Research Paper
E-ISSN No : 2455-295X | Volume : 2 | Issue : 7 | July 2016
REHABILITATION OF BOMB BLAST AFFECTED PATIENT WITH LIMITED MOUTH OPENING USING SECTIONAL OBTURATOR – A CASE REPORT 1
Mariya Khalid | Mohammad Ali Chughtai 1 2
2
(BDS, F.C.P.S), Assistant Professor Prosthodontics Department, Sardar Begum Dental Hospital, Peshawar, Pakistan. (BDS, FCPS. FFD.RCSI), Associate Professor Prosthodontics Department, Sardar Begum Dental Hospital, Peshawar, Pakistan.
ABSTRACT Bomb blasts can cause severe injuries in the survivors. Because of unique pattern of injury, rehabilitation of such patients is always a difficult task. This article describes rehabilitation of a bomb blast affected patient who had a hemimaxillectomy resulting in limited mouth opening. Restricted mouth opening can create significant problems during fabrication of obturator prosthesis as well as with insertion and removal of the prosthesis. This article describes step by step approach to counteract these difficulties and make a successful definitive sectional obturator for such patients. KEYWORDS: Limited mouth opening, maxillectomy, magnet retained sectional obturator and two piece obturator. OBJECTIVE The objective of this case report is to highlight the importance and procedure to counteract limited mouth opening due to scar based contraction while rehabilitating Hemimaxillectomy patients through Maxillary Obturator. INTRODUCTION A blast injury is a complex type of physical trauma resulting from direct or indirect exposure to an explosion. Patients affected by bomb blast are not only injured medically but also psychologically. Such patients present with multiple problems and are difficult to manage (Hicks et al, 2010). Face is the most important part of human body to live a normal social life and it is 'Maxilla' which is responsible for facial esthetics. If for any reason (tumours, explosions), this bone is affected like a person undergoes maxillectomy, it affects not only asthetics but also the speech, deglutition and psychology of patient (Cardelli et al, 2014). Guidelines for designing obturators: The basic principles of designing obturators are same as removable partial denture. Like removable partial denture, components of obturators are major connector, minor connector, direct retainers, means for indirect retention and denture base (Kumar et al, 2013). However, there are few differences in designing obturators which are Ÿ Ÿ Ÿ Ÿ
Bulb of obturator. Increased weight of obturator. Cross arch stabilization. Altered oral environment
Bulb of obturator: Obturator for maxillectomy patients has a bulb whose size depends on size of the defect. The defect should be properly examined inside oral cavity as well as outside on the surveyor to utilize useful undercuts and eliminate undesirable ones. In patients with extensive maxillary defects, form and weight of bulb is important as abutment teeth are subjected to dislodging and rotational forces by the weight of the obturator (Oki et al, 2006). Increased weight of obturator: Though bulb is an important component of obturator prosthesis but unnecessarily increasing the height of bulb will add weight to the prosthesis and will make it unretentive so the limiting point should be that speech becomes intelligible and there is no reflux of liquids and food from nasal cavity (Parr et al, 2005). Filling the entire maxillectomy defect is not required (Sharry et al, 1954). Need for cross arch stabilization: Cross arch stabilization is very important for stability of prosthesis. In most of the cases when teeth on contralateral side are missing, this important aspect is compromised. Obturators without cross arch stabilization are like unilateral removable partial denture resulting in easy dislodgement of the prosthesis (Uludag et al, 2007). Altered oral environment: Maxillectomy patients have loss of facial contour on surgical side proportional to the amount of bone that is resected. There is a desire to use the obturator prosthesis to support the facial tissues but as the tissues are fibrotic, they can only be minimally displaced by the prosthesis. Sometimes,
teeth and flange of the prosthesis cannot be placed labially because of tissue collapse. So, because of altered oral environment, teeth placement is modified. As the teeth are placed palatally due to facial contracture, they may impinge on tongue so it may be necessary to reduce the width of occlusal table on the surgical side to allow for tongue space. Scarring of lip at suture line may occur which disrupts normal drape of lip and consequently teeth position and occlusal plane need to be modified (Jacob, 2000). Large obturators which would occlude the nasal airway need to be fitted with preformed acrylic tube; the position of which needs to be marked through nostril before the master impression is removed (Walter, 2005). General rules for designing obturators Every effort should be made to maintain remaining maxillary teeth and to restore them to optimum state of health for definitive obturator fabrication (Olepu et al, 2014).
Ÿ
Ÿ
Maximize distribution of support for obturator by the use of Occlusal, cingulum rests and vertical guide planes to distribute the functional load (Arcuri and Taylor, 2000)
Ÿ
Two anterior teeth adjacent to resection defect should be splinted. This improves stress distribution and improves clinical life of abutment teeth. Maximum extension should be made on to the residual palate and alveolar process (Lyon et al, 2005).
