Maxillofacial Prosthetic Management of the Maxillary Resection Patient

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Classification

The location, extent, and diagnosis of the neoplasm requiring ablative surgery varies from patient to patient (Fig. 1), requiring differing surgical management techniques and resulting in surgical defects in varying maxillary sites (Fig. 2). The Aramany classification describes the maxillary defect based on anatomic site (Fig. 3). The class I resection is a resection of most of one maxillary bone with a medial cut down the midline. The class II resection is similar but less extensive, leaving

Maxillectomy

The classic maxillectomy procedure involves sectioning the zygomatic process, the frontal process, and the nasal process of the maxilla as well as the floor of the orbit. The cut continues through the alveolus down the midline, and the specimen is sectioned from the pterygoid plates (Fig. 4). Access to these structures is gained through a Webber-Ferguson incision which is made in skin folds beginning at the midline of the lip, below the nose and around the nasal ala, continuing lateral to the

Surgical enhancements

Treatment planning by the oral surgeon and maxillofacial prosthodontist should include surgical enhancements that will improve the prognosis of the prosthodontic rehabilitation but not affect the patient's prognosis for cure.

Retain as many maxillary teeth as possible. A maxillary obturator prosthesis always will be more retentive and stable if the prosthesis can attach to teeth either by engaging undercuts similar to a removable partial denture or by using overdenture-type attachments. Even

Stages of maxillofacial prosthetic treatment of the patient undergoing maxillary resection

The stages of treatment for the patient undergoing maxillectomy can be described as surgical, interim, and definitive. The surgical phase, during which a surgical obturator is fabricated, lasts from the time of surgery until the prosthesis and surgical packing are removed 5 to 10 days later. The interim phase, during which an interim obturator is worn, usually lasts about 3 months while the patient continues to heal from surgery. Finally, in the definitive phase, the definitive obturator is

Surgical obturation

The surgical obturator serves as a matrix for the surgical packing, helping it maintain good adaptation of the split-thickness skin graft to the denuded tissues of the facial flap and resulting in better healing of the graft. Because the surgical obturator separates the oral environment from the nasal cavity, there is less contamination of the wound with food and oral secretions. With the surgical site obturated, speech is more effective, and, more importantly, the patient is able to swallow,

Surgical obturator fabrication

An alginate impression of the maxillary arch is made in a stock impression tray (Fig. 14). A cast is poured in dental stone and trimmed (Fig. 15). The cast is trimmed with a headpiece and bur back to normal contours. If needed, stone can be added in areas where the contour is deficient (Fig. 16). In the dentate patient, stainless steel wires are adapted to fabricate clasps (used for retention when the surgical obturator is converted to an interim obturator). Wax sheets are adapted to the cast

Interim obturation

Approximately 5 to 10 days after the maxillectomy procedure, the surgical obturator is removed along with the surgical packing. Because of the possibility of complications such as bleeding, it is recommended that the oral surgeon remove the packing and débride the surgical site. The patient is referred immediately to the maxillofacial prosthodontist; the surgical obturator is sent with the patient. Although this procedure may be a little inconvenient for the patient and requires excellent

Definitive obturation

Usually about 3 months of healing after surgery or 3 months after radiation therapy is sufficient to consider beginning fabrication of the definitive obturator. For the dentate or partially edentulous patient, diagnostic impressions can be made with alginate impression material and poured in improved dental stone. Because the anatomy of the surgical site usually is not a consideration in framework design, the surgical site can be blocked out with gauze for patient comfort during the impression.

Implants

The patient undergoing maxillary resection may benefit from endosseous implants placed in the surgical site. Unfortunately, the lack of suitable bone quantity and quality brings the prognosis for implants in this location into question. If placed in this location, the implants generally are difficult to use adequately for the prosthetic rehabilitation and are very difficult for the patient to maintain. Implants placed in the unresected alveolus improve retention and stability of the obturator

Summary

The treatment of the patient requiring a maxillectomy involves a multidisciplinary approach. Paramount in that collaboration is communication. This article provides the oral surgeon with some insight into the maxillofacial prosthetic rehabilitation of the patient, surgical enhancements that can improve the prognosis of the rehabilitation, and classification of maxillary surgical defects with the goal of improving that communication.

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