SURGICAL ONCOLOGY AND RECONSTRUCTION

Quality of Life After Maxillectomy and

Prosthetic Obturator Rehabilitation
Radhika Chigurupati, DMD, MS,* Neelam Aloor, DDS,y Richard Salas, DDS,z
and Brian L. Schmidt, DDS, MD, PhDx
Purpose: Surgical resection of midface neoplasms and subsequent reconstruction have been shown to
have significant negative effects on quality of life (QOL). The purpose of this pilot study was to assess in-
dividuals health-related QOL after maxillectomy and reconstruction with a prosthetic obturator.
Materials and Methods: The QOL of 25 of 43 patients who underwent maxillectomy and prosthetic
obturator reconstruction at the University of CaliforniaSan Francisco was assessed using 3 questionnaires:
University of Washington Quality of Life version 4 (UWQOL), Obturator Functioning Scale (OFS), and
Mental Health Inventory (MHI).
Results: The response rate to the QOL questionnaires was 92% (23 of 25 patients). Time elapsed from
maxillectomy and prosthetic obturator reconstruction to the QOL survey response ranged from 0.3 to 6.6
years (mean, 2.7 years; standard deviation [SD], 1.9 years). The post-treatment mean QOL scores were 77.3
(SD, 13.6) for UWQOL, 72.0 (SD, 12.6) for OFS, and 4.5 (SD, 0.9) for Mental Health Inventory. Individuals
who received adjuvant radiation scored lower for speech and appearance (OFS, P = .05, P = .03, respec-
tively) as well as for saliva and overall QOL (UWQOL, P = .02, P = .08, respectively). There was a strong
correlation between QOL scores in OFS and UWQOL questionnaires (r = 0.78, P < .001).
Conclusion: The results of this pilot study suggest that postoperative radiation therapy was the strongest
variable affecting QOL in patients with maxillectomy and prosthetic obturator reconstruction. There is fur-
ther need for a multicenter trial with a larger sample to identify how factors affecting QOL of patients after
maxillectomy might influence the choice of reconstruction.
2013 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 71:1471-1478, 2013

Resection, reconstruction, and postoperative radia-
tion therapy for management of midface neoplasms
can have significant negative effects on patients qual-
ity of life (QOL).1,2 Surgical treatment of these tumors
often involves radical resection of the maxilla and
adjacent vital structures (ie, orbit, nose, and
pharyngeal and facial soft tissues). The ensuing
maxillectomy defects alter facial appearance and oral
functions such as speech, swallowing, and
mastication. Facial esthetics and oral functions are
essential for social interaction and have an impact on
an individuals QOL. Reconstruction of the
maxillectomy defect should aim to minimize the
facial deformity, restore oral function, and preserve
psychological well-being.3,4
Maxillectomy defects have been reconstructed sur-
gically with local soft tissue pedicled or free flaps3,5-9
or a prosthetic obturator.10-13 Recent advances in
presurgical planning techniques have facilitated
anatomic reconstruction of the bony infrastructure
of the maxilla with composite free flaps.3,8,14 The
various reconstructive options have specific
indications and advantages depending on the size
and location of the ablative defect, comorbid medical
conditions, type of tumor, stage of disease, and
prognosis of the patient.15-17 The anatomic features

*Associate Professor, Department of Oral and Maxillofacial
Surgery, Boston University, Boston, MA.
yGeneral Dentist, Private Practice, Chicago, IL.
zResident PGY II, Oral and Maxillofacial Surgery, Weill Cornell
Medical College, New York, NY.
xProfessor, Department of Oral and Maxillofacial Surgery, and
Director, Bluestone Research Center, New York University,
New York, NY.
Address correspondence and reprint requests to Dr Chigurupati:
Department of Oral and Maxillofacial Surgery 100 East Newton
Street, Suite G-407 Boston, MA -02118; e-mail: rchiguru@bu.edu
2013 American Association of Oral and Maxillofacial Surgeons
0278-2391/13/00193-6$36.00/0
http://dx.doi.org/10.1016/j.joms.2013.02.002

