I

MPACT OF EXTRACORONALPRECI
SION ATTACHMENTS ON
HEALTH RELATED QUALI
TY OF LI
FE I
N MAXI
LLECTOMY
PATI
ENT’
S–ACASEREPORT

ABSTRACT

Maxi
l
lar
ydef
ect
s ar
e due t
o congeni
talordev
elopment
almal
for
mat
ions,sur
gical
t
reat
mentofbeni
gnormal
i
gnantneopl
asmsandacci
dent
alt
rauma.Rehabi
l
itat
ionof
suchmaxi
l
lar
ydef
ecthasdi
rectef
fectoncosmet
icf
unct
ionandpsy
chol
ogyoft
he
pat
ient
.Pr
eci
si
onat
tachment
shav
ebeenusedt
oret
ainobt
urat
orsf
orsomet
ime.The
useofpr
eci
si
onat
tachment
sinadent
atemaxi
l
lect
omypat
ientcany
iel
dsi
gni
fi
cant
f
unct
ionalandest
het
icadv
ant
agesi
nhemi
maxi
l
lect
omypat
ient
s.Thi
scl
i
nicalr
epor
t
descr
ibest
hepr
ost
het
icr
ehabi
l
itat
ionofmaxi
l
lar
ydef
ect
swi
thanobt
urat
orr
etai
ned
usi
ngext
racor
onal
resi
l
ientpr
eci
sionat
tachment
s.

Key
wor
ds:Maxi
l
lof
aci
alpr
ost
hesi
s,cl
ass1 ar
amany
,qual
i
tyofl
i
fe,
recov
eryof
f
unct
ion

I
NTRODUCTI
ON

Ar
ewar
ding ar
eaofpr
ost
hodont
icsi
sther
ehabi
l
itat
ion ofpat
ient
swi
th acqui
red
maxi
l
lar
ydef
ect
s.Acqui
reddef
ect
scanoccurduet
omanyr
easonst
rauma,
pat
hol
ogi
cal
changes,
radi
ati
on,
bur
ns,
orsur
gical
int
erv
ent
ion.
Oralmal
i
gnanci
esi
sthemai
ncauseof
t
hesedef
ect
sint
hepr
esentscenar
io.
Oralcanceri
saser
iouspr
obl
em andi
sthesi
xth
mostcommont
umouri
nthewor
ld,
andamongmeni
t’
sfour
thmostcommoncancer
.It
1
r
epr
esent
s25t
o30per
cent
ageofal
lcancer
sinsomeasi
ancount
ri
es.
Pr
imar
ytr
eat
mentmodi
l
tyf
ort
hesecancerpat
ient
sar
esur
ger
yandchemot
her
apy
.
Howev
eranumberofcompl
i
cat
ionsl
i
kei
mpai
redmast
icat
ion,
dif
fi
cul
tyi
ndegl
uti
ti
on
andswal
l
owi
ng,nasall
eakage,
hyper
nasalspeech,cosmet
icdi
sfi
gur
ementoccur
sdue
t
othesur
gical
int
erv
ent
ionaf
fect
ingt
heQOL(
Qual
i
tyofl
i
fe)oft
heseofpat
i s2.
ent

