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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 118-121

Obturator with saliva reservoir


Department of Prosthodontic and Crown and Bridge, Army Dental Center R&R, New Delhi, India

Date of Submission04-Aug-2020
Date of Acceptance13-Dec-2020
Date of Web Publication22-Mar-2021

Correspondence Address:
Dushyant Chauhan
Department of Prosthodontic and Crown and Bridge, Army Dental Center R&R, Delhi Cantt, New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_122_20

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  Abstract 


Maxillectomy defects are usually due to surgical resection of carcinoma and results in a distinctive complication. In maxillectomy, there is a communication between the oral and nasal cavity which aggravates the problem and limits the treatment option. If the patient presents with additional xerostomia, then the level of difficulty increases many folds. This case report presents a patient with maxillectomy undergoing radiotherapy resulting in xerostomia. The patient wanted to have a definitive functional restoration. Due to the complexity of situation a conventional obturator was not enough as removable prosthesis in the dry mouth is not well tolerated. Initially, an interim obturator was fabricated and later definitive obturator using neutral zone technique with saliva reservoir was fabricated. Artificial saliva was used to maintain the moisture in the mouth and provided with adequate lubrication for the removable prosthesis to function. The prosthesis satisfactorily restored function and provided an adequate seal between the nasal and oral cavity. Shortcoming of this prosthesis was that the artificial saliva had to be replaced regularly. However, overall the patient was satisfied with the prosthesis.

Keywords: Obturator, salivary reservoir, xerostomia


How to cite this article:
Chauhan D, Thakur A, Chaudhary R. Obturator with saliva reservoir. Indian J Dent Sci 2021;13:118-21

How to cite this URL:
Chauhan D, Thakur A, Chaudhary R. Obturator with saliva reservoir. Indian J Dent Sci [serial online] 2021 [cited 2021 Apr 20];13:118-21. Available from: http://www.ijds.in/text.asp?2021/13/2/118/311677




  Introduction Top


Carcinoma involving oral tissue is an agonizing experience for the patients, especially if they have no reasonable etiology or predisposing habit. Oral carcinoma is the eleventh most common cancer site. Incidence of oral carcinoma is 12.6 per 100,000 individuals.[1],[2] The treatment is invasive, damaging, and difficult for both the physical and mental state of the patient. Treatment options like any other cancer are chemotherapy, radiotherapy, and surgical intervention.[3] Any treatment modality for oral carcinoma is associated with side effects. Radiotherapy and chemotherapy patients generally have associated xerostomia, oral mucositis, pain, bleeding, infection, etc. Whereas surgical resection of carcinomatous tissues from oral sites results in minor to major anatomic defects. Carcinomas involving the maxillary arch when treated surgically result in defect which are classified by Aramany's into six classes.[4] These defects result in difficulty in swallowing, deglutition, respiration, and speech. Hence, they are rehabilitated prosthetically using obturators.[5]

A patient with xerostomia has many symptoms such as dryness of the mouth, loss of taste sensation, and inflammation. Furthermore, causes in difficulty in the retention of removable prosthesis and ulceration due to abrasion on repeated wear.[6] One of the treatment options to overcome this dryness of the mouth is to introduce artificial saliva. Artificial saliva contains carboxy methylcellulose, flavoring agents, glycerin, and electrolyte basically.[7] The difficult part is how to provide a constant source of artificial saliva in the patient's mouth. Thus, in the patients using removable prosthesis providing a salivary reservoir is beneficial.

In the following case, a patient presented with a large palatal defect extending posteriorly up to the soft palate and superiorly just below the floor of the orbit was rehabilitated with an obturator with saliva reservoir.


  Case Report Top


A 62-year-old female was referred to the Department of Prosthodontics from the Department of Oncosurgery for fabrication of postsurgical/interim obturator following partial resection of the maxilla of the right side. History revealed that the patient was diagnosed with carcinoma of the hard palate and alveolus. She was planned to undergo radiotherapy and had difficulty in speech, swallowing, respiration, along with regurgitation of food. On examination, multiple teeth were missing while remaining teeth were carious and periodontally compromised having hopeless prognosis. Maxillary defect was classified as Class II according to the Armany's classification [Figure 1].
Figure 1: Preoperative palatal defect

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Treatment planning

It was planned to fabricate a delayed surgical obturator and to reline it to act as interim obturator. After 6 months' postradiotherapy, definitive prosthesis was to be given.

