PROSTHETIC TREATMENT OF PATIENT WITH TOTAL HARD PALATE RESECTION

https://www.journal-imab-bg.org 2355 ABSTRACT: Introduction: Operative treatment of tumours of the maxilla impairs the barrier between the oral and nasal cavities, making difficult or impossible to eat, speak, and drink liquids. Aim: The purpose of the clinical case described, is to examine the possibility of prosthetic treatment in patients with fully resected hard palate, the treatment effect and recovery of impaired functions. Materials and methods: The article presents the prosthetic treatment of a patient with resection of the entire hard palate as a result of an oncological disease. Due to complete edentulism, the treatment plan included the construction of an obturator and a complete lower denture. Functional impressions with additive silicone were taken with custom trays of the light-cured acrylic resin after preedging with wax impression material (ISO Functional GS). The dentures were made of a colourless heat cured the acrylic resin. The volume and localization of the defect necessitated a specific shaping of the replacement part of the obturator. In order to provide the necessary retention and stability, we used our own modification of the open cupshaped form in which the edges of the replacement part were extended distally in the area of the soft palate. Results: The results of the treatment showed good retention and stability of the obturator and the lower denture. The feeding, speech and swallowing of the patient were successfully restored. Conclusion: Prosthetic treatment with a definitive obturator allows optimal sealing of the maxillary defect even with a fully removed hard palate.


INTRODUCTION
Studies show a significant increase of oncological diseases in the maxillofacial area, with a tendency for the continuous increase [1,2].Some data suggest that oral cancer is the most prevalent oncology disease after lymphoma and leukaemia [3].Four-fold increased morbidity gives Suba et al. [4] grounds to define oral cancer as the disease of the 21 st century.
Prosthetic treatment methods have a central place in the complex treatment and rehabilitation of patients with Case report

PROSTHETIC TREATMENT OF PATIENT WITH TOTAL HARD PALATE RESECTION
maxillary resection [5,6].Most authors [6, 7] conduct prosthetic rehabilitation after maxillary resection in three stages, by means of a surgical, temporary and definitive obturator.Each of these prostheses allows the recovery of damaged functions through the various stages of treatment, ensuring the maintenance of a relatively good quality of life [8].
Prosthetic treatment of patients with maxillary resection is accompanied by many difficulties and problems associated with providing a stable barrier between the oral and nasal cavities and the sealing of the defect [9].This necessitates preliminary planning of the prosthetic construction in accordance with both the basic prosthetic principles and the individual characteristics of the patient [10].It is necessary to take into account all factors that influence the retention, and stability of the obturator [11].
There are a number of methods for making definitive obturators with different materials and technologies [12,13,14].Some authors [15] give priority to treatment with closed hollow obturators.According to others [16], treatment with hollow or dense buccal flange obturators is associated with a number of difficulties, requiring their replacement by open obturators.Their main advantage is the reduced weight -from 6.55% to 35.06% less than dense obturators [17].Electromyographic studies show better clinical results when using the open cup-shaped form of the replacement part [18].This is explained by reduced weight and volume, making it easier to put in the defect, and providing greater comfort for patients [16].The main disadvantage of open cup-shaped obturators is plaque containment and difficult cleaning [19].

AIM
The purpose of the clinical case described is to examine the possibility of prosthetic treatment in patients with a fully resected hard palate, and the effect of treatment for the recovery of impaired functions.

MATERIALS AND METHODS
The article describes the prosthetic treatment of a 58-year old patient with resection of the maxilla as a result of surgical treatment of oncological disease.Intraoral examination showed a large maxillary defect involving the whole hard palate and passing the A-line [Fig.1].The broken barrier between the mouth and the nasal cavity did not allow normal feeding and speaking of the patient.It was https://doi.org/10.5272/jimab.2019251.2355impossible to drink liquids, which, according to the patient, was a major problem that had a serious impact on his quality of life.The atrophy of the preserved alveolar ridge and the lack of natural teeth made it difficult to plan and carry out the prosthetic treatment.A treatment plan was compiled, which included the construction of an obturator and a complete lower denture.The preliminary impression of the maxilla was taken with a standard metal tray elongated in the area of the soft palate defect.We used an irreversible hydrocolloid impression material after preliminary tamponage of the defect with a gauze.Individual trays of lightcured acrylic were used for taking functional impressions of the two jaws.For the upper jaw, the tray was further shaped so that it's edges entered circularly about 5 mm in the defect.This allowed preliminary edging both on the valve area and on the defect boundary for which ISO Functional (GS) wax was used.An additive silicone was used for finishing off the functional impressions.The occlusion height and the central position of the lower jaw were fixed with wax rims.After a successful trial denture, the dentures were finished in a colourless heat-cured acrylic resin.The volume and localization of the defect necessitated a specific shaping of the replacement part of the obturator.To ensure the necessary retention and stability, we used our own modification of the open cup-shaped form in which the edges of the replacement part were extended distally in the area of the soft palate [Fig.2].This created a prerequisite for additional sealing in the A-line area and stabilized the obturator during eating and swallowing.The dentures were adjusted and articulated in the last clinical stage.At the follow-up examinations, the occurred decubital injuries were treated, and some occlusal contacts were corrected.

RESULTS
The results of the treatment showed good retention and stability of the obturator and the lower denture despite the large size and unfavourable localization of the defect.The modification used to make an open obturator with distal wings to the soft palate allowed optimal sealing and ensures successful recovery of the feeding, speech and swallowing of the patient.The patient's main problem related to the inability to take liquids was also solved.The complex prosthetic treatment with an obturator and a lower denture allowed restoration of the occlusal relationships and the achievement of bilaterally balanced occlusion [Fig.3].Recovery of impaired functions regained the patient's self-esteem and significantly improved his quality of life.

DISCUSSION
The applied treatment method confirmed the concept that prosthetic treatment has a central place in the complex treatment and rehabilitation of patients with maxillary resection [5,6].Proper planning and compliance with the patient's individual characteristics allowed to make an optimal prosthetic construction, which according to most authors [10,11] is important for the success of the treatment.The use of the classical open form of the replace-