Azad Ali Azad*, Muhammad Amjad**, Mubashir Sharif***, Aqeel Ibrahim***, Syed Hammad Hasan*****
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J Pak Dent Assoc.2011; 20(1): 35-39
The objective of this study was to determine the pattern of acquired postsurgical maxillary defects for Prosthodontics rehabilitation in patients at AFID.
A descriptive study was conducted in the Department of Prosthodontics, Armed Forces Institute of Dentistry from January 2002 to February 2010. A total of 38 acquired postsurgical maxillary defect patients referred from Oral & Maxillofacial surgery department, with an age ranging between 37-75 years and a mean age of 56 years were included in the study. Among these 28 (73.68%) were male and 10 (26.31%) were female. These Acquired postsurgical maxillary defects were classified according to Aramany Classification system.
It was observed that 17 (44%) of all patients had unilateral maxillary defects (class I) while 8 (21%) defects were class II. Class III and class V defects were equally found. Unilateral maxillary defect (class I) was most commonly found and class VI defect was least commonly seen in study sample.
Oral rehabilitation of orofacial cancer patient is a challenge for the prosthodontists in term of defect prostheses design and its periodic care. The Aramany classification is helpful in providing basic design framework and enhances communication among prosthodontists.
Acquired postsurgical maxillary defects, Aramany classification.
Obturators for the restoration of maxillary defects should restore mastication, speech, deglutition, facial contours, and dental appearance .To accomplish this for partially edentulous patients, and the clinicians must provide comprehensive treatment planning and sound physiological design principles for a removable partial denture (RPD). Evaluation of the periodontium, the condition of the remaining teeth, and occlusion of the abutments and remaining dentition is necessary. Design principles must also consider the size and retentive qualities of the defect, access to the defect maximum mandibular opening, and change of tissues and oral condition as a result of adjunctive radiation therapy.
Other factors that may affect the overall treatment plan include the age of the patient, other medical conditions, tumor prognosis, individual functional and esthetic demands, manual dexterity, and motivation of the patient. Clinical conditions also dictate that the definitive treatment plan and RPD design be practical, affordable, and capable of meeting the functional needs and demands of the patient. 1
In 1978 the late Dr Mohammed Aramany presented the first published system of classification of postsurgical maxillary defects. He divided all defects into 6 categories based on the relationship of the defect to the remaining teeth and the frequency of occurrence of the defect in a relatively small patient population that he observed over a 6-year period at the Regional Center for Maxillofacial Rehabilitation in the Pittsburg Eye and Ear Hospital. 2
Prosthetic rehabilitation of maxillectomy defects is effective, and surgical reconstruction is usually not indicated. Presurgical planning by the prosthodontist and surgeon is essential. A favorable defect must be designed at the time of tumor removal to provide proper support and sufficient retention and stability of the obturator for the prosthesis to function adequately. In dentate patients, these requirements are easily met by relying on the remaining dentition, retentive tissue undercuts, and support areas within the defect. 3 Therefore this study provided retrospective analysis that was undertaken to assess the pattern of acquired post surgical maxillary defects for prosthodontics rehabilitation according to Aramany classification
The patients were treated at oral & maxillofacial surgery department Armed Forces Institute of Dentistry over a 08-year period, referred to Prosthodontics department of same institute for rehabilitation. A total of 38 patients with postsurgical maxillary defects were included in the study. There were 28 men and 10 women, age ranged from 37 to 75 years with a mean of 56 years. Patients with complete maxillectomy were excluded from the study.
Data for the study were collected from pretreatment and post treatment hospital records. Data had been analyzed using SPSS Version 16. Descriptive statistics were used to describe data. Mean and S.D were calculated for age. Frequency was presented for gender and factors examined.
In the present study, Squamous cell carcinoma was the most common oral cancer followed by ameloblastoma, Table I showed summery of surgical and prosthodontic management of study sample.
Table II shows the pattern of acquired postsurgical maxillary defects patients according to Aramany classification system. Unilateral maxillary defect (class I) was most commonly found and class VI defect was least commonly seen in study sample.
Table II. shows the pattern of Acquired post maxillectomy patients according to Aramanay classification.(n=38).