Phase-I: Delayed surgical obturator

As the patient had reported after 5 days of surgical resection, a delayed surgical obturator was fabricated after making the impression in irreversible hydrocolloid of the maxillary arch. The obturator did not have any extension into the defect to avoid hindrance to the healing of the defect. The prosthesis was inserted and reviewed after 24 h, 3 days, and weekly after that. Any modifications required were made [Figure 2]. Once the wound healing was satisfactory and the patient was stable, extraction of teeth was planned before radiotherapy. All postextraction wounds healed uneventfully. Interim prosthesis was fabricated for the patient before radiotherapy and after total extraction. The patient was closely monitored during radiotherapy for any modifications required. After radiotherapy, the patient did not report for 5 months. In the period of absence, the patient went for a temporal flap surgery to close the defect which failed resulting in necrosis of the temporal flap and a temporal defect.
Figure 2: Delayed surgical obturator in function

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Phase-II: Definitive obturator

Impression

After 5 months' patients returned with interim obturator still in place and functioning adequately. The patient complained that she could not chew the food and wanted a definitive restoration. On examination, it was found that she was completely edentulous with palatal defect (Armany's Class II) and dryness of the mouth. Oral mucosa was dry and wrinkled in appearance. Interocclusal distance was reduced [Figure 3]. Thus for the definitive restoration, an obturator with saliva reservoir was planned. After blocking the undercuts in the defect with paraffin gauze, the primary impression was made in irreversible hydrocolloid extending into defect as much as possible [Figure 4]. Primary cast was poured and special tray was fabricated for both the maxillary and mandibular arch. Maxillary final impression was made first in which green stick compound was used to extend into the defect to support the final impression material. Then the peripheral border molding was carried out. The final impression was made in light body elastomeric impression material [Figure 5]. Conventional border molding was carried out for the mandibular arch and impression made in zinc oxide eugenol impression material. Final casts were poured and temporary denture bases were fabricated in auto polymerizing Polymethylmethacrylate (PMMA).
Figure 3: Maxillary and mandibular edentulous arch with Aramany's Class II defect

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Figure 4: Undercut block out in the defect and primary impression

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Figure 5: Border moulding and final impression of the defect with adequate extension in the defect

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Neutral zone

On the temporary bases, compound rims were made for recording the neutral zone. The rims were softened in hot water bath and inserted into the patient's mouth. The patient was asked to make movements such as pouting, puckering, sucking, and swallowing to record the neutral zone first in the maxillary arch and then in the mandibular arch [Figure 6]. Neutral zone on evaluation showed that on the affected side it was placed more lingually due to fibroses of buccal mucosa and taut buccal muscles. Index of the neutral zone was made in rubber base impression material in putty consistency. Wax was poured in the putty index to get wax rims as per neutral zone, which was adjusted to appropriate height. Then the vertical dimension was adjusted and jaw relation was recorded [Figure 7]. Articulation was done followed by anterior teeth arrangement and wax-up was tried to evaluate esthetics and phonetics. For the posterior nonanatomic teeth were selected and arranged. The trial was then carried out to check for function and occlusion [Figure 8].
Figure 6: Patient making movements to record neutral zone and recorded neutral zone

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Figure 7: Putty index of neutral zone and jaw relation

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Figure 8: Try in and evaluation of occlusion

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Salivary reservoir fabrication

Then, additional modeling wax was adapted to the palatal contours of the trial denture. This will form the lid of the reservoir. It was tried on the patient to check for any difficulty in phonetics [Figure 9]. Then using type-III dental stone, an index was made of the new palatal contour. The index and the wax lid were invested and processed in heat cure clear PMMA. The lid was then trimmed to create space for soft liner and reinvested to line it with permanent soft liner [Figure 10]. After that, the remaining maxillary prosthesis was trimmed and the space was created for hollow obturator, similar to 2-part hollow obturator technique. The prosthesis was then invested, dewaxed, and acrylised with heat-cured PMMA. Later, the prosthesis was retrieved, finished, and polished. Then, the two pieces of the prosthesis were attached with auto polymerizing PMMA creating a reservoir. At the most lower part of the reservoir, 1 mm hole was drilled to act as inlet and outlet of artificial saliva. Using a 5 ml syringe artificial saliva was injected into the reservoir space through the hole created. The patient was taught to extrude the artificial saliva using the tongue to compress the palatal soft liner [Figure 11]. The patient and her attendant were taught to refill the reservoir and keep a record of it. The patient was recalled after 24 h to review and to rectify sore spots. After a week, the patient was recalled to assess the function of the saliva reservoir and obturator both in providing a seal between the nasal and oral cavity and also for providing a steady source of saliva. Patient-reported improvement in function and was feeling much better with the new prosthesis.
Figure 9: Additional palatal contour which will act as a lid for salivary reservoir