1471
1472
of the ablative defect that influence the type of
reconstruction include the extent of palate resection
and involvement of the infraorbital rim, globe, and
facial soft tissues.7 Surgical reconstruction with com-
posite free flaps from the scapula, anterior iliac crest,
and fibula carries the risk of donor-site morbidity,
which, when significant, can compromise QOL.18 In
addition, treatment is complex, recovery time is pro-
longed, and restoring the missing teeth can
be difficult.
Conversely, reconstruction with a prosthetic obtu-
rator has the advantage of a shorter and less complex
operation and quicker recovery with a shorter hospital
stay. These patients also benefit from having their
teeth and smile restored immediately; however, obtu-
rator retention, stability, and function can vary signifi-
cantly among individuals.4,19 The authors institutional
experience has indicated that the use of zygomaticus
implants can improve obturator stability and
retention in these patients.20 Ultimately, the decision
for the type of reconstruction depends on the availabil-
ity of surgical and prosthodontic expertise at the
institution.
Recent studies on QOL of patients with maxillecto-
mies reconstructed with an obturator have shown
a strong correlation between obturator function and
QOL.1,4 Clinical impressions have suggested that QOL
of these patients can be influenced by numerous
factors, including type of tumor and stage of disease,
medical comorbidities, extent of the ablative defect,
time elapsed since surgery, postoperative radiation
therapy, number and condition of remaining maxillary
teeth, demographic and other social variables.1,2,15
However, there are few studies available to guide
clinicians as to the best reconstructive option for
patients requiring a maxillectomy. To provide a relevant
context for choosing among reconstructive options,
the authors assessed patients QOL after maxillectomy
and reconstruction with a prosthetic obturator.
Materials and Methods
This retrospective, cross-sectional pilot study was
conducted at the University of CaliforniaSan Fran-
cisco. Twenty-five of 43 patients treated for benign
and malignant tumors of the midfacial region with
maxillectomy and subsequent rehabilitation with
a prosthetic obturator from 2002 through 2010 were
included. Approval for the study was obtained from
the University of CaliforniaSan Francisco committee
on human research. Eighteen (of 43) patients did not
have complete medical records, could not be con-
tacted by telephone or postal mail, were deceased,
or had surgical reconstruction with tissue transfer
and thus were excluded. Children (<12 years of age)
were excluded. Patients were invited to participate
QOL WITH MAXILLECTOMY AND PROSTHETIC OBTURATOR
in the study during a clinic visit or by postal mail.
Informed consent was obtained from all participating
patients. Treatment and follow-up data were gathered
from progress notes, operative notes, pathology
reports, and radiographic records.
QOL MEASUREMENTS AND SCORING
The authors assessed the following QOL measure-
ments: facial aesthetics (appearance, smile, lip sup-
port), oral function (speech, chewing, swallowing),
and psychosocial performance (mood, anxiety, emo-
tional control) using 3 disease- and domain-specific
QOL questionnaires: 1) University of Washington
Quality of Life Questionnaire version 4 (UWQOL), 2)
Mental Health Inventory (MHI; long version), and 3)
Obturator Functioning Scale (OFS). All 3 question-
naires have been validated and used by other investiga-
tors.1,2,4,19,21 The UWQOL questionnaire has been
