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REVIEW ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 2  |  Page : 255-259

Adjuvant therapy for intra oral surgical oncological defect with ancillary prosthesis: A literature review


Department of Prosthodontics, SRM Dental College, Chennai, Tamil Nadu, India

Date of Web Publication8-Mar-2018

Correspondence Address:
Dr. S C Ahila
Department of Prosthodontics, SRM Dental College, Ramapuram, Chennai - 600 089, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.172118

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 > Abstract 


The role of a maxillofacial prosthodontist in the treatment of facial defects cannot be underestimated. A multidisciplinary approach is required during the rehabilitation procedure to bring out effective results. Ancillary maxillofacial prostheses limit the patient's disability and improve function. These prostheses are inevitable in restoring the function, esthetics, general, and psychological health of the patients. This article reviews the various ancillary-maxillofacial prostheses and throws light on their historical development.

Keywords: Ancillary prosthesis, maxillofacial prostheses, maxillofacial prosthodontist


How to cite this article:
Ahila S C, Jagdish S K. Adjuvant therapy for intra oral surgical oncological defect with ancillary prosthesis: A literature review. J Can Res Ther 2018;14:255-9

How to cite this URL:
Ahila S C, Jagdish S K. Adjuvant therapy for intra oral surgical oncological defect with ancillary prosthesis: A literature review. J Can Res Ther [serial online] 2018 [cited 2018 Jun 18];14:255-9. Available from: http://www.cancerjournal.net/text.asp?2018/14/2/255/172118




 > Introduction Top


Maxillofacial prosthetics is a subspecialty of prosthetic dentistry which deals with the replacement/restoration of stomatognathic and craniofacial structures with removable or fixed prosthesis.[1] As a critical member of any large medical center team, the maxillofacial prosthodontist is involved not only in diagnostic examination, restoration and maintenance of oral function, comfort, esthetics, and health of patients who are undergoing chemo and radiation therapies, but also is involved in the rehabilitation of acquired and developmental defects through prosthetic repair. Utilizing knowledge of anatomy, physiology, and dental materials a dentist can provide innovative prosthetic aids that will contribute to the comprehensive management of the patient.[2],[3] Ancillary prostheses can be fabricated by the dental clinician to facilitate treatment and rehabilitation of patients with various functional and anatomical deficiencies.


 > History of Maxillofacial Prosthetics Top


The exact origin of maxillofacial prosthetics seems to be unclear but it can be traced back to the times of Etruscan and the Egyptian civilizations. Evidences from mummies suggest that artificial eyes were used by the Egyptians. Ancient Chinese and Indians were known to use artificial nose and eyes.[4] Alexander Petronius during the 16th century developed obturators using wax, cotton wool, or oakum to treat patients with bullet wounds.[5]

One of the first writings on maxillofacial prosthesis was by Sir Ambrose Pare in 1530 AD, who was often referred to as the “father of modern surgery.” Maxillary obturator using sponge was one of the earliest contributions of Pare. A dried sponge was attached to the upper surface of obturator which absorbed moisture from the secretions and expanded intra orally to retain the prosthesis.[6] His other contributions include artificial nose, eyes, and ears. He advocated the use of prosthetic nose made of silver which was attached to the face by means of strings and the junction of the attachment masked by a mustache.[4]

Sir Pierre Fauchard, commonly known as the “father of modern dentistry” also made contributions to maxillofacial prosthesis. He along with a French surgeon and a silversmith fabricated an extensive facial prosthesis replacing the entire lower half of the face. This was worn by a French military man who later came to be known as “gunner with the silver mask.”[4]

A Danish astronomer named Tycho Brache was well known for his artificial nose which he fabricated for himself. He lost his nose in a sword fight and fabricated a nasal prosthesis using silver and gold and attached it to his face with glutinous ointment.[7] Christopher Francois Delebarre was known for two major contributions in maxillofacial prosthetics. The first one was the introduction of metal bands to retain maxillary obturators on to teeth. He was also the first to design and construct an artificial velum.[8]

The first major development in materials and methods of fabricating maxillofacial prosthesis came during the “Vulcanite Era” when Nelson Goodyear introduced vulcanite rubber in 1851.[9] Dr. Norman Kingsley pioneered the use of vulcanite in construction of maxillofacial prostheses. Improvements in surgical techniques and design principles were made by Dr. V. H. Kazanjian during the First World War period.[7] Development of acrylic resin started with the introduction of clear acrylates by Dr. Otto Rohm.[9]

The first replacement to vulcanite material was “Veronite” a poly methyl methacrylate based material introduced in 1936.[10] With advancements in polymer chemistry, today many materials such as polyvinyl chlorides, poly urethane, room temperature, and heat pressed silicones are available for use in maxillofacial prosthetics. With these materials, excellent color matching and skin like appearance can be achieved with great precision.[11],[12]

