Prosthetic management after maxillectomy

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Prosthetic Management After Maxillectomy

Overview

Maxillectomy creates a communication between the oral cavity and the nasal/sinonasal cavities, resulting in impaired speech (hypernasal), swallowing, mastication, and facial aesthetics. Prosthetic management centers on the obturator prosthesis - a device that seals this defect to restore function. Management is a three-phase continuum led by the maxillofacial prosthodontist as part of the multidisciplinary team (MDT).

Pre-surgical Assessment

All patients with oral, maxillary, and mid-face tumors should be assessed by the maxillofacial prosthodontist before surgery:

Panoramic dental radiograph (OPG) + detailed oral examination
Assessment of remaining teeth - their periodontal status and role as future abutments
Decision on dental extractions, restorations, and implant planning
Pre-operative impressions of the palate to fabricate the immediate surgical obturator
Patient counseling regarding aims, advantages, and limitations of prosthetic rehabilitation

Classification of Maxillectomy Defects (Aramany Classification)

Class	Defect Description
I	Unilateral resection along the midline
II	Unilateral resection not involving midline (posterior)
III	Central resection (bilateral anterior)
IV	Anteroposterior resection crossing the midline
V	Posterior unilateral defect
VI	Anterior defect only

The Aramany class influences prosthesis design, retention strategy, and complexity of rehabilitation.

Three Phases of Obturator Management

Phase 1 - Surgical (Immediate) Obturator

Fabricated pre-operatively from pre-surgical impressions and inserted at the time of surgery, before extubation.

Functions:

Separates oral and nasal cavities immediately post-op
Supports the surgical pack/dressing
Holds the skin graft against the defect walls
Maintains cheek contour and provides soft tissue support
Allows early oral feeding and speech

Retention methods:

Circumzygomatic or circummalar wires passed through loops on the obturator (see image below)
Screws through the zygoma/remaining palatal bone
In dentate patients, wire clasps on remaining teeth

Surgical obturator with loops for circumzygomatic wires - fabricated on a dental stone model

Figure: Surgical obturator with loops for circum-zygomatic wires (Scott-Brown's Otorhinolaryngology)

Screw-retained surgical obturator relined with silicone putty, placed immediately post-maxillectomy

Figure: Screw-retained surgical obturator relined with silicone putty, intra-operatively (Scott-Brown's Otorhinolaryngology)

Materials used to obturate the defect:

Addition-cured silicone putty (preferred by many - readily available, engages undercuts, provides rigid cheek support, assists haemostasis)
Black gutta percha
Foam-based products

Phase 2 - Interim (Transitional) Obturator

Provided approximately 4-6 weeks post-operatively as the defect contracts and heals:

Replaces or substantially modifies the surgical obturator
Allows progressive wound healing assessment
Adjusted and relined regularly over the following months as the defect changes shape
Carries prosthetic teeth for esthetics and early function
Can incorporate soft silicone "bung" material to engage defect undercuts and aid retention

Key considerations during this phase:

Trismus is common, especially when surgery is combined with radiotherapy - limits access for impression taking and prosthesis insertion; this must be planned for
Defect continues to contract for 3-6 months post-surgery and post-radiotherapy

Phase 3 - Definitive Obturator

Constructed once the defect has stabilized (usually 6-12 months post-surgery, or after completion of adjuvant radiotherapy and adequate tissue recovery):

Optimized for function, retention, and esthetics
May include prosthetic teeth in full occlusion
For low-level partial maxillectomy, a soft silicone bung engages defect undercuts and assists retention alongside dental clasps

The definitive obturator fabricated in synthetic polymer (acrylic resin base) provides oronasal separation, yielding normal speech and swallowing. It allows direct visualization of the defect for tumor surveillance - an important oncological advantage over free tissue transfer.