validated for patients with head and neck cancer and
has an internal consistency score of 0.85. It has the
benefit of being shorter than the European
Organization for Research and Treatment of Cancer
(EORTC) modules.22-24 Domains on pain, mood,
anxiety, function, and aesthetics in the UWQOL
correlate well with the EORTC modules. The MHI
questionnaire provides an assessment of positive and
negative facets of mental health, including anxiety,
depression, loss of behavioral control, positive affect,
and general psychological distress and well-being.25
The authors used the full-length version of the MHI
(38 questions), which has been validated and has
a Cronbach a of 0.93.26 Scoring of responses to the
MHI questionnaire is complex compared with the
UWQOL and OFS.
Responses to the UWQOL questionnaire were
scored for individual domains of pain, appearance,
speech, chewing, swallowing, taste, saliva, shoulder
function, activity, recreation, mood, anxiety, and over-
all QOL. The OFS questionnaire has the advantage of
being simple and short. It has a scoring method that
is similar to the UWQOL and has been used extensively
by several other investigators.2,4,21 Responses to the
OFS questionnaire were scored for individual
domains: satisfaction with facial appearance, speech,
ability to speak in public, swallowingleakage with
liquids and solids, chewing and eating, saliva
dryness of mouth, insertion of an obturator, social
and family interactions, and an overall QOL score. A
numerical value from 0 to 100 was assigned to each
response in the UWQOL and OFS questionnaires.
A score of 0 indicates maximum suffering or
dissatisfaction and a score of 100 indicates that the
patient was asymptomatic or extremely satisfied in
the respective domain (a higher score was better).
In the MHI questionnaire, the responses were scored
CHIGURUPATI ET AL
for overall life satisfaction (scale range, 1 to 6) and 3
select subscales: anxiety (scale range, 9 to 54),
depression (scale range, 4 to 23), and loss of behavior
control (scale range, 9 to 53). The minimum and
maximum scores vary for each MHI subscale. A higher
score indicates a more favorable response in the
overall life satisfaction measurement, whereas
a higher score indicates greater suffering on the MHI
subscales of anxiety, depression, and loss of
behavior control.
STATISTICAL ANALYSES
Data gathered from medical records and patient re-
sponses to questionnaires were scored and analyzed.
The influence of select demographic and treatment
variables on patient QOL was assessed: 1) age (<60
or $60 years), 2) gender (male or female), 3) type of
tumor (benign or malignant), 4) need for adjuvant ra-
diation therapy (yes or no), 5) condition of premorbid
dentition (good or poor), and 6) size of maxillectomy
defect (Class IIb and smaller or larger than Class IIb).
The condition of premorbid dentition was considered
good when no more than 6 maxillary teeth were miss-
ing before surgery and was considered poor when 6 or
more maxillary teeth were missing before surgery.
Sizes of maxillectomy defects were established from
the operative and radiographic records using the mod-
ified Brown classification and were divided into 2
groups: Class IIb and smaller defects and larger than
Class IIb defects.5 The roman numeral refers to the ver-
tical component (maxillary and orbital-zygomatic) of
the defect and the letter refers to the horizontal com-
ponent (palato-alveolar) of the defect.
Statistical analysis was performed using nonpara-
metric Wilcoxon rank tests and Pearson correlation
