Hemimaxillectomy Defect Research Articles

Digital analysis of the human maxilla to enable semistandardized template tool reconstructions with free fibula transplants

ObjectivesThis study analyzed the human maxilla to support the development of mean-value-based cutting guide systems for maxillary reconstruction, bridging the gap between freehand techniques and virtual surgical planning (VSP).Materials and methodsThis retrospective cohort study used routine CT scans. DICOM data enabled 3D modelling and the maxilla was divided into four regions: paranasal (R1), facial maxillary sinus wall (R2), zygomatic bone (R3) and alveolar process (R4). Surface comparisons were made with a reference skull. Statistical analyses assessed anatomical variations, focusing on mean distance (Dmean), area of valid distance (AVD), integrated distance (ID) and integrated absolute distance (IAD). The study addressed hemimaxillectomy defects for two-segmental reconstructions using seven defined bilateral points to determine segmental distances and angles.ResultsData from 50 patients showed R2 as the most homogeneous and R4 as the most heterogeneous region. Significant age and gender differences were found in R3 and R4, with younger patients and females having more outliers. Cluster analysis indicated that males had R1 and R3 positioned anterior to the reference skull. The mean angle for segmental reconstruction was 131.24° ± 1.29°, with anterior segment length of 30.71 ± 0.57 mm and posterior length of 28.15 ± 0.86 mm.ConclusionsAnatomical analysis supported the development of semistandardized segmental resection approaches. Although gender and anatomical differences were noted, they did not significantly impact the feasibility of mean-value-based cutting-guide systems.Clinical relevanceThis study provides essential anatomical data for creating cost-effective and efficient reconstruction options for maxillary defects, potentially improving surgical outcomes and expanding reconstructive possibilities beyond current techniques.

Management of Mucormycosis Resultant Hemimaxillectomy Defect from Interim Hollow Obturator to Definitive Two-Piece Magnet Retained Prosthesis - A Case Report

In case of large surgical defects, single-piece hollow bulb obturator prosthesis may increase the height and weight of the prosthesis resulting in loss of retention and difficulty while insertion and removal of the prosthesis. In the present case, patient presented with a large hemimaxillectomy defect with restricted mouth opening. A novel strategy for rehabilitating the patient with a major palatal deformity and restricted mouth opening by fabricating two-piece prosthesis is described in this case report.

Prosthetic rehabilitation with framework obturator for hemimaxillectomy patient – A case report

Postoperative hemimaxillectomy defects cause the patient to develop conditions such as nasal discharge (hypernasal speech), leakage of fluid in the nasal cavity, and deterioration of masticatory function. Thus, comprehensive rehabilitation is required to improve mastication, speech function and normal orofacial appearance. Successful prosthetic rehabilitation of postoperative hemimaxillectomy defect is a challenging procedure that requires multidisciplina- ry expertise to achieve acceptable esthetics, functional speech and swallowing outcomes. This case report describes clinical steps and laboratory procedures involved in prosthetic rehabilitation of an Aramany Class IV hemimaxillectomy patient with framework obturator.

Rehabilitation of Hemimaxillectomy Defect with Hollow Bulb Obturator – A Case Report

Rehabilitation of Hemimaxillectomy Defect with Hollow Bulb Obturator – A Case Report

Evaluation Of Stresses Distribution Pattern In Implant- Retained Maxillary Obturators Using Nova-Lock, Ball & Locator-Bar Attachment Systems. (Three Dimensional Finite Element Analysis)

