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Surgical Techniques to EnhanceProsthetic Rehabilitation -- Oraland Dental Oncologic Principles      Michael E. Decherd, MD...
Maxillofacial Prosthetics for the       Otolaryngologist      Michael E. Decherd, MD        Anna M. Pou, MD         Decemb...
History• Artificial facial parts found on Egyptian  mummies• Ancient Chinese known to have made facial  restorations• Grov...
Overview• Maxillofacial prosthetics a branch of  prosthodontics• General prosthodontics a branch of  dentistry• Goal is fu...
Maxillofacial Prosthetics• “the art and science of anatomic, functional,  or cosmetic reconstruction by means of  nonlivin...
Types of Rehabilitation•   Preventative•   Restorative•   Supportive•   Palliative
Prosthetic vs. Surgical           Rehabilitation• Individualized decision between patient and  doctor• Removable prosthesi...
Intraoral versus Extraoral• Intraoral -- mostly functional  – Mandible  – Maxilla• Extraoral -- cosmetic  – Ear  – Nose  –...
Psychosocial Issues• Ultimate goal is restoration of quality of life• Functional deficits may be as isolating as  cosmetic...
Psychosocial Issues
Psychosocial Issues
Preoperative Evaluation• Discussion of patient’s expectations and  desires• Consultation with appropriate services• Preope...
Poor Oral Hygiene
Dental Impression• Surgeon has  marked  resection for  prosthodontic  planning
Radiation and teeth•   Obliterative endarteritis•   Xerostomia -- rampant dental caries•   Meticulous oral hygiene -- fluo...
Radiation• Prosthesis may assist in consistent  positioning of tongue, lips
Carious teeth after radiation
Universal Tooth Numbering
Universal Tooth Numbering
Normal function of Oral Cavity• Speech• Mastication• Deglutition
Speech• Complex process• Oral-nasal partition• Palatal augmentation prosthesis can lower  palate to provide better functio...
Deglutition (Swallowing)•   Tongue pulsion•   Nasopharyngeal closure•   Pharyngeal clearance•   Airway protection•   UES o...
Palate Augmentation Prosthesis
Palate Augmentation Prosthesis
Soft Palate• Serves to intermittently couple and  uncouple oral and nasal cavities  – production of consonant phonemes  – ...
Soft Palate• May be better to remove all of soft palate  than partial resection
Soft Palate Prosthesis
Soft Palate Prosthesis• Extension obturates nasopharynx
Soft PalateProsthesis• Small hole may  be plugged• May close  enough with  time for flap  closure
Mastication• Precursor to deglutition• Involves  – Reduction of food particle size  – Sorting of food particles• Masticato...
Mastication• Masticatory efficiency related to occlusal  surface• Superior masticatory efficiency leads to  greater reduct...
Prosthetic Teeth and Masticatory           Efficiency• Fixed partial, rigid support• Removable partial supported by  – tee...
Oral Anatomy
Oral Anatomy
Maxillary defects• Maintain Premaxilla  – can clasp teeth further apart  – force distributed among more teeth• Use palatal...
Premaxilla Preserved
Premaxilla Preserved• Cut through tooth socket
Palatal Mucosa Preserved
Mucosa Not Preserved• Rough edge uncomfortable for patient
Obturator• Restores oro-nasal  partition• At times can be  added to prior  dentures
Skin Grafting of Defect• Less pain while healing• Less contracture of scar band which  obscures cancer surveillance• Accom...
MaxillaryProsthesis• Articulates  with scar band• Hollowed to be  lightweight
MaxillaryProsthesis• Can be made  with a reservoir  to hold artificial  saliva
Timing• Immediate (Intraoperative)  – hold in packs  – provide early function• Interim• Definitive  – 3 to 6 months
Prosthetic Materials• Acrylics• Polyurethanes• Silicone Elastomers  – Room-temperature vulcanizing  – High-temperature vul...
Mandible• Mandibular reconstruction revolutionized  by microvascular and plating techniques• Prosthetics mainly restore oc...
Mandible• Skin graft preserves alveolar ridge for  denture support
Postoperative Malocclusion    • Deviates to surgical side
Maxillary Ramp
Maxillary Ramp
Guide Plane Prosthesis
Guide Plane Prosthesis
Physiotherapy
Physiotherapy
Adjunctive Preprosthetic           Measures• Vestibuloplasty• Lowering of Floor of Mouth• Implants
Vestibuloplasty
Lowering the Floor of Mouth• Goal is to reposition mylohyoid  muscle
Lowering the Floor of Mouth
Edentulous Mandible
MentalForamen
Implants
Implants• Branemark in the 50’s studying bone temp  during drilling• Found temp probes couldn’t be removed  from bone with...
Implants•   Made of titanium•   Have to be drilled at low speed•   Oxide on metallic surface is dipole•   Plasma proteins ...