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Figure 10: Palatal lid made in heat cure Polymethylmethacrylate and soft line attached to it

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Figure 11: Finished prosthesis with palatal lid attached and refilled with salivary substitute, demonstrating release of contents of salivary reservoir on stimulation

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  Discussion Top


Maxillectomy defect leaves the patient with multiple complications such as function, esthetics, phonetics, and a psychological setback.[8],[9] The condition is worsened with the associated radiotherapy or chemotherapy that inflicts additional side effects such as xerostomia which effect the diet and nutrition of already compromised individuals.[10] The technique to incorporate salivary reservoir in a complete denture case is well documented and in this case, a similar technique was used without encroaching on to the tongue space. Not only does the prosthesis rehabilitate esthetics, function, and phonetics but also contributes in maintaining the moisture of the oral cavity, hence improving overall health of the individual.[11] The challenge in such rehabilitation remains patient compliance and motivation. The patient has to repeatedly refill the reservoir with artificial saliva and at the same time maintain good oral and prosthetic hygiene. Moreover, after certain period of time the resilient liner does not function as desired and needs to be replaced adding on to chairside time. With all these hindrances, however, it is still an effective method to replenish the oral cavity with the lost saliva and moisture.


  Conclusion Top


This novel and modified technique has proved to be a simple solution to a group of problems faced by patients with the maxillectomy defect. This type of prosthesis serves multiple functions of sealing the oral cavity reducing regurgitation, improving phonetics and function, and at the same time maintaining the moisture levels in the oral cavity. The prosthesis also improves its own function as prosthesis in a dry mouth are poorly tolerated hence, such technique proves to be a beneficial situation for both the patient and prosthodontist.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Petersen PE. Strengthening the prevention of oral cancer: The WHO perspective. Community Dent Oral Epidemiol 2005;33:397-9.  Back to cited text no. 1
    
2.
Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, et al. Effect of screening on oral cancer mortality in Kerala, India: A cluster-randomised controlled trial. Lancet 2005;365:1927-33.  Back to cited text no. 2
    
3.
Newton JT, Fiske J, Foote O, Frances C, Loh IM, Radford DR. Preliminary study of the impact of loss of part of the face and its prosthetic restoration. J Prosthet Dent 1999;82:585-90.  Back to cited text no. 3
    
4.
Aramany MA. Basic principles of obturator design for partially edentulous patients. Part I: classification. J Prosthet Dent 1978;40:554-7.  Back to cited text no. 4
    
5.
Lethaus B, Lie N, de Beer F, Kessler P, de Baat C, Verdonck HW. Surgical and prosthetic reconsiderations in patients with maxillectomy. J Oral Rehabil 2010;37:138-42.  Back to cited text no. 5
    
6.
Greenspan D. Xerostomia: Diagnosis and management. Oncology (Williston Park) 1996;10:7-11.  Back to cited text no. 6
    
7.
Ahmad N, Rai M, Khan A, Tiwari AK, Ahmad N. Palatal obturator with salivary reservoir-A case report. Ann Prosthodont Restor Dent 2015;1:44-6.  Back to cited text no. 7
    
8.
Keyf F. Obturator prostheses for hemimaxillectomy patients. J Oral Rehabil 2001;28:821-9.  Back to cited text no. 8
    
9.
Matsuyama M, Tsukiyama Y, Tomioka M, Koyano K. Subjective assessment of chewing function of obturator prosthesis wearer. Int J Prosthodont 2007;20:46-50.  Back to cited text no. 9
    
10.
Närhi TO, Meurman JH, Ainamo A. Xerostomia and hyposalivation: Causes, consequences and treatment in the elderly. Drugs Aging 1999;15:103-16.  Back to cited text no. 10
    
11.
Covington JS, Slagle WF, Disney AL. Complete denture salivary fluid reservoirs: A novel approach to xerostomia relief. J Dent Res 1985;64:242.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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