tests with SAS 9.1.3 (SAS Institute, Cary, NC). P < .1
was considered statistically significant.
Results
Of the 25 patients, 23 (92%) responded to the QOL
questionnaires. The demographic and treatment char-
acteristics and overall QOL scores of the 23 patients
are presented in Table 1. The age of the patients
ranged from 14 to 84 years (mean, 61 years; standard
deviation [SD], 15.8 years). Male patients comprised
61% (14 of 23) of the respondents. Time elapsed
from maxillectomy and prosthetic obturator recon-
struction to QOL survey response ranged from 0.3 to
6.6 years (mean, 2.7 years; SD, 1.9 years). Four of the
23 patients were less than 1 year from surgery when
they responded to the questionnaire. Seventy-four per-
cent (17 of 23) of patients had malignant tumors, and
26% (6 of 23) had benign tumors. The most common
malignant tumor diagnosis was squamous cell carci-
noma, and the most common benign tumor diagnosis
1473
was ameloblastoma. Tumor diagnoses included squa-
mous cell carcinoma (8), adenocarcinoma (2), adenoid
cystic carcinoma (2), proliferative verrucous leukopla-
kia (2), osteosarcoma (1), malignant peripheral nerve
sheath tumor (1), hyalinizing clear cell carcinoma
(1), ameloblastoma (5), and recurrent ossifying fi-
broma (1). Twenty-six percent (6 of 23) of patients re-
ceived postoperative radiotherapy, and 1 received
chemotherapy. The premorbid dentition was good in
70% (16 of 23) of patients. Maxillectomy defects
were Class IIb or smaller in 48% (11 of 23) and larger
than Class IIb in 52% (12 of 23) of patients.
The scores for each domain in the 3 questionnaires
are presented below and in Table 2. Scores for the UW-
QOL and OFS domains were calculated by assigning
a numerical value from 0 to 100 to the response. The
mean score for QOL on the UWQOL questionnaire
was 77.3 (SD, 13.6; range, 37.7 to 95). Fifty-two per-
cent (12 of 23) of patients rated their overall QOL
score (UWQOL) above 80. The mean score for QOL
on the OFS was 72.0 (SD, 12.6; range, 40 to 95.3).
On the MHI questionnaire, life satisfaction was fairly
high, with a mean score of 4.5 (SD, 0.9; range, 1 to
6). There was a strong correlation between QOL
scores in the OFS and UWQOL questionnaires (r =
0.78, P < .001), indicating that patients with unsatis-
factory obturator function had a significantly lower
QOL. Also, patients with poor obturator function
had more anxiety (r = 0.53, P = .01), depression (r =
0.55, P = .01), and loss of behavior control (r = 0.50,
P = .01). The issues that were most important to this
group of patients were chewing, speech, and appear-
ance. Fifty-two percent (12 of 23) reported that do-
mains related to function, namely speech and
chewing, were most important in the 7 days before re-
sponding to the questionnaire. The strongest correlate
of QOL in patients with maxillectomy and obturator
prosthesis was radiation therapy. In addition, QOL
was affected by age and tumor diagnosis. The impact
of the select demographic and treatment variables on
QOL domains are presented below and in Table 3.
AGE
Patients younger than 60 years could chew and swal-
low better than patients who were older than 60 years
(P = .04). Younger patients rated their appearance
slightly worse than older patients, but this was not sig-
nificant. There was not a significant difference in over-
all QOL between younger and older patients.
GENDER
Female patients had slightly higher anxiety levels
and reported lower scores for appearance compared
with male patients; however, these differences were
not significant.
1474 QOL WITH MAXILLECTOMY AND PROSTHETIC OBTURATOR