Purpose: This study was an in in-vitro study conducted to compare the stress distribution pattern in implant retained maxillary obturators with three different attachment systems with the aid of three dimensional finite element analysis.Methods: CT scan was made for a patient with hemi-maxillectomy defect. The CT scan file was exported to a personal computer with Materialize Mimics 10.01 program (Materialize, interactive medical image (Materialize Leuven, Belgium). Mimics were utilized to modify the CT scan of the maxilla to construct 3-D model with Solid Works, Concord, Massachusetts, USA) for finite element stress analysis. All components of the models were constructed thereafter, superimposed till construction of maxillary obturator models. Three implants were inserted in the alveolar bone on the intact side. Ball & Nova-lock locator/ bar attachment systems were simulated according to their structural configurations. A static load of 100 N load was applied vertically & obliquely on the defect side. ANSYS program (Canonsburg, PA, USA) was utilized to solve the problems, The resultant Von Misses stresses in bone surrounding implants were evaluated and compared in the 3 studied models.Results: The highest Von Misses stresses were found in cortical bony layers around the implant adjacent to defect & the least stresses at the area of 3rd implant. Nova-lock retained implant obturtors had recorded the least Von Misses stresses (20. 479 &21.675 Mpa) in comparison to Ball (40.762 & 41.488 Mpa) & locator bar attachment systems (43.526 & 47.203 Mpa) under vertical & oblique load application respectively. All models had shown the highest stresses on oblique load application on the defect side.Conclusions: Within the limitations of this study various conclusions could be drawn: The load direction has more important role than the attachment type in stress distribution pattern in implant retained maxillary obturators.Nova- lock attachment system may induce the least stresses onto implant/ bone interface followed by Ball & locator bar attachment systems.The Locator/ bar attachment may allow better stress distribution in implant retained maxillary obturators than other Bar systems.

Prosthodontic rehabilitation in an elderly patient with a hemi-maxillectomy defect

Prosthodontic rehabilitation in an elderly patient with a hemi-maxillectomy defect

Rehabilitation of Phonetic, Esthetics and Function in Subtotal Maxillectomy Defect by Cast Partial Obturator: A Case Report

Rehabilitation of hemimaxillectomy defects with prosthetic obturator can be challenging in term of providing adequate retention, support and stability to the prosthesis and expected outcome. Nasal reflux and hypernasal voice are the two major sequel after surgery that can affect patient social involvement and can have great psychological impact. The prosthodontist is limited by the properties of the materials available for facial restorations, the mobility of soft tissue surrounding the defects, the difficulty of establishing retention for large prosthesis, and the patient ability to accept the outcome. The outcome of prosthesis can be improved remarkably due to better coordination between surgeon and prosthodontist and careful designing of prosthesis. Dramatic improvement in the acceptance of prosthesis is seen if the prosthodontist participation can begin early in the course of patient care which ultimately will increase the quality of life (QOL) of the patient.

A Comfortable Palatal Delayed Surgical Obturator for Hemimaxillectomy Patients

A surgical obturator prosthesis is commonly used as an effective means for rehabilitating patient with hemi-maxillectomy defect. The obturator supports the soft tissues after surgery and minimizes the contraction of scar and disfigurement thereby making a positive effect on patient’s overall function and psychology. The goal of prosthodontics to restore missing orofacial structures for improving facial esthetics and oral function for such patients. The inability to achieve adequate retention, stability, support and comfort due to the friability of healing tissues are the common problems associated with prosthetic treatment in the initial phase of treatment. This case report demonstrates a simple technique to overcome such difficulties by the use of soft lining materials in the delayed surgical obturator.

Finite element analysis of displacement with single and two piece hollow bulb obturator prosthesis

BackgroundRehabilitation of hemi-maxillectomy defects is difficult and challenging when there is displacement of obturator prosthesis. The literature lacks data on the displacement of different types of obturators. The intent of the study was to evaluate the differences in displacement between the single and two piece hollow bulb obturator prosthesis in Aramany Class I maxillectomy defect. MethodsFinite element (FE) model of Aramany Class I maxillectomy defect restored with single and two piece closed bulb obturator was fabricated based on patient computed tomography (CT) scan. Finite element analysis (FEA) with three different load applications was done to measure the displacement of the obturator. Graphical and numerical values of displacement were obtained and the results were tabulated. ResultsThe results were obtained as displacement colour images and the numerical displacement values. The displacement of two piece obturator was 4.779e−8, 6.372e−8, 7.965e−8 compared to single piece obturator 4.509e−8, 6.012e−8, and 7.5151e−8. There was marginal numerical increase in magnitude of displacement in two piece obturator compared to single piece obturator. ConclusionThe study observed no significant difference in displacement between the obturator. The numerical difference in displacement is more in two piece obturator compared to the single piece obturator.