Obturators

An obturator is a maxillofacial prosthesis used to close a congenital or acquired tissue opening, primarily of hard palate and or contiguous alveolar or soft tissue structures1. They are surgical, interim, and definite type.[1]

Surgical obturator

Obturation may be accomplished either with the placement of an immediate surgical obturator after surgery or with the placement of delayed surgical obturator 6–10 days postsurgically. Immediate surgical obturation is indicated for most patients.[13],[14] Surgical obturator has been prepared with variety of restorative and materials including sponges, gutta percha, and inflatable bulbs.[4],[15],[16]

Immediate surgical obturator

The prosthesis provides a matrix on which the surgical packing can be placed. It reduces oral communication of the wound during the immediate postsurgical period and reduces the incidence of local infection. It enables the patient to speak more effectively during the postoperative period by reproducing normal palatal contour by covering the defect. It permits deglutition thus eliminates the use of nasogastric tube. In addition, it reduces the psychological impact of surgery and reduces the period of hospitalization.[17]

Delayed surgical obturator

Prosthesis which is given after 6-10 days of maxillectomy is called delayed surgical obturator. If the patient is edentulous and margins are in question, this approach may be an acceptable alternative.[18]

Interim obturator

A definitive prosthesis is indicated until the surgical site is healed and dimensionally stable and the patient is prepared properly and emotionally for the restorative care that may be necessary. For some patients particularly with large defects appropriate function and comfort cannot be sustained without construction of either a new prosthesis or a significant modification of the immediate or delayed obturator. The interim prosthesis bridges the gap between the immediate surgical obturator and the definitive prosthesis. It serves as a backup prosthesis which may be useful when the definitive prosthesis needs to be repaired, relined, or rebased. In many instances, the surgical obturator can be utilized to fabricate the new interim prosthesis. It can be given after 2 weeks of surgery.[19]

Definitive obturator

Three to four months after surgery consideration may be given to the construction of a definitive obturator. Mostly a cast denture base is used in the fabrication of this prosthesis. The principles of construction of definitive obturators have been discussed in detail by Aramany[20] [Figure 1].
Figure 1: Definitive obturator

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Feeding appliance

An ancillary prosthesis that closes the oro-nasal cavity defect, thus enhancing sucking, swallowing, and maintains the right and left maxillary segment of infants with cleft palates in their proper position until surgery is performed to repair the cleft.[1]

Nasal stent

Stents provide support for cartilage during postsurgical healing for the correction of nasal deformities in cleft lip patients. Period, after surgical excision of nasal cartilage associated with sinus tumor, nasal stents can be used to maintain contour and minimizes scar contracture following in grafting procedures to the nostrils. To facilitate the nasal breathing, aperture can be created inside the nasal stent, so that the patency of the airway can be maintained. It can be easily disinfected, also it is light weight. It can be used to counteract previously formed scar tissue and to widen the nostrils of trauma or burn patients prior to grafting procedures[22],[23] [Figure 2].
Figure 2: Nasal stent

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Guiding flange

Mandibular guidance restoration therapy begins when the immediate postsurgical sequelae have subsided. It consists of a removable partial denture frame work with a metal flange extending 7–10 mm laterally and superiorly on the buccal aspect of the bicuspids and molars on the nondefect side. This flange engages the maxillary teeth during mandibular closure, thereby directing the mandible into an appropriate intercuspal position. The partial denture framework must be suitably stable and retained to counteract the lateral forces generated upon the prosthesis during closure[24],[25] [Figure 3].
Figure 3: Guiding Flange

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Palatal ramp

It is indicated in most patients with mandibular deviation. They are more adjustable than mandibular guidance ramp, preferred for patients with severe mandibular deviation[26] [Figure 4].
Figure 4: Palatal ramp

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Cock screw

It is a threaded tapered screw made of acrylic resin. The patient places the screw between his posterior teeth and gradually turns it to wedge his teeth apart. The threads guide the teeth along the increasing taper while the patient controls timing and degree of pressure to gradually increase the jaw separation[1] [Figure 5].
Figure 5: Cock screw

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Velopharyngeal closure (palatal lift appliance)

Palatopharyngeal incompetence may be related to degenerative disease, cerebrovascular accidents or trauma. When palatopharyngeal incompetence is encountered, rehabilitative efforts are designed to elevate the soft palate. Palatal lift prosthesis is used to raise the soft palate to the level of the hard palate This elevation places the junction of the middle and posterior thirds of the soft palate in close proximity to the posterior pharyngeal wall creating a muscular seal that prevents nasal regurgitation of fluid and food during deglutition. The prosthesis also prevents the escape of air into the nose when speaking. Because this prosthesis provides a mechanical rather than a functional closure of the palatopharyneal valve, the ideal closure that prevents the passage of air and/or food and liquids will also result in an inability to breath through the nose. Reduction of the prosthesis to allow nasal breathing may be needed. It must be remembered that palatal lift prosthesis only addresses palatopharyngeal closure. The physiologic acts of speaking and swallowing are dependent upon the coordinated function of many other oral and pharyngeal muscle groups which may also be affected in palatopharyngeal incompetence. The prosthesis may stimulate a return of muscular function in some patients but, depending upon the etiology, others may experience little or no improvement.