Rehabi
l
itat
ionoft
hesedef
ect
sisusual
l
ytr
eat
edpr
ost
hodont
ical
l
y,asduet
ogener
al
heal
thoft
hepat
ientsur
gicalr
econst
ruct
ionofmaxi
l
lect
omydef
ect
sisnotal
way
s
possi
ble3.
Pref
err
edmet
hodf
ort
her
est
orat
ionofmast
icat
ion,speech,degl
uti
ti
on,and
4
est
het
icsf
ormost
maxi
l
lect
omy pat
ient
sis pr
ost
het
icr
ehabi
l
itat
ion. Pr
imar
ygoalof
pr
ost
het
icobt
urat
ioni
scl
osur
eoft
hedef
ect
sandsepar
ati
onoft
heor
alcav
ityf
rom t
he
si
no-
nasalcav
iti
esi
nor
dert
opr
eventhy
per
-nasalspeechandl
i
qui
dleakage5.
Basi
c
desi
gnpr
inci
plesofobt
urat
orpr
ost
hesi
sfr
amewor
kfol
l
owst
hesamepr
inci
ple of
r
emov
abl
epar
ti
aldent
uref
ramewor
kdesi
gn,
wit
hsomemodi
fi
cat
ionst
oincor
por
ate
6
t
heuni
quer
equi
rement
sofmaxi
l
lect
omypat
ient .
Themaj
ori
tyofmaxi
l
lar
ydef
ect
scan
ber
ehabi
l
itat
edwi
thconv
ent
ionalsi
mpl
eobt
urat
orpr
ost
hesi
susi
ngv
ari
ouscl
aspsas
7 ,
8 .
t
he r
etent
ive el
ement I
nor
der t
o enhance f
unct
ion and
est
het
ics,
preci
si
onat
tachment
sasr
etent
iveel
ement
shasl
ongbeenconsi
der
edasone
oft
hemostsophi
sti
cat
edf
ormsoft
reat
ment
.I
ncaseswher
eest
het
icsi
smaj
orconcer
n
f
orpat
ient
,especi
all
yinant
eri
orr
egi
onat
tachmentr
etai
nedpr
ost
hesi
sispr
efer
redov
er
conv
ent
ionalcl
aspi
ng.I
tal
soof
fer
sal
evelofr
esi
l
iencet
ocompensat
eforst
resses
9.
f
rom mast
icat
ionaswel
laspr
event
sfoodi
mpact
ioni
ntot
hedef
ect

Thi
scl
i
nicalr
epor
tdescr
ibest
hepr
ost
het
icr
ehabi
l
itat
ionofamaxi
l
lar
ydef
ect
swi
than
obt
urat
or r
etai
ned wi
thext
racor
onal r
esi
l
ient pr
eci
sion at
tachment
s.Obt
urat
or
Funct
ionalScal
e(OFS)quest
ionnai
res,wasser
vedt
opat
ientf
ir
sti
nit
ial
l
ypr
eoper
ati
vel
y
andf
inal
l
y agai
n 15day
spost
oper
ati
vel
y.
Thepur
posewas t
oassessandcompar
e
heal
thr
elat
edqual
i
tyofl
i
fei
nconv
ent
ional
vsat
tachmentr
etai
nedpr
ost
hesi
s.

CASEREPORT

A20-
year
-ol
dmal
epat
ientv
isi
tedt
heDepar
tmentofPr
ost
hodont
ics,
foranev
aluat
ion
f
orpr
ost
het
ict
reat
ment
.Thepat
ient
’smaj
orcompl
aint
swer
elackofr
etent
ionand
i
nst
abi
l
ityoft
hepr
ost
hesi
s,i
mpai
redspeechandmast
icat
ion,
andf
lui
dleakagei
ntot
he
or
alcav
ity
.