Computer-Assisted Reconstruction of the Hemimaxillectomy Defects With a Composite Iliac Crest Bone Free Flap: Case Reports

The authors present a revised application of the composite iliac crest bone free flap for hemimaxillectomy defects. This flap solely can give a support to the eye globe and the dental implants without osteotomies and titanium meshes. The upper ridge of the flap can be shaped to replicate the curvature of the orbital floor. The inner oblique muscle and the deep fascia can serve as an additional material for separation of the oral cavity from the nasal airway. Utilization of the Customized Contour Implants gives a surgeon a refining instrument for aesthetic correction of facial projection.

Reconstruction of the maxilla following hemimaxillectomy defects with scapular tip grafts and dental implants

Treatment of post-resective defects of the maxilla can be challenging and usually requires dental obturation or microvascular reconstruction. As compared to soft-tissue microvascular grafts, bone reconstruction can additionally allow for facial support and retention of dental implants. The aim of this study was to evaluate scapular tip grafts with respect to their applicability for maxillary reconstruction and their potential to retain dental implants for later dental rehabilitation. In this retrospective study, 14 patients with hemimaxillectomy defects were reconstructed with free scapular tip grafts, oriented horizontally, to rebuild the palate and alveolar ridge. After bone healing, three-dimensional virtual implant planning was performed, and a radiographic guide was fabricated to enable implant placement in the optimal anatomic and prosthetic position. All patients' mastication and speech were evaluated, along with the extent of defect closure, suitability of the graft sites for implant placement, and soft-tissue stability. Pre- and postsurgical radiographs were also evaluated. A good postoperative outcome was achieved in all patients, with complete closure of maxillary defects that were class II, according to the system of Brown and Shaw. Additional bone augmentation was necessary in two patients in order to increase vertical bone height. Patients were subsequently treated with 50 dental implants to retain dental prostheses. In all cases, additional soft-tissue surgery was necessary to achieve a long-term stable periimplant situation. No implants were lost during the mean observation period of 34 months. Due to its specific form, the scapular tip graft is well suited to reconstruct the palate and maxillary alveolar ridge and to enable subsequent implant-retained rehabilitation. Due to the limited bone volume, an accurate three-dimensional graft orientation is essential. Furthermore, most cases require additional soft-tissue surgery to achieve a long-term stable periimplant situation.

Implant-prosthetic rehabilitation of hemimaxillectomy defects with CAD/CAM suprastructures.

Patients with hemimaxillectomy defects after tumor surgery can alternatively be rehabilitated with dental obturators or microvascular flaps. When general medical or oncologic conditions do not permit microvascular surgery, dental obturators are the only solution, yet retention for edentulous patients is often poor. The aim of this study was to evaluate whether CAD/CAM suprastructures supported by implants placed in both residual alveolar ridges and contralateral zygomatic bone could enhance obturator stability and improve functional outcomes. Five edentulous patients with class IId hemimaxillectomy defects were included in the study. Implant-retained reconstructions were planned to support cross-arch CAD/CAM milled suprastructures. Patients had to rate their restorations on a 100-mm visual analogue scale before and after treatment. Additional evaluation was performed using the Oral Health Impact Profile (OHIP-EDENT) questionnaire. In the 5 patients, 7 conventional implants were placed in the remaining zygomatic bone and 16 in the remaining contralateral alveolar ridge. After 4 months of submerged healing, CAD/CAM suprastructures were fabricated that connected all respective implants with each other. All of the prosthetic restorations were removable and bar-retained. They all achieved good defect closure and showed significant improvements concerning general satisfaction (p=0.0343), stability (p<0.0001), ability to chew (p=0.0077), esthetics (p=0.0173) and foreign body sensation (p=0.0207). According to the OHIP-EDENT questionnaire (p=0.0036) the improvements were significant. During the observation period of 29.4 months, no mechanical or biological complications occurred. The CAD/CAM suprastructures improved retention in all treated patients without any complications.

