip Mix Corp, Louisville, Ky) to obtain casts.Mount casts in a semi-adjustable articulator (Hanau;Teledyne Water Pik, Fort Collins, Colo) in maxi-mum intercuspation.

2. Outline the anticipated line of resection on themaxillary definitive cast including questionableteeth (Fig. 2). Review the design with the surgeonto verify the anticipated scope of the planned re-section.

3. Contour .030-inch round stainless steel orthodonticwire (3M; Unitek, Monrovia, Calif) to fabricate claspsthat engage the labial infrabulge retentive areas of theteeth on the nonresected side, including the teeth inquestion (Fig. 3). Fix the wire extension to the palatalsurface with sticky wax (Kerr USA, Romulus, Mich).

4. Mix vinyl polysiloxane putty material (Reprosil;Dentsply International Inc, Milford, Del) to fabri-cate a dental index, and position it over the teeth onthe maxillary cast. Cover the labial, occlusal, and in-cisal surfaces. Trim the matrix with a scalpel to exposethe palatal surface.

5. On the cast, remove the teeth in the area of resection,including the teeth in question, and trim the sur-rounding alveolar process (Fig. 4). Carve and con-tour the surgical obturator in wax (Baseplate wax;Henry Schein, Port Washington, NY). Adjust artifi-cial teeth and position into the dental index. Includeonly the anterior teeth that are required esthetically.Arrange the teeth according to the most radical re-

Poster presented at the annual meeting of the American Academy ofMaxillofacial Prosthetics, Orlando, Fla, November, 2002.

aSenior Prosthodontist, Maxillofacial Prosthetics Rehabilitation Unit,Chaim Sheba Medical Center.

bResident, Maxillofacial Prosthetics Rehabilitation Unit, ChaimSheba Medical Center.

cSenior Clinical Lecturer, Department of Oral Rehabilitation, Schoolof Dental Medicine.

510 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 90 NUMBER 5

section extent. Ensure no occlusal contacts exist onthe resected side.

6. Remove the artificial teeth in question from the waxbefore processing the obturator. Develop indenta-tions in the wax in the form of the gingival aspect ofthe artificial teeth for optional placement of theseteeth. Eliminate the wax and process with gingival-colored autopolymerizing resin (Jet Acrylic; LangDental Manufacturing Inc, Wheeling, Ill).

7. Finish, polish and sterilize the prosthesis in glutaral-dehyde 2% solution (Sekucid; Paragerm Lab, Carros,France).

8. Adapt the obturator after the maxillectomy has beenperformed. In situations in which the surgeon re-moves the teeth in question, reset the artificial teethto the obturator in their exact position and securewith autopolymerizing resin. A more conservative

line of resection preserving the questionable teethwill require only a slight adaptation of the base andthe retentive clasps engaging the teeth in questionand removal of the buccal flange adjacent to the re-maining teeth (Fig. 5, A and B).

9. Reline the tissue surface of the obturator with tis-sue conditioning material (Coe Comfort; GCCorp, Tokyo, Japan) to gain maximum supportand seal from the cheek and adjacent soft tissues(Figs. 6 and 7).

DISCUSSION

The technique described overcomes many of the dif-ficulties associated with current techniques for the de-sign and fabrication of surgical obturators. The advan-tages are the following: (1) easy adaptation of the

Fig. 1. Intraoral view of tumor in right posterior maxilla.Location of anterior resection line is uncertain.

Fig. 2. Presurgical maxillary cast. Red line indicates radicalsurgical resection line, including right central and lateralincisors. Blue line indicates surgical obturator prosthesisborder.

Fig. 3. Wrought-wire clasps placed on teeth on nonresectedside and on each incisor with questionable prognosis.

Fig. 4. Cast trimmed according to most radical resectionmargins.

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obturator to optional resection lines; (2) time saving inthe operating room; (3) elimination of the need for thepresence of a prosthodontist to perform obturator mod-ifications; (4) immediate esthetic improvement follow-ing the resection; (5) retention and enhanced bracingeffect provided by wire clasps, thereby reducing obtura-tor movement in the horizontal plane; (6) the samesurgical obturator can later serve as an interim obturatorfollowing modification of the tissue surface, and (7) costeffectiveness, as only one obturator is prepared.