Cancer surgery, malformation or trauma may cause broad facial defects that cannot be covered by patients because of their exposed site. Such defects lead to functional deficits and enormous psychological strain and require rehabilitation at all ages. The optimal reconstructive therapy of maxillary defects remains controversial 6.7,8 Several therapeutic approaches have been published, including prosthetic obturators, nonvascularised grafts, local flaps, regional flaps and free tissue transfer.9-10 Reconstruction of maxillary defects by either reconstructive surgery or an obturator prosthesis depends on patient characteristics, such as age, medical history and defect size.8,11
Defects because of tumor resection also result in high level of morbidity with significant psychological and functional implications for patients, including difficulty to masticate, swallow and speak.12 In contrast, fabrication of obturator prosthesis shortens the procedure time and offers the possibility of immediate and adequate dental rehabilitation. The surgical site can be easily examined after removing the obturator prosthesis, and tumor recurrence may be detected in a timely manner. Obturators can be used for provisional or definitive rehabilitation.10, 13, 15
2, 4, 5 design. In this study, class III defects were 4 (11%) of study sample.
CLASS I. CURVED ARCH FORM (Fig. 2)The class I category represents the classic maxillary resection defect where the hard palate, alveolar, ridge, and dentition are removed to the midline. This unilateral defect is the one most commonly seen in the maxillofacial rehabilitative practice. Aramany made several recommendations regarding the framework design for this class, proposing a linear design if the remaining anterior teeth were not to be used for support or retention and a tripodal design if the anterior teeth were used. In present study, unilateral defect is most commonly seen 17 (44%) of sample size which is similar to findings of Parr, Thrap, and Rahn.2
CLASS I. LINEAR ARCH FORM
The linear design is used for the class I defect when there are no anterior teeth present or when one does not desire to use the anterior teeth. The remaining posterior teeth are usually in a relatively straight line.
Class II includes arches in which the premaxilla and the premaxillary dentition on the contralateral side is maintained. A single, unilateral defect is located posterior to the remaining teeth. This arch is similar to a Kennedy class II in that a bilateral, tripodal design can always be used. In present study, 8 (21%) of defects categorized as class II.
Class III involves a midline defect of the hard palate and may include a variable portion of the soft palate as well. The dentition is usually preserved, making this obturator prosthesis design simple and effective. The classification and design closely resemble the Kennedy class III RPD design. In this study, class III defects were 4 (11%) of study sample
Class IV situations involve the surgical removal of the entire premaxillae, leaving a bilateral defect anteriorly and a lateral defect posteriorly. There are often a few remaining posterior teeth located in a relatively straight line, creating a unilateral linear design problem where leverage cannot be used to an effective degree. Total number of class VI seen in present study were 3 (8%) of sample size
This situation involves a bilateral posterior surgical defect located posterior to the remaining teeth. Many or all of the teeth are present anterior to the defect. Labial stabilization and the use of splinting, especially of the terminal abutments, are desirable. In this study, we found 4 (11%) defects of class V which is similar to class III.
The class VI defect is a rare surgical creation. Most often it results from a congenital anomaly or trauma such as an automobile accident or a self-inflicted wound that removes the entire premaxillae (and may include a portion of one or both of the maxillae), leaving a single bilateral defect located anterior to the remaining teeth. Surgical defects of this nature are usually small. Nonsurgical defects are usually large and difficult to manage. In present study, class VI defects were least commonly seen 2 (5%) of total study sample. Almost 5% of all cancers affect mouth structures, tongue, oropharynx, nasopharynx and larynx.16 After excision of these lesions, problems regarding chewing, swallowing and speech may appear. Furthermore, changes in appearance, psychosocial function and vocational status may affect the quality of life of these patients after surgical intervention.17
The problems created by maxillectomy defect are notably mastication, speech, olfactory and gustatory sensations. These patients also experience problems such as seepage of nasal secretions into the oral cavity, poor lip seal, xerostomia, exophthalmoses and diplopia. Moreover, the patient develops aesthetical and psychological problems.6, 7, 18 These problems can be minimized by proper design framework and periodic follow up visits for adjustment need of continuously changing oral environment.
Oral rehabilitation of head and neck cancer patient is a challenge for the prosthodontists in term of defect prostheses design and its periodic care. The Aramany classification is helpful in providing basic design framework and enhances communication among prosthodontists.
This study was funded by Research and Development program by Higher Education Commission (HEC) of Pakistan through National University of Sciences and Technology (NUST), Islamabad, Pakistan and presented at 2nd Oral & Maxillofacial Association Congress Balik Antalya Turkey.
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