Implant-Retained Obturator for an Edentulous Patient with a Hemimaxillectomy Defect Complicated with Microstomia.

Patient. A 68-year-old man was operated on for squamous cell carcinoma (T3N3M0) of the maxilla creating the hemimaxillary surgical defect on right side. The remaining arch was completely edentulous. There was remarkable limitation in the oral opening with reduced perimeter of the oral cavity due to radiation and surgical scar contracture. This article describes prosthetic rehabilitation by modifying the design of the obturator and achieving the retention with dental implant. Discussion. Severe limitation in the oral opening may occur in clinical situations following the postsurgical management of oral and maxillofacial defects. The prosthetic rehabilitation of the surgical defect in such patients becomes a challenging task due to limited access to the oral cavity. This challenge becomes even more difficult if the patient is edentulous and there are no teeth to gain the retention, stability, and support. Conclusion. In severe microstomia prosthesis insertion and removal can be achieved with modification of the maximum width of the prosthesis. Dental implant retention is useful treatment option in edentulous patients with maxillary surgical defect provided that sufficient bone volume and accessibility are there for implant placement.

A unique conjoined orbital and maxillary removable “Bottle opener” prosthesis for hemi-maxillectomy defect with orbital exenteration

Introduction: A 79 year old Caucasian male underwent left sided extended hemi-maxillectomy and orbital excenteration for T4 N0 M0 poorly differentiated squamous cell carcinoma of the left maxillary antrum in 2003.He subsequently had left sided elective neck dissection for nodal disease and chemo radiotherapy. Initial rehabilitation included an adhesive retained orbital prosthesis with maxillary obturator and denture. He could not tolerate the eye prosthesis due to sensitivity over the bony ridges and elected to wear an eye patch instead. He only had two teeth in the right hemi-maxilla which were periodontally compromised and were therefore extracted. He had peri orbital implants for a bar retained orbital prosthesis. Due to his dementia he and his wife found it difficult to clean around the fixed prosthesis. Material and Methods: A removable connector was designed to incorporate a large multipurpose magnet (Technovent ®) for retention of obturator and the orbital prosthesis. This allows easy placement of orbital prosthesis followed by the obturator. The patient fondly calls this his “bottle opener”. Results: This has helped to solve both the defect obliteration and his dexterity issues for its maintenance. Conclusion: We describe and demonstrate a unique removable connector to make the hemi-facial prosthesis modular and removable. As far as our knowledge this modification is unique and not described in the literature

Prosthodontic Rehabilitation of a Patient with Subtotal Maxillectomy using a Hollow Bulb Obturator

ABSTRACT Successful prosthetic reconstruction of hemimaxillectomy defects is a challenging procedure that requires multidisciplinary expertize to achieve acceptable function, speech and esthetics. Rehabilitation of an acquired maxillary defect improves the quality of life for the patient as close to normal as possible. Obturation of the defect depends on its volume and position of remaining hard and soft tissues, to be utilized for retention, stability and support for the prosthesis. The prosthesis should be simple to handle, easy to maintain, biocompatible, light in weight and convenient for future adjustments. This case report describes a clinical case of subtotal maxillectomy, which was successfully rehabilitated with a hollow bulb obturator. How to cite this article Rani G, Gambhir A. Prosthodontic Rehabilitation of a Patient with Subtotal Maxillectomy using a Hollow Bulb Obturator. Int J Prosthodont Restor Dent 2012; 2(1):24-28.

