A medically fit and well 13-year 11-month-old male was referred to the oral and maxillofacial surgery department at Alder Hey Children’s Hospital in Liverpool in regard to an intra-oral swelling of the right palatal region (Fig. 2). An incisional biopsy was initially reported as a pleomorphic adenoma of the premolar region. Subsequently, a CT scan showed no significant bony abnormality, and a wide local excision was carried out with the application of a surgical palatal dressing plate. Histopathology of this resected tissue appeared to show tumour of intermediate malignant grade at the base of the specimen.
Further investigations undertaken to stage the tumour included a repeat CT scan which presented no evidence of significant bony involvement or erosion. An MRI scan showed no significant asymmetry or signal abnormality in the region of the hard palate, and there was no evidence of loco-regional metastasis of this tumour.
Following a discussion of the craniofacial multidisciplinary team and numerous paediatric pathologists, a diagnosis of intermediate-grade sarcoma of the oral mucosa and hard palate was re-affirmed. A partial right-sided maxillectomy was planned to gain adequate tumour clearance, and prior to surgery, the patient attended for dental impressions and counselling regarding the procedures involved, together with instructions regarding the obturator prosthesis.
A low-level right-sided standard hemi-maxillectomy was carried out via an intra-oral approach with preservation of the pterygoid plates (December 2013). The anterior alveolar cut was undertaken through the right lateral incisor socket following the extraction of this tooth in order to maximise the bone support on the maxillary central incisor abutment tooth. The residual zygomatic body on the right side was exposed, and two 37-mm zygomatic oncology implants (Southern Implants Ltd, South Africa) (Fig. 3) were placed with excellent stability, ensuring that the prosthetic heads were positioned beneath the body of the obturator prosthesis and in a useful position for retention of the obturator. The posterior aspect of the cavity was dressed using the buccal pad of fat and the right inferior turbinate removed to facilitate access to the defect for the obturator. An interim prosthetic obturator was fitted and relined with silicone putty material and retained by dental clasps and a single bone screw into the midline of the remaining palatal bone. Recovery from the procedure was uneventful, and the patient was discharged home the following day. Histopathology confirmed the diagnosis of myxoid spindle cell carcinoma of the right maxilla excised with good margins with no need for adjuvant treatment.
Four weeks later, the patient was returned to the operating room for removal and modification of the obturator. The cavity was healing well, and both implants were firm with no evidence of infection. The initial obturator was modified with the application of a soft lining material and the patient subsequently discharged with instructions on the insertion and removal of the obturator.
At the 12-week review (Fig. 4), it was noted the patient had a degree of mucosal polypoidosis in the antral cavity, most probably plaque induced, where the patient found it difficult to clean around the implants. Oral hygiene instruction was reiterated, and construction of the definitive implant bar-retained obturator was commenced.
Four months following surgery (April 2014), a definitive implant bar-retained maxillary obturator was fitted utilising precision attachments (Rhein attachments, Rhein83, NY, USA.) (Figs. 5 and 6). The retention and support given by the obturator was excellent, and the patient and parents were very pleased with the aesthetic and functional outcome (Figs. 7, 8, 9 and 10) provided by this prosthetic rehabilitation. The patient was put on a regular maintenance programme of review at 6-month intervals and continued to display an excellent standard of oral hygiene around the implants and to report a high degree of oral functioning using it. All mucosal polyposis resolved very quickly following the patient’s improved hygiene measures. He continued under review with no evidence of recurrence or problems with the implants or prosthesis in the 22 months since the surgery. The plastic Rhein female attachments were replaced at 18 months, but no other modifications have been required to this obturator since it was fitted. A recent radiographic review (Fig. 11) demonstrated no significant peri-implant bone resorption, and clinically, there had been no alteration in facial growth or appearance (Fig. 12) of this young patient who was 16 years of age at the time of his final review (February 2017). He continues under regular review.