Table 1. PATIENT DEMOGRAPHICS, TUMOR DIAGNOSIS, TREATMENT CHARACTERISTICS, AND QUESTIONNAIRE

SCORES

Defect Time From Overall Overall MHI Life

Patient Age Resection Size Surgery Premorbid UWQOL OFS Satisfaction
Number (yr) Gender Diagnosis Site Class Radiotherapy (yr) Dentition Score Score Score

1 56 F malignant IIb 0.75 good 82.7 85.7 5

2 50 M malignant IId yes 2 poor 73.5 65.6 5

3 55 F benign IIb 0.3 good 59.18 61.1 3

4 53 M benign IId 5 good 88.9 81.8 6

5 65 M malignant IIb 3 poor 84.1 79.6 5

6 71 F benign IId 5.5 poor 83.4 70.6 5

7 59 F benign IId 1.5 good 92.5 88.4 5

8 74 F malignant IIb yes 2 poor 71.5 70.4 5

9 81 F malignant IIc 6 good 90.8 95.3 6

10 42 F malignant IId yes 5 good 63.9 65.3 4

11 48 F malignant IId yes 4 good 82.7 75.9 6

12 68 F malignant IIb 2 poor 61.3 64.9 4

13 67 M malignant IIb 0.8 good 92.4 84.8 5

14 60 M malignant IIb 2.5 good 64.9 49.5 4

15 84 M malignant IId 6.5 poor 79.5 76.3 5

16 77 F malignant IId yes 3 poor 40.9 40 3

17 55 M malignant IId 1.5 good 65.3 63 3

18 14 F benign IIIb 2 good 78.6 78.8 5

19 73 M benign IIb 0.8 good 86.2 69.1 4

20 42 F malignant IId yes 4 good 75.9 69.5 4

21 64 M malignant IIb 1.5 poor 93.1 64.1 3

22 74 F malignant IIb 5.5 good 76.5 72.9 5

23 78 F malignant IIb 1 good 79.9 84.9 4

Abbreviations: F, female; M, male; MHI, Mental Health Inventory; OFS, Obturator Function Scale; UWQOL, University of
Washington Quality of Life. The red areas indicate the palato-alveolar defect and the grey areas indicate the retained palato-
alveolar portion after resection.
Chigurupati et al. QOL with Maxillectomy and Prosthetic Obturator. J Oral Maxillofac Surg 2013.

TUMOR DIAGNOSIS marginally more anxious (P = .08) and had slightly

Patients with benign tumors had normal saliva less control of emotions (P = .09). There were no
consistency (P = .03) and better activity (P = significant differences in obturator function, facial
.05) scores compared with those with malignant appearance, or overall QOL between these
tumors. Patients with malignant tumors were 2 groups.
CHIGURUPATI ET AL 1475

Table 2. SCORES FOR SPECIFIC DOMAINS IN UWQOL, OFS, AND MHI QUESTIONNAIRES

Scoring* Best Worst Patients

(Lowest- Reported Reported Score, With
Domain Highest) Score Score Mean (SD) Best Score

UWQOL 0-100
Pain 100 75 92.0 (11.9) 68%
Change in facial appearance 100 0 70.6 (19.4) 17%
Speech 100 67 72.6 (16.3) 21%
Chewing 100 0 54.3 (25.7) 17%
Swallowing 100 0 80.5 (22.8) 52%
Taste 100 33 78.3 (24.3) 43%
Saliva 100 33 83.0 (24.7) 65%
Shoulder 100 0 80.3 (30.3) 65%
Activity 100 50 83.0 (19.4) 50%
Recreation 100 50 81.5 (18.7) 43%
Mood 100 25 72.6 (27.2) 33%
Anxiety 100 33 70.1 (24.0) 30%
Overall UWQOL score 95 37.7 77.3 (13.6)
OFS 0-100
Satisfaction with facial 100 25 64.0 (21.4) 13%
appearance
Speech 100 33 70.8 (17.8) 30%
Speechability to speak in 100 33 74.0 (22.4) 35%
public
Swallowingleakage with 100 33 68.2 (23.8) 26%
liquids
Swallowingleakage with 100 33 75.8 (23.4) 39%
solids
Chewing/eating 100 0 60.0 (24.3) 4%
Salivadryness of mouth 100 0 56.5 (26.3) 17%
Insertion of obturator 100 50 82.6 (24.3) 65%
Social-family interaction 100 33 86.9 (24.1) 74%
Overall OFS score 95 40 72.0 (12.6)
MHI
Anxiety subscale 9-54 14 30 19.8 (3.5) 4%
Depression subscale 4-23 4 14 6.7 (2.9) 25%
Loss of Behavior Control 9-53 20 40 32.3 (4.8) 25%
subscale
Life satisfaction 1-6 6 3 4.5 (0.9)
Abbreviations: MHI, Mental Health Inventory; OFS, Obturator Function Scale; SD, standard deviation; UWQOL, University of
Washington Quality of Life.
* A higher score indicates that a patient is asymptomatic or extremely satisfied for all domains in the UWQOL and OFS ques-
tionnaires and for life satisfaction in the MHI questionnaire; a higher score indicates greater distress for MHI subscales of anxiety,
depression, and loss of behavior control.
Chigurupati et al. QOL with Maxillectomy and Prosthetic Obturator. J Oral Maxillofac Surg 2013.

