MAXILLOFACIAL PROSTHETICS TEMPOROMANDIBULAR JOINT DENTAL IMPLANTS I. KENNETH
Role
ADISMAN,
of the
LOUIS
general
J. BOUCHER,
dentist
Section editors
in maxillofacial
Robert Y. W. Tang, D.D.S., M.S.D.* Marquette University, School of Dentistry,
Milwaukee,
D
prosthetics
Wis.
entistry has an important part in the treatment of patients with oral cancer. The dentist’s knowledge of the basic biologic sciences, the stomatognathic system, and the manipulation of materials qualifies him to perform this important service. The dentist’s responsibilities include the routine maintenance of oral health, the removal of teeth in regions planned for radiation, and the construction of prostheses for irradiated areas. Facial disfigurement following eradication of cancer of the head and neck presents almost insurmountable difficulties in surgically restoring acceptable function and/or esthetics. The employment of radical and sophisticated surgical and radiation treatment has resulted in the survival of large numbers of patients. Increased population growth and life expectancy, with a growing demand for health care delivery, place dental professionals in an important role in the treatment of patients with oral cancer. Maxillofacial prosthetics may be defined as the art and science of dental practice concerned with the restoration of the stomatognathic system and associated facial structures. The primary objectives of maxillofacial prosthetics are the restoration of function, preservation of residual structures, and the improvement of esthetics. The accomplishment of these objectives will expedite the patient’s return to society. Despite the growing number of medical centers that offer prosthodontic rehabilitation for these patients and the increasing number of training programs in this phase of dentistry, the problem of “demand” and “supply” still exists. There is an insufficient number of available personnel to treat the increasing numbers of patients. Although most definitive maxillofacial services will be performed in medical centers by trained prosthodontists, the general dentist can provide invaluable assistance in the management of the maxillofacial patient. It is not the intention of this article to discuss in detail the various types of maxillary and mandibular defects and their prosthodontic restorative procedures, all of which can be found in the literature.‘-* *Assistant Professor, Department of Removable Prosthodontics. 416
General dentist’s
Fig, 1. The
surgical
defect
resulting
role in maxillofacial
from
jwosthetics
417
a hemimaxillectomy.
The purpose of this article is to familiarize the general dentist with (1) the basic problems encountered by patients with intraoral defects resulting from surgical removal of cancerous lesions and (2) the care the general dentist can provide for these patients.
INTRAORAL DEFECTS The major head-and-neck surgical procedures performed on patients with oral cancer are often mutilating and incapacitating. Unless otherwise informed, the surgical patient assumes that treatment ends with the elimination of the disease. Nothing can be more demoralizing to a patient than a large defect in the palate directly connecting the nasal and antral cavities. It is not enough to prevent deathmaking the patient’s life more endurable and as normal as possible should be the objective of the dentist. The patient faces urgent and immediate problems in his return to his community, his family, and his business. Functional impairment and facial distortion can have a crippling psychologic effect on the patient’s self-image. Postoperative rehabilitation of the patient by surgery or prosthodontic procedures must be considered an integral part of the total treatment procedure. Maxillary defects affect the normal functions of mastication, deglutition, and speech. The degree of impairment depends on the extensiveness of the defect. A defect directly connecting the oral and nasal cavities not only affects normal eating habits but results in nasal emission of fluids and food (Fig. 1) . ,4 nasogastric tube may be necessary to insure adequate intake of foods by the patient. Without obturation of the defect, the development of sufficient intraoral pressure for speech, blowing the nose, and smoking is difhcult, if not impossible. Speech is characterized by hypernasality and unintelligibility. In addition, the patient may be left with a facial disfigurement which may be repulsive to the average person as well as to the patient himself. The patient may isolate himself from others and abstain from participation in normal social activities. If prosthodontics is the treatment of choice, it involves obturation of the defect with a prosthesis. The objectives are restoration of mastication, deglutition (by elimination of nasal emission of fluids and food), facial contour,
418
J. Prosthet. October,
Tang
Fig. 2. Hemimandibulectomy. in (A) opening the jaws
and
Note the medial (B) closing.