Pat
ient
s hi
stor
yrev
eal
ed t
hat5 y
ear
s ear
li
erhe was di
agnosed wi
th ost
eogeni
c
sar
comaoft
hel
eftmaxi
l
la,
and wassubsequent
lyt
reat
edbyauni
l
ater
almaxi
l
lect
omy
f
oll
owed by post
-sur
gicalr
adi
ati
on t
her
apy
(fi
g 1)
.As a r
esul
tof sur
ger
y and
r
adi
other
apy
,the pat
ient had exper
ienced f
ibr
osi
s and scar cont
ract
ion.
Pat
ient
pr
esent
edwi
thaconv
ent
ionalobt
urat
orpr
ost
hesi
s,whi
chwasnol
ongerr
etent
ive.
He
had di
ff
icul
tyi
n mast
icat
ion, hy
per
nasalspeech,and nasaldi
schar
ge.
Ext
ra-
oral
exami
nat
ion r
eveal
ed a col
l
apsed mi
dface and di
plopi
a.(
fi
g2)
.I
ntr
aor
alexami
nat
ion
r
eveal
edpar
ti
almaxi
l
lect
omyoft
hel
eftsi
de,wi
thr
esect
ionoft
hehar
dpal
ate,al
veol
ar
bone,t
eet
handsof
tti
ssuet
hatdi
dnotexceedt
hemi
dli
ne. Pat
ienthadal
lvi
abl
e
maxi
l
lar
yteet
hont
her
ightsi
def
rom r
ightcent
rali
nsi
cort
osecondmol
ar.
(f
ig3,
4).
The
def
ectwascl
assi
fi
edaccor
dingt
oAr
amanyasaCl
assICur
vedAr m7.Pat
chFor ient
wassuggest
edwi
thapr
eci
sionat
tachmentr
etai
nedpr
ost
hesi
stof
ulf
il
lhi
sobj
ect
ives
ofest
het
ics,
ret
ent
ionandf
unct
ion.
Theobt
urat
orf
ramewor
kwasdesi
gnedaccor
ding
t
oKennedyCl
assIRPDdesi
gnpr
inci
ples,i
ncl
udi
ngt
oot
hsuppor
t,pl
acementofdi
rect
r
etai
neradj
acentt
othedef
ectext
ensi
onbase,
andi
ndi
rectr
etent
ion.Theobt
urat
orwas
r
etai
nedusi
ngext
racor
onalr
esi
l
ientat
tachment
stopr
eventt
hedi
spl
ayofr
etent
ive
buccal
claspsi
ntheest
het
icr
egi
on.

CLI
NICALPROCEDURE:

Bef
ore st
art
ing t
he i
mpr
essi
on pr
ocedur
e,obt
urat
orf
unct
ionalscal
e (OFS)scal
e
quest
ionnai
rewasgi
vent
othepat
ientandt
otalscor
ewascal
cul
ated,t
oassest
he
f
unct
ionofconv
ent
ionalpr
ost
hesi
sandf
inal
l
ycompar
eitwi
that
tachmentr
etai
ned
pr
ost
hesi
slat
eron.

Thepr
imar
yimpr
essi
onoft
heupperar
chi
smadewi
thi
rr
ever
sibl
ehy
drocol
l
oid,af
ter
bl
ocki
ngt
hedef
ectar
eausi
ngwetgauze.Thel
oweri
mpr
essi
onwasal
somadeatt
he
sameappoi
ntmentusi
ng t
hesamemat
eri
al(
fi
g 5)
.Di
agnost
iccastwassur
vey
ed,
det
ermi
ningt
hepat
hofi
nser
ti
on i
nrel
ati
ont
othedef
ect
(fi
g6)
.Recont
our
ingoft
eet
h
waspl
annedandper
for
medonacastpr
iort
oabut
mentpr
epar
ati
on.

Toot
hpr
epar
ati
onwasdoneonr
ightf
ir
st secondmol
ar,
cani
nel
ater
alandcent
ral
i
nci
sor t
orecei
veamet
alcer
ami
cpr
ost
hesi
swi
thabal
lat
tachment
(Pr
eci
sagi
x)(
fi
g7)
.
Thef
inalmet
alcer
ami
cpr
ost
hesi
swi
tht
hemal
ecomponentwast
est
edf
orf
it
.(
fi
g8)
.
The f
inali
mpr
essi
on was r
ecor
ded wi
th a pol
yvi
nylsi
l
oxane (
Aquasi
l
,Dent
spl
y,
Ger
many
),whi
chi
ncl
udedt
hei
nfer
iorone-
thi
rdoft
hedef
ect
,ther
emai
ningt
eet
h,and
t
hepr
ost
hesi
swi
that
tachment
.(f
ig9).
Thedef
ini
ti
vecastwast
henexami
nedi
nor
der
t
ore-
eval
uat
etheobt
urat
orpat
hofi
nser
ti
on,af
terwhi
cht
heobt
urat
orf
ramewor
kwas
wax
edont
her
efr
act
orycast
(fi
g10).Thef
ramewor
kpat
ter
ncast
edi
nbase-
met
alal
l
oy
wasf
ini
shed,pol
i
shedandev
aluat
edi
ntr
aor
all
y.Thef
ramewasf
abr
icat
edandt
hej
aw
r
elat
ionshi
pwasr
ecor
dedoni
t.Thef
itoft
heat
tachment
,occl
usi
on,comf
ort
,and
est
het
icswer
ever
if
ieddur
ingt
hewaxt
ry-
inappoi
ntment
(fi
g11)
.Theat
tachment
swer
e
pl
aced at i
nci
sorand mol
arar
ea t
o gai
n maxi
mum st
abi
l
ityf
ort
he obt
urat
or
.
Processi
ngoft
heobt
urat
orpar
twasdonef
inal
l
yusi
ngpol
ymet
hylmet
hacr
ylat
eresi
n.
Femal
ecomponentwast
henaddedf
oll
owi
ngt
heacr
yli
sat
ionoft
heobt
urat
or.
(f
ig12)
.