The soft palate extension of the palatal lift prosthesis is designed to elevate an immobile soft palate to the approximate level of the palatal plane.[18],[19],[20] The posterior target of the elevation is the dorsal tubercle of the first cervical vertebrae (atlas). The ease of elevation is dependent upon the elasticity, fibrosis and muscular activity of the soft palate. When elevated, the soft palate will tend to displace the palatal lift and this displacement must be resisted by the retentive components of the prosthesis.[21] The retentive clasps must be rigid and placed as close as possible to the obturator portion of the prosthesis. Occlusal (cingulum, incisal) rests will resist displacement of the prosthesis toward the tissue but it is the retentive aspect of occlusal rests (indirect retainers) that are most critical in this prosthesis. The further away from the fulcrum line the more effective the occlusal rests will be as indirect retainers. Parallel guide planes may also resist rotational displacement of palatal lift prosthesis if there is sufficient clinical crown length.

When natural teeth are absent, retention of the prosthesis is severely compromised. In the absence of favorable anatomy, it may be impossible to use palatal lift prosthesis unless dental implants can be placed as denture adhesive is usually not sufficient to counteract the displacement forces of the soft palate. When reduced denture retention is anticipated it may be prudent to first fabricate a conventional prosthesis and then gradually add to the posterior aspect of the prosthesis while attempting to minimize the amount of elevation. The lift section of palatal lift prosthesis is formed after the oral portion of the prosthesis is completed. A retentive loop is extended posterior from the palatal portion of the prosthesis to facilitate placement and retention of impression material to raise the soft palate.[27],[28],[29],[30]


 > Discussion Top


The maxillofacial prosthetic treatment is not a substitute for plastic and reconstructive surgery, in certain circumstances it may be an alternative. Certain patients may simply not be good candidates for plastic surgery because of their advanced age, poor health, very large deformity, or poor blood supply to irradiated tissue. Moreover, maxillofacial prosthetic treatment is indicated when anatomical parts of the head and neck are not replaceable by living tissue, when recurrence of malignancy is likely, when radiotherapy is being administered, or when fragments of facial bones are severely displaced in a fracture. A temporary prosthesis may cover a defect when plastic surgery repair requires many steps, and speech appliances may be used when surgery is considered no advantageous for the closure of a cleft palate. Surgically reconstructed sites also require maxillofacial prosthetic treatment with or without implants.

As maxillofacial prosthetic training and materials continue to improve, and as implants become more and more important to facial rehabilitation, the maxillofacial prosthodontist and maxillofacial prosthetist become ever more important. Moreover, their contribution is often of the longest duration. During the 2–4 years, they may be working with a patient, they are the ones who often develop the closest relationships with the patient, and become even more important to the medical center team.


 > Conclusion Top


The role of a maxillofacial prosthodontist in the treatment of facial defects cannot be underestimated. A multidisciplinary approach is required during the rehabilitation procedure to bring out effective results. Ancillary maxillofacial prostheses limit the patient's disability and improve function. These prostheses are inevitable in restoring the general and psychological health of the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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Bulbulian AH. Maxillofacial prosthetics: Evolution and practical application in patient rehabilitation. J Prosthet Dent 1965;15:544-69.  Back to cited text no. 4
    
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Park KT, Kwon HB. The evaluation of the use of a delayed surgical obturator in dentate maxillectomy patients by considering days elapsed prior to commencement of postoperative oral feeding. J Prosthet Dent 2006;96:449-53.  Back to cited text no. 18
    
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Moergeli JR, Fuller WW. Interim obturation of palatal perforations. J Prosthet Dent 1985;53:680-1.  Back to cited text no. 19
    
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Aramany MA. Basic principles of obturator design for partially edentulous patients. Part II: Design principles 1978 [classical article]. J Prosthet Dent 2001;86:562-8.  Back to cited text no. 20
    
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Fraser-Moodie W. Mr. Gunning and his splint. Br J Oral Surg 1969;7:112-5.  Back to cited text no. 21
    
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Goyal MK, Goyal S. Prosthetic rehabilitation of large nasal septal defect with an intranasal stent: A clinical report. Indian J Dent Res 2011;22:719-22.  Back to cited text no. 22
[PUBMED]  [Full text]  
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Goveas R, Puttipisitchet O, Shrestha B, Thaworanunta S, Srithavaj ML. Silicone nasal prosthesis retained by an intranasal stent: A clinical report. J Prosthet Dent 2012;108:129-32.  Back to cited text no. 23
    
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Nelogi S, Chowdhary R, Ambi M, Kothari P. A fixed guide flange appliance for patients after a hemimandibulectomy. J Prosthet Dent 2013;110:429-32.  Back to cited text no. 24
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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