Articulation of speech of patients treated with radicular attachment assisted obturator following maxillectomy

Maxillary defect may be congenital or acquired. Acquired maxillary defect are usually result from surgery or trauma1. Maxillary defect results in communication between the oral and nasal cavities2; that have serious problems as far the relationship between structures and functions: inability to chew, swallow, disorders in phonation, aesthetic and important psychological implications3. Obturator prosthesis is used for maxillary defective patients and can result in an improvement in speech, mastication, swallowing and aesthetic by closing the oronasal communication4. Palatal obturators may be used alone or in combination with plastic reconstructive surgery5.


Introduction
Maxillary defect may be congenital or acquired.Acquired maxillary defect are usually result from surgery or trauma 1 .Maxillary defect results in communication between the oral and nasal cavities 2 ; that have serious problems as far the relationship between structures and functions: inability to chew, swallow, disorders in phonation, aesthetic and important psychological implications 3 .Obturator prosthesis is used for maxillary defective patients and can result in an improvement in speech, mastication, swallowing and aesthetic by closing the oronasal communication 4 .Palatal obturators may be used alone or in combination with plastic reconstructive surgery 5 .
It is a great challenge for dental surgeon to rehabilitate the patient with maxillectomy defects to reestablishing oro-nasal separation.In most patient this goals are met by means of prosthetic rehabilitation with obturators, but in some cases, the prosthesis is usually non-retentive and non-stable 6 .To overcome these short comings, it could be improved by making the prosthesis as retentive and stable as possible.Conventional obturator may exert an unfavorable stress to the remaining tooth/teeth which may lead to inflammation to supporting tissue of abutments.
Attachment retained prosthesis are alternative to conventional clasp retained prosthesis 7 .An attachment consists of two functional units, one part incorporated into the abutment and another part, fixed into removable prosthesis.
Use of attachment(s) can have a dramatic effect on the stability and retention of the obturator prosthesis in partially edentulous maxillectomy patients 6 .Attachments combined with post-resection obturator are mostly used to improve retention but it is neces-Corresponds to: Dr. Md.Shahidul Islam, Assistant Professor & Head, Dept. of Prosthodontics, Rangpur Dental College & Hospital, Rangpur, Bangladesh.E-mail: smshaheen0407@yahoo.com

Abstract:
Background: Obturators are used to separate the oro-nasal opening.These improve speech and other oral functions as well as provide psychological support to the patients.Adding radicular attachments in an obturator makes more effective.Objective: To evaluate and compare the effectiveness of obturator with radicular attachment and conventional obturator in articulation of speech.Materials and Methods: Fifty patients, age ranged from 18 to 72 years, with maxillectomy defect were selected as the sample of the study.Among them 25 patients were treated with obturator with radicular attachment and another 25 patients were treated with conventional obturator.After insertion of obturator, data were collected on the basis of articulation of speech.Results: Patients treated with obturator with radicular attachment showed significantly better (P value <0.001) articulation of speech.Conclusion: Obturator with radicular attachment is more effective than conventional obturator.sary to compensate stress during mastication as well as to prevent food impaction into the defect.
As the advancement of radicular attachments, the combination of ball and socket attachment, obturator may be beneficial for rehabilitation of partially edentulous maxillectomy patients.8 Radicular attachments are simple connectors consisting of two parts.One part connects to the root of remaining tooth and the other part to the acrylic base over denture obturator 9 .Radicular attachment is readily available, easily fabricable, easy to use and economical.The placements of radicular attachments have an improved effect on the stability and retention of the obturator prosthesis in partially edentulous maxillectomy patients 10 .
The aim of this study was to evaluate and compare the effectiveness of obturators with radicular attachment and conventional obturators for the rehabilitation in term of speech of post-maxillectomy patients.

Materials and methods
A prospective comparative study was carried out during the period of July'2008 to June'2011 in the department of prosthodontics, Bangabandhu Sheik Mujib Medical University (BSMMU), Dhaka, Bangladesh.Fifty patients, based on following crieteria-partial maxillectomy defect, partially dentate, periodontally sound remaining tooth/teeth, adult patients, at least 4 month after the maxillary surgery were taken as the subejcts of the study.Patients with congenital maxillary defect, debilitated patients, extremely xerostomic patients, patients with restricted mouth opening, insufficient interarch space for placement of attachment and patients with other intraoral surgery along with maxillectomy were excluded from the study.Relevant data were collected at base line and in an every follow up visit according to parameter of articulation of Speech.The study was approved by ehical committee of Bangabandhu Sheik Mujib Medical University (BSMMU) Articulation of Speech: Speech of the respondents was categorized in to three groups like good, fair, and poor on the basis of Listener Judgments.Three healthy and sound listeners who were not involved in this prosthetic work listened to the patient's speech and rated the defectiveness and adequacy of speech.Their judgments were made on a 3 points scale such as -Grade I -Good, clear speech with no nasality, Grade II -Fair, speech with some nasality, Grade III -Poor, speech not clear at all 11 .