Implants• Implant placed first -- closed primarily• Abutment placed 4-6 mo later• Appliance attached  – rigidly  – removab...
Implants• Factors that influence success  –   material  –   macrostructure  –   microstructure  –   implant bed  –   surgi...
Implants
Implants
Implants• Implants can be placed in grafted fibula
Implants• Want to avoid large step-off if possible
Extraoral Prostheses
Extraoral Prostheses -- General            Principles• Goal is cosmetic• Retained with  – adhesives  – implants• Skin graf...
Extraoral Prostheses -- Ear• Retain tragus if possible to camouflage  anterior border
ExtraoralProstheses --    Ear
ExtraoralProstheses --    Ear
Extraoral Prostheses -- Ear  • Tragus hides attachment
Extraoral Prostheses -- Orbit• Skin graft provides base for prosthesis
Extraoral Prostheses -- Orbit  • Glasses help hide margin
Extraoral Prostheses -- Nose• Skin graft provides base for prosthesis• Alar tag undesirable
ExtraoralProstheses --   Nose
ExtraoralProstheses --   Nose
ExtraoralProstheses --   Nose
ExtraoralProstheses --   Nose
Conclusion• Restore function and cosmesis• Use techniques during surgery to aid  prosthetic management• Consultation with ...
Case Presentation• 30 yo WM with palatal tumor• Otherwise healthy• Path SCCa
Case Presentation
Maxillofacial prosthodontics
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Transcript of "Maxillofacial prosthodontics"

  1. 1. Surgical Techniques to EnhanceProsthetic Rehabilitation -- Oraland Dental Oncologic Principles Michael E. Decherd, MD December 8, 1999
  2. 2. Maxillofacial Prosthetics for the Otolaryngologist Michael E. Decherd, MD Anna M. Pou, MD December 8, 1999
  3. 3. History• Artificial facial parts found on Egyptian mummies• Ancient Chinese known to have made facial restorations• Grover Cleveland and Sigmund Freud• 1953 -- American Academy of Maxillofacial Prosthetics founded
  4. 4. Overview• Maxillofacial prosthetics a branch of prosthodontics• General prosthodontics a branch of dentistry• Goal is functional and cosmetic rehabilitation
  5. 5. Maxillofacial Prosthetics• “the art and science of anatomic, functional, or cosmetic reconstruction by means of nonliving substitutes of those regions in the maxilla, mandible, and face that are missing or defective because of surgical intervention, trauma, pathology, or developmental or congenital malformations”
  6. 6. Types of Rehabilitation• Preventative• Restorative• Supportive• Palliative
  7. 7. Prosthetic vs. Surgical Rehabilitation• Individualized decision between patient and doctor• Removable prosthesis allows for cancer surveillance• Not mutually exclusive
  8. 8. Intraoral versus Extraoral• Intraoral -- mostly functional – Mandible – Maxilla• Extraoral -- cosmetic – Ear – Nose – Orbit
  9. 9. Psychosocial Issues• Ultimate goal is restoration of quality of life• Functional deficits may be as isolating as cosmetic ones (i.e. has to eat alone)
  10. 10. Psychosocial Issues
  11. 11. Psychosocial Issues
  12. 12. Preoperative Evaluation• Discussion of patient’s expectations and desires• Consultation with appropriate services• Preoperative imaging• Status of current teeth and XRT
  13. 13. Poor Oral Hygiene
  14. 14. Dental Impression• Surgeon has marked resection for prosthodontic planning
  15. 15. Radiation and teeth• Obliterative endarteritis• Xerostomia -- rampant dental caries• Meticulous oral hygiene -- fluoride• Hyperbaric oxygen if surgery needed• Osteoradionecrosis
  16. 16. Radiation• Prosthesis may assist in consistent positioning of tongue, lips
  17. 17. Carious teeth after radiation
  18. 18. Universal Tooth Numbering
  19. 19. Universal Tooth Numbering
  20. 20. Normal function of Oral Cavity• Speech• Mastication• Deglutition
  21. 21. Speech• Complex process• Oral-nasal partition• Palatal augmentation prosthesis can lower palate to provide better function for a compromised tongue
  22. 22. Deglutition (Swallowing)• Tongue pulsion• Nasopharyngeal closure• Pharyngeal clearance• Airway protection• UES opening
  23. 23. Palate Augmentation Prosthesis
  24. 24. Palate Augmentation Prosthesis
  25. 25. Soft Palate• Serves to intermittently couple and uncouple oral and nasal cavities – production of consonant phonemes – during deglutition• May be better to remove all versus part unless needed for prosthesis retention
  26. 26. Soft Palate• May be better to remove all of soft palate than partial resection
  27. 27. Soft Palate Prosthesis
  28. 28. Soft Palate Prosthesis• Extension obturates nasopharynx
