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Oral Prosthetic in Head andNeck Reconstructions

Jacques Peltier, MD

Faculty Advisor: Anna M. Pou, MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

November 2003

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Preoperative evaluation

Evaluation by surgeon

History, Physical

Endoscopy

Biopsy

CT

MRI

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Preoperative Evaluation

Evaluation by Maxillofacial Prosthodontist

Dental health status (Carries)

Panorex

Extraction?

Preoperative Dental Molds

Surgical suggestions

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Surgical Strategies

Resection limited to disease only

 Avoid hemimaxillectomy if possible

Preserve alveolar ridge

Preserve central incisors

Preserve tuberosity

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Surgical Strategies

Resection through socket of extracted

tooth

Prevents additional loss of teeth

Preservation of strip of mucosa

Used for coverage of bone

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Surgical Strategies

Skin grafting of maxillary cheek

Resection of inferior turbinate

Skin grafting to contact areas of obturator

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Final position of

obturator.

Note retention

dependent on contactwith maxillary sinus.

Skin grafting to area

of contact prevents

complications

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Classification of obturators

Surgical

Postsurgical

Definitive

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Surgical Obturator

Designed preoperatively

Installed sterilely

Scaffolding for packing Increases postoperative function

Psychological advantage for patient

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Surgical obturator design

Communication between surgeon and

prosthodontist

 Anticipated defect

Method of securing surgical prosthetic

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Surgical Obturator Design

Minimal resection coverage

May have incomplete coverage, exposed

packing, poor fit

No need for modification

Radical resection coverage

May require intraoperative modifications by

surgeon

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Methods to secure

surgical obturator

Palatal bone screw

Suturing

Circumzygomatic wiring

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Postsurgical obturators

Used from packing removal to 3-12

months post-op

Bulb extension into defect

Contact with remaining teeth important

 Anterior teeth only

 Avoid occlusive relationship

Tissue-conditioning/soft reline material

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Definitive obturator

Placed after tissue remodeling a minimum

Occlusive relationship important.

Modifications a minimum

Removable to allow cleaning

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Edentulous patient

Resection of inferior turbinate

Skin grafting of contact areas

Tri-poding effect

Spring loaded dentures

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The Irradiated Patient

When to remove teeth

Dental health

Reliability of the patient

Location of teeth in question

 Area to be radiated

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Preservation of Maxillary teeth

Pre-extraction antibiotics

Experienced Oral surgeon

Osteoradionecrosis in 1-30%

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Common Complications

Xerostomia

Trismus

Mucositis

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Xerostomia

Salivary rates as low as 1%

 Artificial saliva

Topical sodium fluoride

• Custom tray

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Mucositis

Erethema, tenderness, desquamation as

early as 2 weeks

Decrease oral intake

Unable to tolerate obturator

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Treatment of Mucositis

Good oral hygiene (soft brush, mild

toothpaste)

Sodium bicarbonate, H2O2 rinses

Benadryl elixirs

Sucrafate solutions

Topical anestheticsG-tube placement

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Trismus

Fibrosis of muscles of mastication, TMJ

Daily exercises required for long periods of

time

Prolonged holiday from exercises results

in permanent fibrosis

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Conclusion

Early consultation with Maxillofacial

Prosthodontist

Surgical planning to include post-operative

rehabilitation

Communication throughout treatment

process