Oral rehabilitation of a patient with sub - total maxillectomy

This clinical report describes oral rehabilitation of a patient with sub-total maxillectomy with palatine process of maxilla and horizontal plate of palatine bone intact to retain the maxillary obturator. Clinical examination has been performed to know the amount of favorable undercuts to be used for retention of the obturator for better functional efficiency. Successful prosthetic reconstruction of hemimaxillectomy defect is a challenging procedure that requires multidisciplinary expertise to achieve acceptable functional speech and swallowing outcomes. This article describes the oral rehabilitation of a patient with sub-total maxillectomy with a maxillary obturator. Oral rehabilitation of sub-total maxillectomy patient is a challenging task. Obturation of the defect depends on volume of the defect, and positioning of remaining hard and soft tissues to be used to retain, stabilize, and support the prosthesis. A maxillary obturator for edentulous patient must provide for retention, stability, support, patient comfort, and cleanliness.

Practical guidelines for the reconstruction of the mandible and maxilla

With the wide range of treatment options now available, surgeons are challenged to select the optimal method, material, and timing for a particular reconstruction. Four areas of the maxillofacial complex frequently require reconstruction: the mandible, maxilla, orbit, and zygoma. Part I of this clinic will cover reconstruction of the mandible and maxilla while Part II will cover the orbit and zygoma. Mandibular defects can be divided into marginal defects, continuity defects, and continuity defects that include the mandibular condyle. Treatment varies among these 3 types of defects and also depends a great deal on the quantity and quality of the surrounding soft tissue. Mandibular defects with well-vascularized surrounding soft tissue of good volume can be treated by a variety of techniques using free autogenous bone grafts. When the soft tissue is deficient in quantity and/or quality, it must be improved or replaced before free autogenous bone grafting or free vascularized flaps may be used. The choice of reconstructive system is based on the experience of the surgeon and on the specific characteristics of the defect and the overall health of the patient. Our preferred technique in the nonirradiated patient with healthy surrounding soft tissue is a combination of a reconstruction plate and block corticocancellous graft from the posterior ilium. These grafts have demonstrated excellent retention over time and are compatible with osseointegrated implants. Maxillary defects can be divided into those defects that have loss of hard and soft tissue and those with loss of hard tissue only. Defects with loss of hard tissue only are less difficult to treat and are frequently treated by placement of free autogenous bone grafts, in many cases with subsequent or simultaneous implant placement. For the hemimaxillectomy defect in which there is loss of both hard and soft tissue, 3 general approaches can be used. The first is use of the traditional prosthetic obturator. A second is use of a pedicled flap such as the temporalis muscle flap, which separates the oral cavity from the nasal cavity and maxillary sinus region. A third would be use of free vascularized tissue transfer of soft tissue or soft tissue and bone. Although the obturator approach may be difficult for younger patients to accept, it has the advantage of avoiding another donor site and may give the most stable and predictable results long term. References Macintosh RB: Current spectrum of costochondral and dermal grafting, in Bell WH (ed): Modern Practice of Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992, p 873 Keller EE: Mandibular discontinuity reconstruction with composite grafts: Free autogenous iliac bone, titanium mesh trays and titanium endosseous implants. Oral Maxillofac Surg Clin North Am 3:877, 1991 Bach DE, Burgess LPA, Zislis T, et al: Cranial, iliac and demineralized freeze-dried bone grafts of the mandible in dogs. Arch Otolaryngol Head Neck Surg 117:390, 1991

Myocutaneous and myo-osseous flaps for oral and maxillofacial reconstruction

have loss of hard and soft tissue and those with loss of hard tissue only. Defects with loss of hard tissue only are less difficult to treat and are frequently treated by placement of free autogenous bone grafts, in many cases with subsequent or simultaneous implant placement. For the hemimaxillectomy defect in which there is loss of both hard and soft tissue, 3 general approaches can be used. The first is use of the traditional prosthetic obturator. A second is use of a pedicled flap such as the temporalis muscle flap, which separates the oral cavity from the nasal cavity and maxillary sinus region. A third would be use of free vascularized tissue transfer of soft tissue or soft tissue and bone. Although the obturator approach may be difficult for younger patients to accept, it has the advantage of avoiding another donor site and may give the most stable and predictable results long term.