Pr
ost
hesi
swast
hendel
i
ver
edt
othepat
ient.
(f
ig13)
.Post
-i
nser
ti
oni
nst
ruct
ionswer
e
emphasi
zedf
orbet
terhy
giene.
Hewasadv
isedt
ocl
eant
hepr
ost
hesi
saf
terev
erymeal
wi
that
oot
hbr
ushandmi
l
dsoapsol
uti
on.
Treat
mentwascompl
etedt
otheest
het
icand
f
unct
ional sat
isf
act
ion of t
hePat
ient
.Af
ter 15 day
spost
oper
ati
vel
y OFSscal
e
quest
ionnai
rewasagai
nser
vedt
othepat
ient,
andt
otal
scor
ewascal
cul
ated.

OFSSCORE – PREOP POSTOP

40 85

DI
SCUSSI
ON:
Pr
ost
hesi
s r
etent
ion depends on v
ari
ety of f
act
ors, i
ncl
udi
ng t
he l
evel of
di
rect
/i
ndi
rect
ret
ent
ionpr
omot
edbyt
her
emai
ningt
eet
h;def
ectsi
ze;av
ail
abl
eti
ssue
11
sur
roundi
ng t
he cav
ity
;and muscul
ar .St
abi
l
ity and est
het
ics al
so cont
ri
but
es t
o
t
reat
mentsuccessi
nter
msof
impr
ovement
sint
hepat
ient
’ssoci
all
i
fe12.
Incaseswi
th
l
argemax
il
lar
ydef
ect
swher
eest
het
icsi
sthepr
imar
yconcer
nofpat
ient,ext
racor
onal
at
tachment
sisoneoft
reat
mentmodal
i
ty t
o i
mpr
over
etent
ioni
ncompar
isont
o
conv
ent
ional
claspi
ngoni
nci
sor
sact
ing ast
ermi
nalabut
mentadj
acentt
oal
arge
13
def
ect
. Obt
urat
ormov
ementdur
ingf
unct
ion cr
eat
est
resst
otheabut
ment
sadj
acent
t
othedef
ectso t
heseat
tachment
sshoul
dber
esi
l
ientenought
oreducest
ressand
shoul
dal
l
ow f
unct
ionalobt
urat
ormov
ement
stowar
dthedef
ect,
tocompensat
efora
14
l
ackofi
ntr
a-def
ectsuppor
ti
ngst
ruct
ures. Ther
etent
ivepr
oper
ti
esshoul
dbeact
ivat
ed
onl
ywhendi
slodgi
ngf
orcesar
eappl
i
ed.

