Fabrication of an interim obturator prosthesis for a patient with hypersensitive gag reflex

This is the authors' abstract. We don't add key points for this paper.

Speech and deglutition are highly affected in patients who undergo palatal resection for the treatment of oral cancer. Palatal carcinomas are the fifth most encountered carcinomas in the head-and-neck region and comprise approximately 3% of all head-and-neck tumors.[1,2] Mucoepidermoid carcinomas are epithelial salivary gland neoplasms that affect mainly the major and rarely the minor salivary glands located in the palate.[3,4] In low-grade mucoepidermoid carcinoma, fenestration surgeries are preferred to preserve the palatal tissues, and an interim obturator prosthesis is required for the functional rehabilitation of such patients as early as possible.[5] Impression procedures and interim prosthesis fabrication are always a challenge for clinicians in the initial phases of healing after surgery. This challenge becomes multifold when a patient has a hyperresponsive gag reflex. Gagging is considered an evolutionary reflex that helps to prevent the aspiration of unwanted substances in the mouth and oropharynx. The palate is one of the five trigger zones of gagging,[6] and gets stimulated either by the material used during the impression procedures or by prosthesis coverage. There are various techniques discussed in the literature to control gagging during dental procedures, which include pharmacological management, distraction and relaxation techniques, and the delivery of palate-less and training dentures.[6,7] Making an impression and fabricating an interim complete palatal obturator for such patients is a challenging task for clinicians. This article describes a simple technique of fabricating a training interim obturator without compromising the principles of obturator fabrication, in a patient with gagging, who underwent palatal fenestration surgery for mucoepidermoid carcinoma. A 30-year-old female patient reported to the head-and-neck unit of the Mahamana Pandit Madan Mohan Malaviya Cancer Center (MPMMCC), Varanasi, India, with the chief complaint of a non-healing ulcer in the oral cavity for six months. On examination, a 3 × 1 cm oronasal fistula was noticed on the posterolateral aspect of the hard palate. Incisional biopsy and histopathological examination revealed a low-grade mucoepidermoid carcinoma with T1N0MX staging. Wide lesion excision and fenestration surgery were performed, and the patient was referred to the Department of Dental and Prosthetic Surgery for delayed surgical obturator prosthesis. Upon intraoral examination, a surgical defect was observed on the left posterolateral aspect of the hard palate. This surgical defect was class I (vertical component), according to the classification proposed by Brown and co-workers.[8] The defect was covered with white slough and had peripheral inflammation [Figure 1]. The patient was advised to report after two weeks for interim obturator prosthesis. On the 15th day, the patient showed satisfactory wound healing with adequate mouth opening [Figure 2]. During the intraoral examination of the defect before impression-making, the patient displayed a moderate sign of gagging, which is very unusual in patients who have undergone palatal surgeries for oral cancers.Figure 1: Intraoral view of the defect five days after surgeryFigure 2: Intraoral view of the healed defectDuring impression making with alginate (Zelgan, Dentsply DeTrey GmbH Pvt. Ltd., Germany), the patient could not cooperate due to the hypersensitive gag reflex and the impression could not be recorded on the first attempt. As the gag reflex was already stimulated, the patient was asked to report the following morning to record the impression. The patient was counseled again regarding the impression procedure. This time, a local anesthetic spray was applied to the posterior part of the hard palate and the anterior part of the soft palate (before impression making). The impression was recorded with fast-setting alginate and disinfected with 0.55% ortho-phthalaldehyde (Cidex OPA, Johnson and Johnson, USA) before cast fabrication. The cast was poured with dental stone type III (Kalstone, Kalabhai Karson Pvt. Ltd., Mumbai, India), for the fabrication of an interim obturator. The obturator was fabricated using the conventional technique and delivered to the patient [Figure 3]. However, the patient was not able to wear the obturator because of the hypersensitive gag reflex. Keeping this in mind, an alternative design of the prosthesis was attempted.Figure 3: Conventional complete palatal interim obturator prosthesisThe prosthesis was fabricated in two components. One component (component A) was to retain the prosthesis and the other component (component B) was the obturator, which would cover only the defect and not the entire palate so as to prevent the stimulation of the gag reflex. The anterior prosthetic part, that is, component A was extended till the premolars to lessen the palatal coverage and posteriorly, the obturator part, that is, component B was connected through a 0.8 mm stainless steel (SS) wire. The connecting SS wire was covered with an infusion tubing (Vented infusion set, Romson Medical Devices, New Delhi, India) to prevent injury to the soft tissues and the palatal defect. The prosthesis was processed and fabricated with an auto-polymerizing resin [Figure 4]. After the final finishing and polishing, the prosthesis was sterilized with 2% chlorhexidine and delivered to the patient [Figure 5]. Post-insertion instructions were given to the patient for the care and usage of the prosthesis. The patient was then able to comfortably use the modified obturator. She followed up with us two weeks later, and there was no complaint of gagging. The timeline of events is provided in Table 1.Figure 4: Interim obturator prosthesis with two components (ACRONYM: SS = Stainless Steel)Figure 5: Intraoral view with interim obturator prosthesisTable 1: Timeline of the sequence of clinical eventsFabricating an intraoral maxillofacial prosthesis is always challenging for clinicians. This challenge might increase due to problems like restricted mouth opening, larger defect, loss of retention, rejection of the prosthesis by the patient, and rarely a hypersensitive gag reflex. These problems can trigger post-traumatic stress disorder[9] and should be minimized as much as possible during the course of rehabilitating the maxillofacial defect. In the present case, a technique was described to fabricate an interim obturator with two components, which were connected by an SS wire. One component was used for partial palatal coverage to retain the prosthesis in place and the other part of the prosthesis was used to cover the fenestration defect to prevent the oronasal communication. In conclusion, this two-part interim obturator prosthesis was used for a patient with palatal defect, who had a hypersensitive gag reflex. Restoring the palatal defect and the oronasal communication is the primary objective of early prosthetic rehabilitation. This newer method of restoring the palatal defect complies with the principles of obturator design to cover the defect and also gratifies the functional demand of the patient, along with a managing the hypersensitive gag reflex. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.