ABSTRACT
Rehabilitation of patients post maxillectomy Total, Partial or Subtotal requires surgical & Prosthetic rehabilitation. If Surgical reconstruction can be done at the time of cancer surgery it can not only help in healing and psychologically comforting the patient but it also reduces the need of obturators for the patient. If it is supported by a good prosthesis later an overall improvement in the quality of life of the patient can be seen. This case report discusses the prosthodontic rehabilitation of a 60 year old male patient who had undergone right subtotal maxillectomy for pleomorphic adenocarcinoma and a Temporalis Flap reconstruction over the defect.
Keywords: Maxillectomy, Reconstruction , Temporalis Myofacial Flap, Prosthodontic rehabilitation.
INTRODUCTION
Reconstructing the of maxillofacial defects after hemimaxillectomy can be achieved by surgical or prosthetic rehabilitation methods. Post maxillectomy total or partial , immediate surgical reconstruction can have the following advantages: avoids the secondary reconstruction, provides psychological comfort to the patient.1
From the several different surgical options, the temporalis myofascial flap is considered a reliable and reasonable option for the primary closure of various oral and maxillofacial defects because of ease of elevation and manipulation, reliable blood supply, and proximity to the oral and maxillofacial area.2,3 Owing to advances in surgical procedures, some surgeons insist that a microvascular free flap reconstruction is a better treatment option compared with a prosthodontic reconstruction using obturators.4,5 Though, this is not always an advantage to the patient, and it could compromise the prosthodontic phase of reconstruction. The direct vision of the area is no longer possible and if the disease recurs, it is often not found until it has reached an advanced stage with a poor prognosis, the position of the flap may change over time because of contraction or the resultant effects of gravity which require prosthetic revision continuously. The Movement of the flap due to mandibular attachment of the temporalis muscle can result in difficulty in maintaining a functional posterior palatal seal. The flap is also found to be bulky and may limit the placement of a prosthesis. Obstructing the hard palate surgically could also lead to problems like nasal reflux of food while swallowing and inaccurate pronunciation which may be better addressed by obturator prosthesis.6
CASE REPORT
A 60 year old male patient was diagnosed with Pleomorphic adenoma for which he underwent reight subtotal maxillectomy & myofascial temporalis flap reconstruction at All India Institute of Medical Sciences Rishikesh on 13th March 2019. The patient was in followup and was referred to the Department of Maxillofacial Prosthodontics & Oral Implantology Seema Dental College & Hospital Rishikesh on the 4th of November 2020.
On examination it was found that the graft tissue was well adapted but slightly mobile, the patient showed no pain or discomfort when pressure was applied. He was Partially edentulous irt 11,12,13,14,15,16,117,24,25,26,27,34,35,36,37,41,42,43,44,45,46,47.
A diagnostic impression was made irt the maxilla and mandible using alginate e and diagnostic casts were poured, since the tissue was slightly mobile it was thought that constructing a special tray over the maxillary diagnostic cast and retaking the impression for the maxilla using alginate would be a better process, thus it was done and a primary cast was obtained. Over the Primary cast a special tray was again fabricated using a wax spacer 2mm thickness and self cure acrylic resin material. On the next visit the tray was trimmed and adapted into the patients mouth , border molding done using green stick compound, and secondary impression was taken using medium body . The master cast was poured in dental stone and a bite was created irt the mailla and mandible. Since after the surgery the patient had been partially edentulous since quite a while the bite had changed and the patient was closing in a class III relation which wasn’t possible to mend. The bite was transferred to an articulator and teeth setting done in crossbite manner.The try in was done in the next sitting and the bite was rechecked, the patient was comfortable with the same closure. Clasps were made and we proceeded with the final curing of the removable partial denture denture irt 11,12,13,14,15,16,117,24,25,26,27,34,35,36,37,41,42,43,44,45,46,47 using high impact heat cure acrylic resin. Finishing and polishing was done and final prosthesis was inserted in the next visit.
The patient was recalled after 24 hours, sores and pressure points were checked, then the patient was recalled after 1 week of time, clasps were tightened, slight denture adjustments were made ad it was polished and reinserted. It's been more than 6 months now and the patient is satisfied with his prosthesis, he can eat & chew better, also improvement in his speech and facial aesthetics can also be appreciated by his family.
Figure 1: PRE REHABILITATIVE INTRAORAL PICTURE
Figure 2: DIAGNOSTIC IMPRESSION TAKEN USING ALGINATE
Figure 3: CUSTOM TRAY FABRICATED OVER THE DIAGNOSTIC IMPRESSION TO TAKE THE PRIMARY IMPRESSION USING ALGINATE AGAIN
Figure 4: PRIMARY CAST POURED USING DENTAL STONE & A SPECIAL TRAY FABRICATED OVER IT, BORDER MOLDING DONE USING GREEN STICK
Figure 5: WAX SPACER REMOVED & SECONDARY IMPRESSION TAKEN USING MEDUIM BODY
Figure 6.a.b: TRY IN DONE
Figure 7: POST REHABILITATIVE INTRAORAL PICTURE
DISCUSSION
A stable obturator prosthesis offers a simple method for separating the oral and nasal cavities for small to medium defects and provides functional and aesthetic satisfaction without the need for an second surgery.6 Though stability and retention of prosthetic devices can be significantly compromised in conditions with unfavorable postoperative conditions such as edentulous maxilla and/or extensive resection and missing perpendicular hard palate. The prodigious tipping forces towards the defect area often result in poor prosthetic stability during mastication and an increase in oronasal reflux accompanied by the fluid leakage and nasal speech.7
Early surgical reconstruction achieved using a variety of soft tissue flaps focuses on the advantage of a permanent tissue closure of the palatal defect.2,4,5 Dexter and Jacob8 reported a treatment using the conventional prosthodontic reconstruction emphasizing on the importance of the extent of the defect in relation to stability. They Stability of the maxillary obturator varies depending on where the defect extends in relation to the midline. Pigno,9 from his study reported that movement of the free flap and absence of the buccal vestibule did not allow adequate retention of the maxillary prosthesis.
Though a surgical reconstruction does have the advantages of phonetics and swallowing, the following prosthetic phase is much more difficult and, in some patients, results in failure of the prosthesis. For our case it has been extremely successful but if the patient was reffered earlier for prosthodontic rehabilitation a better result could be achieved.
Figure 8.a.b: PRE AND POST REHABILITATIVE EXTRA ORAL PICTURE
CONCLUSION
Treating a maxillectomy patient requires the involvement of various specialties but the degree of rehabilitative success can often be traced to the presurgical planning between a head and neck surgeon and a maxillofacial prosthodontist. Consequently, the treatment of a maxillectomy patient presents as an excellent opportunity for the surgeon and the prosthodontist to coordinate their plan and efforts to enhance the quality of the patient’s immediate postsurgical healing period and ultimate rehabilitation.
REFERENCES
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- Dallan I, Lenzi R, Sellari-Franceschini S, et al. Temporalis myofascial flap in maxillary reconstruction: anatomical study and clinical application. J Craniomaxillofac Surg 2009;37:96Y101
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- Futran ND, Haller JR. Considerations for free-flap reconstruction of the hard palate. Arch Otolaryngol Head Neck Surg 1999;125:665Y669
- Triana RJ Jr, Uglesic V, Virag M, et al. Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects. Arch Facial Plast Surg 2000;2:91Y101
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