deviation
of the remaining
mandibular
Dent. 1976
segment
intelligible speech (by elimination of hypernasality) , and a normal, productive life.3-5 Mandibular defects caused by surgical jaw resection result in functional impairment, facial disfigurement, and problems in restoration. Discontinuity of the mandible following segmental resection also will result in impaired muscle control of the residual segment or segments. Disruption of mandibular continuity results in deviation of the remaining fragment medially and superiorly and rotation upon occlusal contact (Fig. 2). The loss of maxillomandibular occlusal relationships makes mastication difficult. Defects which include the cheeks or lips result in constant drooling, retention of food in the oral cavity, and difficulty in swallowing. The facial disfigurement may have a detrimental psychologic effect on the patient. The primary objectives in the rehabilitation of postsurgical maxillofacial patients are restoration of occlusal function, acceptable speech, and esthetic appearance. Prosthodontic management involves (1) stabilization of the remaining mandibular segment by intermaxillary wiring from the time of the operation up to 4 to 6 weeks postoperatively and (2) the attachment of a vertical guide flange to the remaining mandibular posterior teeth to permit normal opening and closing of the jaws and to prevent medial deviation of the residual mandibular segment. ROLE
OF GENERAL
DENTIST
AS early as 1932, the late Charles H. Mayo” wrote: “The modern dentist, to satisfy public demand, must not only assume greater responsibility in the care of the teeth, but must also be able to recognize bodily diseases which are manifest in the mouth, of which there are twenty-eight, that he may give timely advice to his dental patients.” The cancer problem is not solely the responsibility of the few who specialize in cancer research and treatment but of all members of the health services, including the dental profession. The general dentist has an important role in the detection and control of oral cancer. Three questions which face the general dentist are: (1) what part does the general dentist play in diagnosis, (2) to whom does the general
Volume Number
36 4
General
dentist’s
role in maxillofacial
prosthetics
419
dentist refer the maxillofacial patient, and (3) what is the role of the general dentist in the treatment of maxillofacial patients? The importance of early diagnosis of cancer lesions should be emphasized. The cause of cancer is still unknown. The incidence of cancer increases with increasing age after middle age. The chance of confirming a cure 5 years postoperatively increases if treatment is instituted early in the development of the disease. The implication of these findings is important. Older patients who are in a symptomless state of general health but who are partially or completely edentulous seek professional health service from the dentist only. They often neglect regular physical examinations. Therefore, the dentist has an excellent opportunity to observe suspicious tissue changes in the region of the mouth and face. Early malignant tumors usually present no serious symptoms; therefore, diagnosis involving a thorough, definitive examination of the patient is a necessity in a general dentist’s office. Complete medical and dental histories, radiographs, photographs, diagnostic casts, and symptoms should be taken and a thorough inspection of the soft tissues of the head, neck, and mouth should be done to detect any suspicious lesion. The most reliable means of evaluating suspicious tissue changes is to remove part of the tissue for histologic identification. Most procedures of maxillofacial surgery and prosthetic rehabilitation are performed in medical centers located in large cities, The general dentist can be called upon by the surgeon, the radiotherapist, or the prosthodontist for assistance. The maintenance of oral hygiene is a most important service. Prior to surgery and/or irradiation, an optimum hygienic oral environment should be established to provide freedom from infection or irritation. Preliminary preparation can reduce the hazards of radiation necrosis and facilitate recovery of irradiated noncancerous tissue. The dentist should provide a thorough dental prophylaxis, perform caries-control measures, eliminate residual infection, and extract nonsalvageable teeth and teeth in the field of irradiation. The success of a prosthesis is influenced by the extent of the defect and the retention and stability provided for the prosthesis. The presence of natural teeth and their preservation by proper oral care and hygiene are of vital importance. If the patient has to travel some distance for treatment, the prosthodontist may contact the local dentist who can (1 j provide follow-up care for the patient, including periodic dental prophylaxis, evaluation of oral hygiene habits, and minor adjustments of the temporary or definitive prosthesis, and (2) report any suspicious tissue changes. The coordinated effort by the prosthodontist and the local general dentist can save the patient considerable time and expense by reducing the number of visits to the prosthodontist. Not all maxillofacial defects involve extensive loss of tissues. The restoration of a small maxillary defect or a marginal resection of the mandible in which the continuity of the arch is preserved may require only slight modification of a conventional prosthesis. Every dentist trained in the basic principles of maxillofacial prosthetics is qualified to restore physiologic function to the maxillofacial patient. In addition to applying the fundamental principles of complete and removable partial denture construction, several pertinent points need to be emphasized. In making maxillary impressions involving a small palatal defect, the defect should be
420
Tang
J. Prosthet. Dent. October, 1976
blocked out with moist cotton or gauze to prevent accidental intrusion of impression material into the nasal-maxillary sinus cavity. Attention also should be given to (1) securing maximum coverage of intact mucosal areas without displacement to enhance stability of the prosthesis, (2) multiple clasping for stress distribution and retention, and (3) modification of the occlusal scheme to minimize stress. CONCLUSIONS
Care of oral cancer patients requires the opinions and coordinated efforts of various consultants or therapists functioning as a multidisciplinary team to treat individual patients’ physical, social, and economic problems. The modem medical concept of total treatment of the patient must include dentistry. Every dentist with interest and training in the basic principles of maxillofacial prosthetics can offer invaluable assistancein the treatment of maxillofacial patients. References 1.