Theobt
urat
orf
unct
ionalscor
e(OFS)wasappl
i
edt
oassesst
hesel
f-
repor
tedf
unct
ionof
obt
urat
orpr
ost
heses.OFSScal
econsi
stedof Ei
ghtquest
ion,
incl
udi
ngabi
l
ityt
ospeak
i
npubl
i
c,l
eakagewi
thl
i
qui
dsandsol
i
ds,
sat
isf
act
ionwi
thf
aci
alappear
ance,
dry
nessof
mout
h,i
nser
ti
on ofan obt
urat
or,chewi
ng oreat
ing,
soci
al-
--
fami
l
yint
eract
ionsand
ov
eral
lOFS,wer ed15.
escor OFSscor
ingwasdonewi
thnumer
icalv
aluef
rom 0t
o100,
f
oreachr
esponsei
nthequest
ionnai
resused.Ascor
eof0i
ndi
cat
esmaxi
-mum pr
obl
em
ordi
ssat
isf
act
ionandascor
eof100i
ndi
cat
est
hatt
hepat
ientwasasy
mpt
omat
icor
16
ext
remel
ysat
isf
iedi
nther
espect
ivedomai
n. I
nthi
scaser
epor
t,compar
ed wi
th
conv
ent
ionalpr
ost
hesi
s,t
heat
tat
chmentr
etai
nedpr
ost
hesi
s demonst
rat
ed much
bet
terscor
esi
nal
ldomai
nsofOFS,par
ti
cul
arl
yinswal
l
owi
ng,
speechandchewi
ng.
Pat
ient
swi
thobt
urat
orpr
ost
hesi
swhi
chwasenhancedbyst
udat
tachmentdobet
ter
t
han conv
ent
ional
and magnet
icr
etent
ive pr
ost
hesi
sini
mpr
ovi
ng or
alf
unct
ion,
especi
all
yin speech and swal
l
owi
ng. Thusobt
urat
or pr
ost
hesi
s enhanced by
at
tachment
sdobet
tert
hanconv
ent
ionalpr
ost
hesi
s,
impr
ovi
ngt
heor
alf
unct
ionand
qual
i
tyofl
i
feoft
hesepat
ient
s.Addi
ti
onall
abor
ator
yandcl
i
nicalpr
ocedur
est
her
eby
l
eadi
ngt
ohi
ghcostar
esomeoft
hedi
sadv
ant
agesoft
heabov
ement
ionedt
reat
ment
.
SUMMARY:

Rehabi
l
itat
ionofhemi
maxi
l
lect
omyort
otalmaxi
l
lect
omyi
sachal
l
engi
ngt
askf
ort
he
maxi
l
lof
aci
al pr
ost
hodont
ics .
Two most i
mpor
tant consi
der
ati
ons when t
he
pr
ost
hodont
icschoosest
hemet
hodofr
ehabi
l
itat
ioni
stheet
iol
ogyandsi
zeoft
he
def
ect
.Ret
ent
ion,
stabi
l
ity
,andsuppor
tar
ethet
hreemaj
orf
act
orst
hatapr
ost
hodont
ist
hast
odeal
wit
hwhenapat
ienti
srehabi
l
itat
edwi
tht
heobt
urat
or.Thi
scaser
epor
t
descr
ibest
hef
abr
icat
ionofanobt
urat
orf
oral
eftsi
deacqui
redmaxi
l
lar
ydef
ectwi
tha
modi
fi
eddesi
gn,
thati
sret
ainedwi
thapr
eci
sionat
tachment
.Thepr
imar
yadv
ant
ageof
t
hismodi
fi
cat
ioni
senhancedest
het
icsandf
unct
ion.Thi
swasf
urt
herascer
tai
nedby
bet
terOFSscor
est
hanf
orconv
ent
ional
desi
gn.
REFRENCES:

1.Nar
ayanKM,
Ali
MK,
Kopl
anJP.Gl
obal
noncommuni
cabl
edi
seases-
wher
ewor
lds
meet
.NEngl
JMed2010;
363:
1196-
1198.

2.Bi
azev
icMG,Ant
unesJL,TongiJ,deAndr
adeFP,deCar
val
hoMP,Wonsch-
Fil
ho
V.sur
viv
alandqual
i
tyofl
i
feofpat
ient
swi
thor
alandor
ophar
yngealcancerat1-
y
earf
oll
ow-
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