Ÿ
Extension to involve any load bearing area within the defect. For example; in posterior lateral region by obturator contact with the pterygoid plate or surface of temporal bone if pterygoid plate has been removed. These structures should be considered for skin grafting if considered for support (Arcuri and Taylor, 2000).
Ÿ
Placement of implants in available bone sites should be considered where possible in extensive maxillectomies ( Leles et al, 2010).
Ÿ
Placement of clasps as close to and as far from the defect as possible. Where possible, retentive undercuts within defect should be utilized ( Desjardins, 1978).
Ÿ
Use of precision attachments for improved esthetics and retention can also be used (Murat et al, 2012). Multiple occlusal rests in between the two terminal clasps will also provide indirect retention ( Parr et al, 2005).
Ÿ
To resist the rotational displacement of the obturator, guide planes should be created on the sides of the teeth facing the obturator. This is especially important when surgical defect extends across the midline and remaining teeth are in straight line (Parr et al, 2005).
CASE REPORT A 24 years old bomb blast affected patient named Syed Badshah (Figure 1, 2), reported to the department of Prosthodontics, Sardar Begum Dental Hospital with the chief complaint of inefficient chewing, speech and unsightly appearance. History revealed that the patient was injured in bomb blast in Afghanistan and was surgically managed right after (Figure 3). There was no history of using surgical and interim obturator prostheses during the 6 months after which he
Copyright© 2016, IESRJ. This open-access article is published under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License which permits Share (copy and redistribute the material in any medium or format) and Adapt (remix, transform, and build upon the material) under the Attribution-NonCommercial terms.
International Educational Scientific Research Journal [IESRJ]
5
Research Paper
E-ISSN No : 2455-295X | Volume : 2 | Issue : 7 | July 2016
reported. Lack of postoperative mouth opening exercise and no use of surgical plate or interim Obturator was the probable reason for his limited mouth opening. Besides this, his extra oral examination revealed Ÿ
Thin and unsupported upper lip
Ÿ
Upward contracture of lower lip on left side(giving an asymmetrical appearance)
Ÿ
Wrinkled skin(more on the left side)
FIGURES
While intraoral findings were Aramany's Class IV maxillectomy defect
Ÿ Ÿ
Upper left second bicuspid and first and second molars were present.
Ÿ
Lower incisors were missing
Fig 1: Before bomb blast.
Fig 2: After bomb blast.
So the problem list was as follows: Bad oral hygiene
Ÿ Ÿ
Difficulty in chewing
Ÿ
Unintelligible speech
Ÿ
Limited mouth opening(27 mm)( Fig 4)
Ÿ
Large hemimaxillectomy defect (Fig 5)
Ÿ
Remaining few maxillary dentition
Ÿ
Missing mandibular incisors (Fig 6)
Ÿ
Wrinkled skin
Ÿ
Depression
Fig 3: Orthopantomogram of patient after bomb blast
Treatment plan was decided for the patient. In the first phase of treatment, patient was referred for scaling and was educated about importance of oral hygiene and its effect on the prognosis of future treatment. Patient was kept on follow up to assess his oral hygiene. Sectional obturator prosthesis was planned for the patient. Because of limited mouth opening, impression of the defect ONLY was precisely recorded and cast in dental stone (Figure 7). Cast of defect was surveyed and rotational path of placement was decided for this portion of obturator. Bulb section was fabricated in heat cure acrylic resin which was tried in patient's mouth and lined with soft liner. (Figure 8). Magnet was placed on side facing towards oral cavity (Figure 9,10) Impression of the remaining maxillary dentition was recorded in irreversible hydrocolloid and was poured in dental stone. Defect portion of the cast was blocked. The cast was surveyed and vertical path of placement was decided. Teeth preparation was planned on the cast with the help of surveyor. After the planned tooth preparation was carried out, definitive impression (Figure 11) was recorded to get a master cast on which the metal framework was fabricated for dental arch section of obturator prosthesis (Figure 12). An impression was recorded with the bulb section and metal framework in situ and cast was obtained (Figure 13) to correlate the dental arch section to the bulb section. The objective was to record the impression of external surface form of the bulb section. Fitting surface of the second section of prosthesis was contoured according to the external surface of the bulb section. After the correct placement of two sections of prosthesis was verified, maxillomandibular relation was recorded. Artificial teeth were selected and approved by patient. Occlusal scheme selected for patient was monoplane. Trial was done and definitive prosthesis processed in heat cure acrylic (Figure 14). For the lower missing incisors, six unit fixed dental prosthesis was given using mandibular canines as abutments.