Adisman, K.: Prosthetic Reconstruction of a Resected Mandible, J. PROSTHET. DENT. 12: 384-392, 1962. 2. Grunewald, A. H.: The Prosthodontist’s Role in Cranioplasty, J, PROSTHET. DENT. 5: 235243, 1955. 3. Ackerman, A. J.: The Prosthetic.~ Management of Oral and Facial Defects Following Cancer Surgery, J. PROSTHET. DEST. 5: 413-432, 1955. 4. Laney, W. R.: Maxillofacial Prosthetics: Intraoral Defects, Mayo Clin. Proc. 39: 22-25, 1964. 5. Appleman, R. M.: The Prosthetic Repair of Defects of the Maxilla Resulting From Surgery, J. PROSTHET. DENT. 1: 424-437, 1951. 6. Mayo, C. H.: Organized Effort and Dentistry’s Place in the Sun, J. Am. Dent. Assc~c. 19: 2156~:!160, 1932. DEPARTMENT MARQUETTE SCHOOL
MILWAUKEE,
OF REMOVABLE UNIVERSITY
OF DENTISTRY
WIS. 53233
PROSTHODONTICS
Role
ADISMAN,
of the
LOUIS
general
J. BOUCHER,
dentist
Section editors
in maxillofacial
Robert Y. W. Tang, D.D.S., M.S.D.* Marquette University, School of Dentistry,
Milwaukee,
D
prosthetics
Wis.
entistry has an important part in the treatment of patients with oral cancer. The dentist’s knowledge of the basic biologic sciences, the stomatognathic system, and the manipulation of materials qualifies him to perform this important service. The dentist’s responsibilities include the routine maintenance of oral health, the removal of teeth in regions planned for radiation, and the construction of prostheses for irradiated areas. Facial disfigurement following eradication of cancer of the head and neck presents almost insurmountable difficulties in surgically restoring acceptable function and/or esthetics. The employment of radical and sophisticated surgical and radiation treatment has resulted in the survival of large numbers of patients. Increased population growth and life expectancy, with a growing demand for health care delivery, place dental professionals in an important role in the treatment of patients with oral cancer. Maxillofacial prosthetics may be defined as the art and science of dental practice concerned with the restoration of the stomatognathic system and associated facial structures. The primary objectives of maxillofacial prosthetics are the restoration of function, preservation of residual structures, and the improvement of esthetics. The accomplishment of these objectives will expedite the patient’s return to society. Despite the growing number of medical centers that offer prosthodontic rehabilitation for these patients and the increasing number of training programs in this phase of dentistry, the problem of “demand” and “supply” still exists. There is an insufficient number of available personnel to treat the increasing numbers of patients. Although most definitive maxillofacial services will be performed in medical centers by trained prosthodontists, the general dentist can provide invaluable assistance in the management of the maxillofacial patient. It is not the intention of this article to discuss in detail the various types of maxillary and mandibular defects and their prosthodontic restorative procedures, all of which can be found in the literature.‘-* *Assistant Professor, Department of Removable Prosthodontics. 416
General dentist’s
Fig, 1. The
surgical
defect
resulting
role in maxillofacial
from
jwosthetics
417
a hemimaxillectomy.