Procedure:
Patients seating in the upright position, intraoral examination were done thoroughly, special attention given to the healing surface, size of the defect, scar tissue band and remaining teeth.A gauze piece was tied with thread and dipped with petroleum jelly (Vaselin) and then the gauze piece was packed into the defect before impression making.Impression was made by alginate impression material (Lygin, USA) as it is elastic in nature and easy to handle 12 .Model was prepared with dental stone (Diestone, USA).Unfavorable undercut was blocked out.Trial denture was prepared and try-in was performed.Obturator with denture was processed in laboratory performing routine procedures.When the obturator was inserted properly and checked for adaptability, placement of radicular attachment was considered.Tooth was selected for placement of the radicular attachment.Endodontic treatment and tooth reduction was done of selected tooth for placement of radicular attachment.Root canal preparation for radicular attachment is similar to that for a post space 6 .Pattern for male part of attachment was fabricated with self cure acrylic resin (Ashvin, India).The pattern was cast in dental laboratory.After finishing and polishing of male part, pattern for female part was made on male part.Casting, finishing and polishing of female part was done.The male component of the attachment was checked for its fit in the prepared root canal.When the fit was found satisfactory, the male component was cemented using GIC luting cement (GC, Japan).After cementation, the location of the male component was transferred to the final prosthesis for fixation of the female component.The prosthesis was fully relieved at that point.
The female component was attached to the male part and fixed to final prosthesis with the help of auto polymerizing resin (Ashvin, India).The prosthesis was then removed and the position of the component was rechecked.The prosthesis was finished, polished and inserted into patient's mouth.The patient was instructed for maintenance of prosthesis.The post insertion follow-up and patient care was carried out at the prescribed intervals of time.

Statistical analysis
The collected data were analyzed by Statistical Package for Social Science-SPSS Version-16 (IBM).Statistical significance was determined according to the objectives of the study.The results were presented in tabulated form and figures.? 2 test was done to find out the p value.p value of <0.05 was considered as significant.

Results
At the day insertion, majority (n=15, [60.0%]) of patients showed good speech, and with group II obturator, 2 (8.0%) patients showed good speech.At 1 st follow up visit, majority (n=14, [56.0%]) of patients showed good speech and 11 (44.0%)patients showed fair speech with group I obturator while with group II obturator, 1 (4.0%) patient showed good speech,13 (52.0%) patients showed fair speech.At 2 nd follow up visit, maximum (n=15, [60.0%]) of patients showed good speech, 9 (36.0%)patients showed fair speech with group I obturator.In group II obturator, 2 (8.0%) patients showed good speech, and majority of (n=14, [56.0%]) patients showed poor speech.At 3 rd follow up visit, 17 (68.0%)patients showed good speech and 8 (32.0%) patients showed fair speech with group I obturator.In group II obturator, 5(20.0%)patients showed good speech, majority of (n=14, [56.0%]) patients showed fair speech.Analysis revealed that all follow up visits including at the day of insertion articulation of speech were statistically significant between group I and group II obturator.

Table I: Distribution of patients according to articulation of speech with obturator (n=50).
p value reached from ? 2 test , S=Significant at P<0.05 Grading: Grade I -Good, no licking of liquid through nasal cavity and Grade II -Poor, licking of liquid through nasal cavity.

Conclusion
By radicular attachment the obturator gets retention and stability from root of abutment tooth.Thus it improves articulation of speech.For ball and socket joint it is easy to insertion and remove, so patient feel more comfort.Obturator with radicular attachment does not show metallic clasp, so it is more aesthetic.It can be concluded that obturator with radicular attachment is more acceptable than conventional obturator.

Fig 1 :Fig 2 :
Fig 1: Distribution of patients according to speech with group I obturator It might be due to radicular attachment provides good retention and sufficient stability that prevent movement of obturator thus allow production of good speech without any nasal emission of voice.Padmandabhan et al 6 (2009) reported that obturator with radicular attachment have good retention and stability which helps in clear speech.Ramaraju et al 10 .(2010) stated, obturator with radicular attchment effectivly improve speech of pstm-axillectomy patients.Regarding Speech, the result of current study correlates with above mentioned previous study.