The disadvantages of the technique are the additionalsteps needed to fabricate the obturator and the possibleinterference with surgical wiring of the obturator to an-terior teeth.

SUMMARY

For patients undergoing maxillary resection, the de-finitive lines of resection are, of necessity, determined at

the time of the surgical procedure. An alternative tech-nique is described for surgical obturator fabrication thatallows for its modification to the actual, rather than theanticipated, resection lines relative to the anterior teeth.

The authors wish to thank Prof Shlomo Taicher and Dr RanYahalom of the Oral and Maxillofacial Surgery Department, ChaimSheba Medical Center, and Eli Schnieder, CDT, for their assistance.

REFERENCES1. Huryn JM, Piro JD. The maxillary immediate surgical obturator prosthesis.

J Prosthet Dent 1989;61:343-7.2. King GE, Martin JW. Cast circumferential and wire clasps for obturator

retention. J Prosthet Dent 1983;49:799-802.3. Wolfaardt JF. Modifying a surgical obturator prosthesis into an interim

obturator prosthesis. A clinical report. J Prosthet Dent 1989;62:619-21.4. Arcuri MR, Taylor TD. Clinical management of the dentate maxillectomy

patient. In: Taylor TD, editor. Clinical maxillofacial prosthetics. CarolStream (IL): Quintessence; 2000. p. 103-20.

5. Beumer J, Curtis TA, Marunick MT. Maxillofacial rehabilitation: prosth-odontic and surgical considerations. St. Louis: Medico Dental Media Inter-national; 1996.

Fig. 5. Finished surgical obturator on original cast allowing optional designs. A, Preservation of 1 or 2 questionable anteriorteeth requiring removal of adjacent buccal flange and 1 retentive clasps. B, Removal of teeth in question, requiring resettingof artificial teeth to respective position.

Fig. 6. Obturator relined with tissue conditioning material. Fig. 7. Final esthetic result.

THE JOURNAL OF PROSTHETIC DENTISTRY PENN, GROSSMANN, AND SHIFMAN

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Reprint requests to:DR YOAV GROSSMANN

DEPARTMENT OF ORAL REHABILITATION

CHAIM SHEBA MEDICAL CENTER

TEL HASHOMER

ISRAELFAX: 972-3-674-2443E-MAIL: grolaw@bezeqint.net

Copyright © 2003 by The Editorial Council of The Journal of ProstheticDentistry.

0022-3913/2003/$30.00 � 0

doi:10.1016/S0022-3913(03)00532-8

Noteworthy Abstractsof theCurrent Literature

Influence of timing of coronal preparation on retention ofcemented cast posts and cores.Al-Ali K, Talic Y, Abduljabbar T, Omar R. Int J Prosthodont2003;16:290-4.

Purpose. This study investigated the effect of coronal preparation by high-speed handpiece on theretention of cemented cast posts and cores.Materials And Methods. Cast posts and cores were fabricated for 90 extracted single-rootedhuman teeth cemented with zinc-phosphate cement and randomly divided into 6 groups of 15specimens each. The 6 groups were matched randomly 2 by 2, such that 1 of each of the matchedgroups was subjected to a 4-minute period of high-speed preparation of the cores. Castings fromthe first pair (1 and 2) were subjected to an axially directed removal force using a universal testingmachine 15 minutes from the start of cement mixing; castings from the second (3 and 4) and third(5 and 6) pairs were tested at 1 hour and 24 hours, respectively, having been stored in water at 37°Cfor the waiting periods. The forces required for dislodgment of posts from their prepared spaceswere recorded. Data were statistically analyzed using two-way and one-way ANOVA and theStudent t test.Results. The results showed increased mean retentive strengths of posts as the time to testingincreased for both unprepared and prepared groups. Significantly higher mean retentive strengthsof posts were recorded for unprepared compared to prepared groups tested at 15 minutes and 1hour after cementation.Conclusion. High-speed preparation had a significant negative effect on the retentive strengths ofposts tested at 15 minutes and 1 hour after cementation, but not on those tested at 24 hours.—Reprinted with permission of Quintessence Publishing.

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