The purpose of this article is to familiarize the general dentist with (1) the basic problems encountered by patients with intraoral defects resulting from surgical removal of cancerous lesions and (2) the care the general dentist can provide for these patients.
INTRAORAL DEFECTS The major head-and-neck surgical procedures performed on patients with oral cancer are often mutilating and incapacitating. Unless otherwise informed, the surgical patient assumes that treatment ends with the elimination of the disease. Nothing can be more demoralizing to a patient than a large defect in the palate directly connecting the nasal and antral cavities. It is not enough to prevent deathmaking the patient’s life more endurable and as normal as possible should be the objective of the dentist. The patient faces urgent and immediate problems in his return to his community, his family, and his business. Functional impairment and facial distortion can have a crippling psychologic effect on the patient’s self-image. Postoperative rehabilitation of the patient by surgery or prosthodontic procedures must be considered an integral part of the total treatment procedure. Maxillary defects affect the normal functions of mastication, deglutition, and speech. The degree of impairment depends on the extensiveness of the defect. A defect directly connecting the oral and nasal cavities not only affects normal eating habits but results in nasal emission of fluids and food (Fig. 1) . ,4 nasogastric tube may be necessary to insure adequate intake of foods by the patient. Without obturation of the defect, the development of sufficient intraoral pressure for speech, blowing the nose, and smoking is difhcult, if not impossible. Speech is characterized by hypernasality and unintelligibility. In addition, the patient may be left with a facial disfigurement which may be repulsive to the average person as well as to the patient himself. The patient may isolate himself from others and abstain from participation in normal social activities. If prosthodontics is the treatment of choice, it involves obturation of the defect with a prosthesis. The objectives are restoration of mastication, deglutition (by elimination of nasal emission of fluids and food), facial contour,
418
J. Prosthet. October,
Tang
Fig. 2. Hemimandibulectomy. in (A) opening the jaws
and
Note the medial (B) closing.
deviation
of the remaining
mandibular
Dent. 1976
segment
intelligible speech (by elimination of hypernasality) , and a normal, productive life.3-5 Mandibular defects caused by surgical jaw resection result in functional impairment, facial disfigurement, and problems in restoration. Discontinuity of the mandible following segmental resection also will result in impaired muscle control of the residual segment or segments. Disruption of mandibular continuity results in deviation of the remaining fragment medially and superiorly and rotation upon occlusal contact (Fig. 2). The loss of maxillomandibular occlusal relationships makes mastication difficult. Defects which include the cheeks or lips result in constant drooling, retention of food in the oral cavity, and difficulty in swallowing. The facial disfigurement may have a detrimental psychologic effect on the patient. The primary objectives in the rehabilitation of postsurgical maxillofacial patients are restoration of occlusal function, acceptable speech, and esthetic appearance. Prosthodontic management involves (1) stabilization of the remaining mandibular segment by intermaxillary wiring from the time of the operation up to 4 to 6 weeks postoperatively and (2) the attachment of a vertical guide flange to the remaining mandibular posterior teeth to permit normal opening and closing of the jaws and to prevent medial deviation of the residual mandibular segment. ROLE
OF GENERAL
DENTIST
AS early as 1932, the late Charles H. Mayo” wrote: “The modern dentist, to satisfy public demand, must not only assume greater responsibility in the care of the teeth, but must also be able to recognize bodily diseases which are manifest in the mouth, of which there are twenty-eight, that he may give timely advice to his dental patients.” The cancer problem is not solely the responsibility of the few who specialize in cancer research and treatment but of all members of the health services, including the dental profession. The general dentist has an important role in the detection and control of oral cancer. Three questions which face the general dentist are: (1) what part does the general dentist play in diagnosis, (2) to whom does the general
Volume Number
36 4
General
dentist’s
role in maxillofacial
prosthetics
419