Surgical Modifications to Facilitate Obturator Provision

Surgeons should work in coordination with the prosthodontist:

Palatal mucosal incisions should be made laterally to bone cuts to create a keratinized mucosal flap over the cut palatal bone edge - acts as a cushion/fulcrum for the prosthesis during masticatory function
Split-skin graft to the cheek defect - produces a scar band which engages the obturator and provides retention (particularly important for conventional obturators without implants)
Inferior turbinate removal - provides vertical space for the obturator elements and prevents trauma
Abutment teeth - periodontal health must be maintained, as remaining teeth are vital for obturator support, retention, and stability

Multi-part Obturators and Osseointegrated Implants

Multi-part Design

Used when:

The defect is large
Significant trismus limits access (prosthesis inserted in two parts and joined intra-orally)
For posterior maxilla defects where access is restricted

A separate dental prosthesis component joins the obturator component intra-orally.

Osseointegrated (Endosseous) Implants

Implants dramatically improve obturator retention and stability, especially in:

Edentulous patients (no teeth for clasping)
Large defects (limited remaining bone and soft tissue support)
Patients in whom conventional retention is inadequate

Placement options:

At the time of primary surgery (primary/simultaneous implant placement)
As part of secondary definitive rehabilitation

Zygomatic implants are particularly useful after total maxillectomy where alveolar bone is absent - they anchor in the zygomatic arch and can support an obturator or fixed prosthesis. A 2025 study (Kumari et al., JMOS) specifically addresses rehabilitation using zygoma implants in maxillectomy patients.

A novel technique described in recent literature uses an intramucosal retention system to improve obturator stability without implants (Alves et al., 2024, PMID 38963534).

Obturator vs. Free Flap Reconstruction

Factor	Obturator	Free Flap
Invasion	Non-invasive	Requires second surgical site
Tumor surveillance	Direct visualization of defect	Limited inspection
Complexity	Requires ongoing maintenance	Single surgical procedure
Large/complex defects	Difficult; retention challenging	Better HRQoL with microvascular flap for complex resections
Edentulous patients	Worse outcomes vs. dentate	Offers bone for implants
Radiotherapy effect	Worsens mouth opening and oral/swallowing function	Also affected but anatomically more stable

Obturator prosthesis is a highly positive and non-invasive approach to improve quality of life for maxillectomy defects - Scott-Brown's Otorhinolaryngology, p. 390. For large complex resections (palate + maxilla + sinuses + orbit), microvascular reconstruction may give better HRQoL outcomes.

Prosthetic Management of Facial Defects

After total maxillectomy or mid-facial resections involving the orbit and nose:

Extra-oral facial prostheses (nasal, orbital, or combined auricular prostheses) may be required
Facial prostheses are fabricated from medical-grade silicone, intrinsically or extrinsically colored to match skin
Retention via: spectacle frames, adhesives, magnets, or osseointegrated implants (craniofacial implants)
Osseointegrated implants in the supraorbital rim, zygomatic arch, or mastoid region provide superior retention over adhesives

Dental Rehabilitation Considerations

Post-ablative surgery patients face significant dental challenges:

High rates of dental phobia and anxiety
Many are edentulous at presentation
Resective surgery removes sections of dentition
Adjuvant radiotherapy causes xerostomia, increased caries risk, and osteoradionecrosis risk
Bulky soft-tissue free flaps can obstruct dental rehabilitation (vestibuloplasty and flap reduction may be needed)

Pre-surgical decisions on remaining teeth must weigh:

Patient motivation and oral hygiene
Tumour site, stage, and prognosis
Adjuvant radiotherapy dose/fields and effect on remaining teeth
Implant timing and site planning

Summary Flowchart

Diagnosis → Pre-surgical assessment (prosthodontist + MDT)
         → Dental treatment / OPG / implant planning
         → Surgery + IMMEDIATE SURGICAL OBTURATOR (inserted pre-extubation)
         → 4-6 weeks → INTERIM OBTURATOR (serial relining/adjustments)
         → 6-12 months (after RT recovery) → DEFINITIVE OBTURATOR
         ↓ (if retention inadequate or edentulous)
         Osseointegrated / zygomatic implants → implant-retained obturator or fixed prosthesis

Sources:

Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Chapter 31 (Prosthetic Rehabilitation), pp. 542-549
K.J. Lee's Essential Otolaryngology, Palatal Reconstruction, p. 851
Cummings Otolaryngology Head and Neck Surgery, Hard Palate and Subtotal/Total Maxillectomy chapters

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