PREMORBID DENTAL CONDITION
Patients with good dentition showed a trend toward
better chewing (P = .18), speech (P = .25), and overall
obturator function (P = .27) scores, but these differ-
ences between good and poor premorbid dentition
did not achieve significance.
SIZE OF MAXILLECTOMY DEFECT
There were no significant differences in overall QOL
(P = .97), obturator function, or facial appearance
between patients with maxillectomy defect size Class
IIb and smaller and those with defect size greater than
Class IIb.
RADIATION THERAPY
Patients who had received radiation therapy had sig-
nificantly lower scores for facial appearance (P = .03),
saliva (P = .01), speech (P = .05), and overall QOL (P =
.07) compared with those who had not received radi-
ation therapy.
1476 QOL WITH MAXILLECTOMY AND PROSTHETIC OBTURATOR

Table 3. IMPACT OF TREATMENT AND DEMOGRAPHIC VARIABLES ON SELECTED INDIVIDUAL DOMAINS OF

QUALITY OF LIFE AND OBTURATOR FUNCTION

Predictor Variable Domain Questionnaire Patients, ny Score, Mean (SD) P Value

Age: <60 vs >60 yr chewing OFS 9 (<60 yr) 79.3 (13.7) .04
14 (>60 yr) 63.4 (19.5)
Female vs male none*
Diagnosis: B or M activity UWQOL 6 (B) 95.8 (10.2) .05
16 (M) 78.1 (20.2)
saliva UWQOL 6 (B) 100.0 (0.0) .04
16 (M) 77.5 (27.2)
Defect size: Class #IIb vs >IIb none*
Premorbid dentition: poor vs good shoulder UWQOL 6 (poor) 73.3 (25.8) .08
14 (good) 88.6 (27.7)
Postoperative radiation therapy: no or yes appearance UWQOL 17 (no) 73.5 (24.3) .03
6 (yes) 54.2 (18.8)
saliva UWQOL 17 (no) 90.9 (19.5) .02
5 (yes) 60.0 (30.0)
speech UWQOL 17 (no) 74.3 (18.4) .04
6 (yes) 60.6 (6.3)
shoulder UWQOL 16 (no) 88.1 (26.4) .07
6 (yes) 66.7 (31.4)
overall QOL UWQOL 17 (no) 80.3 (11.9) .08
6 (yes) 69.2 (16.2)
Abbreviations: B, benign; M, malignant; OFS, Obturator Function Scale; QOL, quality of life; SD, standard deviation; UWQOL,
University of Washington Quality of Life.
* No significant differences in the OFS and UWQOL domains between groups for gender and defect size.
y Number may vary based on the number of patients who responded to a specific question.
Chigurupati et al. QOL with Maxillectomy and Prosthetic Obturator. J Oral Maxillofac Surg 2013.