dentist refer the maxillofacial patient, and (3) what is the role of the general dentist in the treatment of maxillofacial patients? The importance of early diagnosis of cancer lesions should be emphasized. The cause of cancer is still unknown. The incidence of cancer increases with increasing age after middle age. The chance of confirming a cure 5 years postoperatively increases if treatment is instituted early in the development of the disease. The implication of these findings is important. Older patients who are in a symptomless state of general health but who are partially or completely edentulous seek professional health service from the dentist only. They often neglect regular physical examinations. Therefore, the dentist has an excellent opportunity to observe suspicious tissue changes in the region of the mouth and face. Early malignant tumors usually present no serious symptoms; therefore, diagnosis involving a thorough, definitive examination of the patient is a necessity in a general dentist’s office. Complete medical and dental histories, radiographs, photographs, diagnostic casts, and symptoms should be taken and a thorough inspection of the soft tissues of the head, neck, and mouth should be done to detect any suspicious lesion. The most reliable means of evaluating suspicious tissue changes is to remove part of the tissue for histologic identification. Most procedures of maxillofacial surgery and prosthetic rehabilitation are performed in medical centers located in large cities, The general dentist can be called upon by the surgeon, the radiotherapist, or the prosthodontist for assistance. The maintenance of oral hygiene is a most important service. Prior to surgery and/or irradiation, an optimum hygienic oral environment should be established to provide freedom from infection or irritation. Preliminary preparation can reduce the hazards of radiation necrosis and facilitate recovery of irradiated noncancerous tissue. The dentist should provide a thorough dental prophylaxis, perform caries-control measures, eliminate residual infection, and extract nonsalvageable teeth and teeth in the field of irradiation. The success of a prosthesis is influenced by the extent of the defect and the retention and stability provided for the prosthesis. The presence of natural teeth and their preservation by proper oral care and hygiene are of vital importance. If the patient has to travel some distance for treatment, the prosthodontist may contact the local dentist who can (1 j provide follow-up care for the patient, including periodic dental prophylaxis, evaluation of oral hygiene habits, and minor adjustments of the temporary or definitive prosthesis, and (2) report any suspicious tissue changes. The coordinated effort by the prosthodontist and the local general dentist can save the patient considerable time and expense by reducing the number of visits to the prosthodontist. Not all maxillofacial defects involve extensive loss of tissues. The restoration of a small maxillary defect or a marginal resection of the mandible in which the continuity of the arch is preserved may require only slight modification of a conventional prosthesis. Every dentist trained in the basic principles of maxillofacial prosthetics is qualified to restore physiologic function to the maxillofacial patient. In addition to applying the fundamental principles of complete and removable partial denture construction, several pertinent points need to be emphasized. In making maxillary impressions involving a small palatal defect, the defect should be
420
Tang
J. Prosthet. Dent. October, 1976
blocked out with moist cotton or gauze to prevent accidental intrusion of impression material into the nasal-maxillary sinus cavity. Attention also should be given to (1) securing maximum coverage of intact mucosal areas without displacement to enhance stability of the prosthesis, (2) multiple clasping for stress distribution and retention, and (3) modification of the occlusal scheme to minimize stress. CONCLUSIONS
Care of oral cancer patients requires the opinions and coordinated efforts of various consultants or therapists functioning as a multidisciplinary team to treat individual patients’ physical, social, and economic problems. The modem medical concept of total treatment of the patient must include dentistry. Every dentist with interest and training in the basic principles of maxillofacial prosthetics can offer invaluable assistancein the treatment of maxillofacial patients. References 1.
Adisman, K.: Prosthetic Reconstruction of a Resected Mandible, J. PROSTHET. DENT. 12: 384-392, 1962. 2. Grunewald, A. H.: The Prosthodontist’s Role in Cranioplasty, J, PROSTHET. DENT. 5: 235243, 1955. 3. Ackerman, A. J.: The Prosthetic.~ Management of Oral and Facial Defects Following Cancer Surgery, J. PROSTHET. DEST. 5: 413-432, 1955. 4. Laney, W. R.: Maxillofacial Prosthetics: Intraoral Defects, Mayo Clin. Proc. 39: 22-25, 1964. 5. Appleman, R. M.: The Prosthetic Repair of Defects of the Maxilla Resulting From Surgery, J. PROSTHET. DENT. 1: 424-437, 1951. 6. Mayo, C. H.: Organized Effort and Dentistry’s Place in the Sun, J. Am. Dent. Assc~c. 19: 2156~:!160, 1932. DEPARTMENT MARQUETTE SCHOOL
MILWAUKEE,
OF REMOVABLE UNIVERSITY
OF DENTISTRY
WIS. 53233
PROSTHODONTICS