Fig 4: Limited mouth opening
Fig 6: Missing lower incisors
Fig 8: Intaglio surface of Bulb prosthesis
Fig 5: Intra oral view
Fig 7: Cast of defect impression
Fig 9: Bulb section of prosthesis with magnet placed on side facing oral cavity
For the wrinkled skin, patient was referred to cosmetic surgeon. By the end of the treatment, patient was out of his depressive state as his speech and esthetics were restored and mastication was improved. The patient was completely satisfied with his prosthesis and for the first time went out of dental clinic without covering his face. CONCLUSION One piece obturator prosthesis was difficult to fabricate in laboratory and almost impossible to insert and remove because of limited mouth opening (Figure 15, 16). It was made possible using magnetically integrated sectional obturator prosthesis. Another advantage of magnet retained sectional prosthesis is that they are self-seeking and patient does not have to learn complex maneuvers to locate two parts. Fig10: Bulb section in situ with optimum retention (mirror view)
6
International Educational Scientific Research Journal [IESRJ]
Research Paper
E-ISSN No : 2455-295X | Volume : 2 | Issue : 7 | July 2016 REFERENCES
Fig11: Definitive Impression recorded for dental section prosthesis
Fig 12: Cast metal framework for dental arch section of prosthesis
1.
Arcuri, MR., Taylor, TD.(2000): Clincal management of the dentate maxillectomy patient,in: Clinical Maxillofacial Prosthetics, Taylor,TD(ed.), Quintessence Publishing Co.. Chicago, pp. 103-120.
2.
Cardelli P, Bigelli E, VertucciV, Balestra F, Montani M, De Carli S. (2014). Palatal obturators in patients after maxillectomy.Oral Implantol (Rome), 7, p. 86-92.
3.
Desjardins RP. (1978). Obturator prosthesis design for acquired maxillary defects. The Journal of Prosthetic Dentistry, 39, p.424-435.
4.
Hicks R, Fertig S, Desrocher R, Koroshetz W, Pancrazio J. (2010). Neurological effects of blast injury.J Trauma, 68, 1257-1263.
5.
Jacob,R.(2000): Clincal management of edentulous maxillectomy patient,in: Clinical Maxillofacial Prosthetics, Taylor,TD(ed.), Quintessence Publishing Co.. Chicago, pp. 85-102.
6.
Kumar P, Jain V, Thakar A, Aggarwal V. (2013). Effect of varying bulb height on articulation and nasalance in maxillectomy patients with hollow bulb obturator. J Prosthodont Res, 57, p. 200-205.
7.
Leles CR, Leles JLR, Souza CP. Martins RR, Mendonca EF. (2010). Implant –supported obturator overdenture for extensive maxillary resection patient: a clinical report. Journal of Prosthodontics, 19, p. 240-244.
8.
Lyon KM, Beumer J, Caputo A. (2005). Abutment load transfer by removable partial denture obturator frameworks in different acquired maxillary defects. J Prosthet Dent, 94, p. 281-288.
9.
Murat S, Gurbuz A, Isayev A, Dokmez B, Cetin U. (2012). Enhanced retention of maxillofacial prosthetic obturator using precision attachments: two case reports. Eur J Dent, 6, p. 212-217.
10. Oki M, Iida T, Mukohyama H, Tomizuka K, Takato T, Taniguchi H. (2006). The vibratory characteristics of obturators with different bulb beights and form designs. Journal of oral rehabilitation, 33, p. 43-51. 11. Olepu SR, Kumar M, Rajesh R, Kalra T. (2014). Prosthetic rehabilitation of maxillary defects: A review. Int J Dent Health Sci, 1, p. 632-643. 12. Parr G, Tharp G, Rahn A.(2005). Prosthodontic principles in the framework design of maxillary obturator prostheses. J Prosthet Dent, 93 , p. 405-411.
Fig 13: Cast obtained from impression of bulb section of prosthesis and metal framework together
13. Sharry JJ. (1954). The meatus obturator in cleft palate prosthesis. Oral Surg Oral Med Oral Pathol, 7 , p.852–855. 14. Uludag B, Celik G. (2007). Technical tips for improved retention and stabilization of unilateral removable partial denture. J Oral Implantol, 33, p. 344-346. 15. Walter J. (2005). Obturators for acquired palatal defects. Dental update, 32, p. 277-285.
Fig 14: Both sections of obturator prosthesis
Fig 15: Sectional obturator prosthesis with magnet keeping the two sections together
Fig 16: Combined height of two sections of obturator prosthesis was 43 mm, whereas maximum vertical mouth opening of rima oris was 27 m.
International Educational Scientific Research Journal [IESRJ]
7