Management of acquired maxillary defects: Prosthetic rehabilitation after head and neck cancer surgery
- Joseph A Toljanic, DDS
Joseph A Toljanic, DDS
- Associate Professor
- Midwestern University School of Dental Medicine
- Section Editors
- Bruce E Brockstein, MD
Bruce E Brockstein, MD
- Section Editor — Cancer of the Head and Neck
- Clinical Associate Professor of Medicine
- University of Chicago Pritzker School of Medicine
- Marvin P Fried, MD, FACS
Marvin P Fried, MD, FACS
- Section Editor — Head and Neck Surgery
- Professor and University Chairman, Department of Otorhinolaryngology - Head and Neck Surgery
- Montefiore Medical Center, Albert Einstein College of Medicine
Surgical treatment of head and neck cancer can cause significant difficulties in orofacial function and can impair quality of life [1,2]. The use of a prosthesis (obturator) to close such a defect can help to restore functions such as deglutition, control of secretions, mastication and phonetics, as well as to aesthetically replace the missing orofacial structures .
Current prosthodontic options for the management of the acquired hard palate defect will be reviewed here. The prosthodontic management of soft palate defects, mandibular and facial defects are discussed separately (see "Mandibular and palatal reconstruction in patients with head and neck cancer").
Initial planning for patients about to undergo treatment of head and neck cancer should include evaluation by a prosthodontist. Even if surgical reconstruction is planned, dental prosthesis may be considered as part of the definitive rehabilitation. The expertise of a dental specialist is necessary to address subtle dentoalveolar concerns that may impact decision making, such as plane of occlusion, articulation of teeth, tooth mobility, preexisting temporomandibular joint dysfunctions, orodental parafunctional habits (eg, nocturnal grinding or clenching of the teeth), preexisting benign conditions, anatomic variations and postoperative orodental care. (See "Oral toxicity associated with chemotherapy" and "Speech and swallowing rehabilitation of the patient with head and neck cancer".)
A complete orofacial examination should be performed. The surgical plan and the postsurgical complications that will have to be addressed prosthodontically should be explained to the patient. At this time, a detailed evaluation of the existing dentoalveolar condition should be undertaken. Restorative and periodontal treatments, as well as extractions should be planned. Depending on the preliminary design of the resection, even compromised teeth should be potentially considered as supports for a prosthesis.
Splinting teeth with a conventional bridge or a supracrestal bar (Hader or Dolder type) might prove beneficial for retention, support and stability of a removable obturator. However, torquing forces should be evaluated and the design modified accordingly. Preexisting conditions that may impact on successful prosthodontic outcome (eg, the presence of a maxillary torus or bucco-alveolar exostosis that will not be included within the resection) should also be evaluated and corrected prior to definitive surgery. A preexisting fixed partial denture that crosses the planned resection cut is easily sectioned prior to the planned surgery .
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- TREATMENT PLANNING
- SURGICAL CONSIDERATIONS
- Palatal mucosal incision
- Preservation of teeth
- Preservation of disease-free osseous structures
- Split-thickness skin graft
- Soft palate considerations
- Elimination of nasal turbinates
- Posterolateral support
- Vestibular depth
- Removal of coronoid process of mandible
- PROSTHODONTIC REHABILITATION
- Immediate (surgical) obturator prostheses
- Transitional obturator prosthesis
- Definitive (permanent) obturator prosthesis