  29. 29. Soft PalateProsthesis• Small hole may be plugged• May close enough with time for flap closure
  30. 30. Mastication• Precursor to deglutition• Involves – Reduction of food particle size – Sorting of food particles• Masticatory efficiency = ability to reduce food to a given size in a given time
  31. 31. Mastication• Masticatory efficiency related to occlusal surface• Superior masticatory efficiency leads to greater reduction of particle size at swallowing threshold• Afferent sensory input improves efficiency – Experiment: unilateral anesthesia
  32. 32. Prosthetic Teeth and Masticatory Efficiency• Fixed partial, rigid support• Removable partial supported by – teeth only – teeth and edentulous ridge – edentulous ridge only
  33. 33. Oral Anatomy
  34. 34. Oral Anatomy
  35. 35. Maxillary defects• Maintain Premaxilla – can clasp teeth further apart – force distributed among more teeth• Use palatal mucosa if possible• May need to take turbinates
  36. 36. Premaxilla Preserved
  37. 37. Premaxilla Preserved• Cut through tooth socket
  38. 38. Palatal Mucosa Preserved
  39. 39. Mucosa Not Preserved• Rough edge uncomfortable for patient
  40. 40. Obturator• Restores oro-nasal partition• At times can be added to prior dentures
  41. 41. Skin Grafting of Defect• Less pain while healing• Less contracture of scar band which obscures cancer surveillance• Accomodates obturator better
  42. 42. MaxillaryProsthesis• Articulates with scar band• Hollowed to be lightweight
  43. 43. MaxillaryProsthesis• Can be made with a reservoir to hold artificial saliva
  44. 44. Timing• Immediate (Intraoperative) – hold in packs – provide early function• Interim• Definitive – 3 to 6 months
  45. 45. Prosthetic Materials• Acrylics• Polyurethanes• Silicone Elastomers – Room-temperature vulcanizing – High-temperature vulcanizing
  46. 46. Mandible• Mandibular reconstruction revolutionized by microvascular and plating techniques• Prosthetics mainly restore occlusion and occlusal surface• Implants able to restore high degree of function
  47. 47. Mandible• Skin graft preserves alveolar ridge for denture support
  48. 48. Postoperative Malocclusion • Deviates to surgical side
  49. 49. Maxillary Ramp
  50. 50. Maxillary Ramp
  51. 51. Guide Plane Prosthesis
  52. 52. Guide Plane Prosthesis
  53. 53. Physiotherapy
  54. 54. Physiotherapy
  55. 55. Adjunctive Preprosthetic Measures• Vestibuloplasty• Lowering of Floor of Mouth• Implants
  56. 56. Vestibuloplasty
  57. 57. Lowering the Floor of Mouth• Goal is to reposition mylohyoid muscle
  58. 58. Lowering the Floor of Mouth
  59. 59. Edentulous Mandible
  60. 60. MentalForamen
  61. 61. Implants
  62. 62. Implants• Branemark in the 50’s studying bone temp during drilling• Found temp probes couldn’t be removed from bone without fracturing• Led to study of osseointegration
  63. 63. Implants• Made of titanium• Have to be drilled at low speed• Oxide on metallic surface is dipole• Plasma proteins adhere
  64. 64. Implants• Implant placed first -- closed primarily• Abutment placed 4-6 mo later• Appliance attached – rigidly – removable – samarium-cobalt magnets
  65. 65. Implants• Factors that influence success – material – macrostructure – microstructure – implant bed – surgical technique – loading conditions
  66. 66. Implants
  67. 67. Implants
  68. 68. Implants• Implants can be placed in grafted fibula
  69. 69. Implants• Want to avoid large step-off if possible
  70. 70. Extraoral Prostheses
  71. 71. Extraoral Prostheses -- General Principles• Goal is cosmetic• Retained with – adhesives – implants• Skin grafting may help• Smooth edges
  72. 72. Extraoral Prostheses -- Ear• Retain tragus if possible to camouflage anterior border
  73. 73. ExtraoralProstheses -- Ear
  74. 74. ExtraoralProstheses -- Ear
  75. 75. Extraoral Prostheses -- Ear • Tragus hides attachment
  76. 76. Extraoral Prostheses -- Orbit• Skin graft provides base for prosthesis
  77. 77. Extraoral Prostheses -- Orbit • Glasses help hide margin
  78. 78. Extraoral Prostheses -- Nose• Skin graft provides base for prosthesis• Alar tag undesirable
  79. 79. ExtraoralProstheses -- Nose
  80. 80. ExtraoralProstheses -- Nose
  81. 81. ExtraoralProstheses -- Nose
  82. 82. ExtraoralProstheses -- Nose
  83. 83. Conclusion• Restore function and cosmesis• Use techniques during surgery to aid prosthetic management• Consultation with maxillofacial prosthodontist for optimal rehabilitation
  84. 84. Case Presentation• 30 yo WM with palatal tumor• Otherwise healthy• Path SCCa
  85. 85. Case Presentation
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