Some comments of patients are listed below:
I have anxiety that my cancer might come back,
and concerned that 15 months after my surgery
my food and liquid intake sometimes still comes
out of my left nostril after swallowing, sometimes
when I swallow food it takes a while to go down
my throat.
When I take out my obturator at night before going
to bed there are times when my family and friends
(on the phone) have a hard time understanding
what I say.
Smiling is important to meI have always been
a person with a smile. Now I am self-conscious be-
cause I know my smile is crooked.
My job entails speaking to large groups and individ-
ual counseling. When I talk loud and for extended
periods of time I find I tire easily. That is probably
the biggest stressor for me.
My age has affected my life more than the cancer be-
cause of the excellent treatment and care. Overall I am
satisfied with the results and my obturator. The only
complaint I have is that when I eat or drink, saliva ac-
cumulates in my obturator then runs out of my nose.
My quality of life is good. Eating in public is some-
times embarrassing; I dont dwell on it. I can usually
eat everything; nuts are kind of hard to eat. I keep
busy so I dont get depressed much.
Discussion
In this study, the authors evaluated the QOL of
patients who underwent prosthetic obturator rehabil-
itation after maxillectomy. QOL is a valuable outcome
measurement that extends beyond the traditional out-
come measurements of mortality and morbidity for
patients with cancer. The authors analyzed the impact
of specific demographic and treatment variables on
QOL in this group of patients. The strongest predictor
of QOL was postoperative radiation therapy. Twenty-
six percent (6 of 23) of patients required postoperative
radiation therapy. Patients with malignant tumors who
received postoperative radiation therapy developed
significant trismus, difficulty with obturator insertion,
and dryness and soreness of the oral mucosa. These
patients also had lower scores for appearance, saliva,
speech, and overall QOL compared with those who
did not receive radiation therapy. Similar findings
were reported by Genden et al15 in patients who un-
derwent reconstruction with an obturator. They re-
ported that patients who required postoperative
radiation therapy had pain and difficulty tolerating
CHIGURUPATI ET AL
the prosthesis and needed frequent adjustment of the
prosthesis.15 The authors did not evaluate QOL in pa-
tients who underwent reconstruction with
microvascular free flaps; however, patients who un-
derwent reconstruction with this approach might
have been better after radiation therapy because the
vascularized tissue can seal the defect and potentially
prevent soreness of the oral mucosa caused by
radiation-induced xerostomia.
Size of the maxillectomy defect, particularly the ex-
tent of the hard and soft palate resection, has been
shown to affect obturator function and QOL.1,17,19,27
Patients often experience regurgitation of fluids or
solids while drinking or eating and hypernasality of
speech, particularly when the defect is not well
sealed. Kornblith et al4 reported that patients who
had no more than a third of the soft palate and a fourth
of the hard palate resected had better speech scores
and overall obturator function. Rogers et al2 noted
that patients with larger defects had lower scores for
activity, recreation, physical function, and overall
QOL. Similarly, Okay et al16 reported that stability of
the prosthesis was compromised as defect size in-
creased, resulting in poor obturator function and
QOL. They concluded that defects that involved
more than half the hard palate or included the premax-
illa and both canines were poor candidates for pros-
thetic reconstruction. The vast majority of patients
in this study had Class II defects according to the max-
illectomy defect classification by Brown and Shaw.5 In
this classification, it must be noted that the superior
portion of the zygoma remains intact in Class II de-
fects. Brown and Shaw5 reported that, in their experi-
ence, obturator reconstruction was offered for
patients with Class I to IIa and IIb defects, but a com-
posite free flap option was preferred for larger alveolar
(Class IId) and Class III to VI defects, when appropri-
ate to the patients medical fitness and informed
choice. This formed the basis of the authors compar-
ison of patients with Class IIb and smaller defects to
those patients with a defect size larger than Class IIb.
About half the patients in the present series had Brown
Class IIb defects involving at least a third of the hard
and soft palate and about half the patients had Brown
Class IId defects involving greater than half of the hard
and soft palate. In the present study, 5 of the 6 patients
who had radiation therapy had Class IId defects and
one patient had a Class IIb defect. The patients with
advanced malignant tumors are also more likely to
have larger defects and frequently require radiation
therapy. It is important to recognize that this is an in-
herent bias in patient selection in these studies that
cannot be eliminated, as indicated by other investiga-
tors.2 Unlike previous studies, patients in the present
study with smaller defect sizes (Class IIb and smaller)
did not differ significantly in obturator function and
1477
QOL compared with those who had larger defects
(greater than Class IIb). The lack of a significant impact
of defect size on QOL may be due to the present cross-
sectional study design and small sample. Patients may
have adapted to the use of an obturator over time re-
gardless of defect size and may have under-reported
negative effects. The vast majority (19 of 23) of pa-
tients in this study used the prosthetic obturator for
longer than 1 year. The experience of the prosthodon-
tist fabricating the obturator also may have influenced
this variable. All patients in this series were treated
by an experienced maxillofacial prosthodontist who
rehabilitates patients with ablative defects.
The condition of the remaining teeth was also eval-
uated in this study. Other investigators have docu-
mented that the number of remaining abutment
teeth, periodontal health, and root form can affect ob-
turator stability and retention. The distance of the
direct retainer to the fulcrum line of the prosthesis
can also affect the stability of the obturator.16 In the
present series, 70% of patients had good premorbid
dentition, and the ipsilateral or contralateral central in-
cisor was preserved in half the patients. However, the
authors did not find a significant difference in obtura-
tor function and QOL between patients with good den-
tition and patients with poor dentition.
As in previous studies, the present findings showed
that obturator function correlated strongly with QOL
for patients who underwent construction with a pros-
thetic obturator after maxillectomy.1,4,21 The authors
also noted a significant correlation between obturator
function and MHI subscales of anxiety, depression,
and loss of behavioral control. Kornblith et al4 reported
that patients with a poorly functioning obturator ex-
hibited significant psychological distress. They found
that patient QOL improved as obturator function im-
proved. Psychological distress might be seen in patients
who underwent reconstruction with an obturator, be-
cause orofacial functions (speech, smiling, swallowing,
and chewing) essential for social interaction are af-
fected by obturator stability and retention.
QOL is difficult to measure because it is multidimen-
sional and subjective and changes with time and cir-
cumstances. Studies evaluating QOL in patients with
head and neck tumors have shown that the most signif-
icant QOL changes occur during the first year after di-
agnosis.20,28,29 One limitation of an evaluation of QOL
in a cross-sectional study is that it does not reflect tem-
poral changes, as in the present study. In addition, the
authors were not able to analyze the differences in
QOL scores for the groups who were less than 1 year
and more than 1 year from surgery owing to the small
sample. Four of the 23 patients enrolled in this study
had their QOL evaluated at less than 1 year from sur-
gery. Of these 4 patients, 1 patient who responded
to the questionnaire within 6 months of tumor
1478
resection and prosthetic rehabilitation had much
lower QOL scores compared with the others. This
finding is consistent with previous evidence that pa-
tients self-reported QOL tends to be poorest in the im-
mediate months after surgery and improves at 1 year.30
Although global QOL scores tend to improve toward
baseline values after 1 year, outcomes in head- and
neck-specific domains often show continued deficits.
There are several limitations in this study. The small
sample and highly limited statistical power in this
cross-sectional study make causal interpretations diffi-
cult. The retrospective design of this study did not per-
mit a preoperative QOL assessment. The lack of
analyses of other important predictors of health-
related QOL, such as sociodemographic variables
(education, marital status, ethnicity, smoking, and al-
cohol use) and treatment variables (time elapsed since
surgery, stage of disease of malignant tumors, and
medical comorbidities), are other limitations of
this study. Retrospective assessment of premorbid
dentition and defect size from medical records in
a standardized manner was difficult. Data on length
of hospital stay, recovery time, and cost of prosthetic
treatment were not gathered. Patients with a zygomati-
cus implantretained prosthesis were not included in
this study. This might have altered some of the findings
on obturator retention, stability, function, and QOL.
A prospective, longitudinal, multicenter study with
a larger sample analyzing additional sociodemographic
and treatment variables should be considered in
the future.
The results of this pilot study suggest that postopera-
tive radiation therapy was the strongest variable affect-
ing QOL in patients with maxillectomy and prosthetic
obturator reconstruction. Further studies are necessary
to identify how factors affecting QOL of patients after
maxillectomy might influence choice of reconstruction.
Acknowledgments
The authors thank Jimmy Hwang, PhD, senior statistician at the
University of CaliforniaSan Francisco Cancer Center, for his help
with the statistical analyses. They thank Professor Dr Arun Sharma,
Division of Prosthetic Dentistry, University of CaliforniaSan
Francisco School of Dentistry, for his expertise in the care of patients
with prosthetic obturators after maxillectomy.
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