Chapter 1
Behavioral and Psychosocial Issues in
Head and Neck Cancer
Ellen R. Gritz and Alisa Hoffman*
No cancer is minor to the affected individual. The
threat to physical health and even to survival, to function­
ing, and to social and emotional well-being, precipitated by
a malignancy, varies dramatically among individuals ac­
cording to the location and severity of the disease. Cancers
of the head and neck have the potential for producing
obvious disfigurement and dysfunction, which may be only
partially compensated for by prostheses and rehabilitation.
The diagnosis, treatment and long-term adjustment to head
and neck cancer presents both physical and psychological
challenges to an individual that cannot be summarized by
or equated with statistics on treatment response, disease
progression, and survival. Thus, it is particularly important
to address nontraditional outcomes, such as patient well­
being, in this group of diseases1.
Recently, the concept of quality of life (QOL) has
emerged as an organizing schema around which to describe
and evaluate the experience of cancer patients in Clinical
research. However, QOL can be used to evaluate patient
outcome in any treatment. QOL is treated as a “subjective
(i.e., patient rated), multidimensional concept”2. While
there are widely varying definitions, the overarching con­
cept reflects the “subjective feeling of well-being of the
individual”3. Gotay and her colleagues have proposed a
more specific definition: “a state o f well-being which is a
composite of 2 components: (1) the ability to perform
everyday activities which reflect physical, psychological,
and social well-being; and (2) patient satisfaction with
levels of functioning and the control o f disease and/or
treatment-related symptoms”4. The specific number of di­
mensions may vary, but leading investigator groups agree
on the value of a general score or scale and a series of
subscales measuring physical and functional abilities, cog­
* The authors wish to express their gratitude to Walter F. Baile, M.D. for his insightful comments and suggestions on manuscript content,
Ingrid Nielsen, R.N., M.N. for technical assistance, and Cynthia Sierra for expert manuscript preparation.
nitive, social and emotional functioning. Additional dimen­
sions might include spirituality, sexuality, occupational
performance, family and marital adjustment, future orienta­
tion, medical interaction and treatment satisfaction5-6-7.
Cancer-specific QOL instruments that are being used
most frequently at the present time include the Cancer
Rehabilitation Evaluation System (CARES)6* the QLQ-
C30 of the European Organization for Research and Treat­
ment of Cancer (EORTC)7-8, and the Functional Assess­
ment of Cancer Therapy scale (FACT)2. The latter 2
instruments contain general items with several subscales
which are intended to be supplemented by modules for
specific cancers. For example, in head and neck cancer, the
EORTC module assesses disease symptoms, treatment-
related side effects, nutritional aspects and social func­
tions8. In the FACT module, mastication, voice, and cosme-
sis are measured1-9.
QOL instruments that are specific to the head and neck
population focus on the primary functional and social
deficits encountered by head and neck cancer patients. A
Karnofsky-type Performance Status Scale for head and
neck cancer patients utilizes observer ratings based on the
ability to communicate verbally, the normalcy of diet, and
eating in public10. Another example is a newly-developed
instrument to assess radiation-related acute morbidity and
QOL, as rated by the patient11. Gotay and Moore have
completed a comprehensive review of QOL assessment for
head and neck cancer patients1. The reader is referred to
their article (see references at the end of this chapter) for a
detailed description of definitions, QOL dimensions, in­
strumentation, methodological issues, and future applica­
tions to research.
 Behavioral and Psychosocial Issues in Head and Neck Cancer
Depression is the first emotion to consider in conjunc­
tion with altered body image. The loss of a facial area and
the accompanying dysfunction have both physical and
emotional significance66. The eyes, nose and mouth are
particularly important in defining the face and personality.
The fear and insecurity regarding social reaction to disfig­
urement may lead to social isolation which can further
perpetuate depression76. Feelings of shame and inadequacy
can also contribute to social isolation and depression.
It is not surprising that disfiguring surgery can give
rise to anxiety states related to fears of separation, aban­
donment or a damaged or disintegrated self66. Patients can
experience increased vulnerability, feeling that they don’t
have the “equipment” to deal with the world in the manner
to which they are accustomed76. Anxiety can also contrib­
ute to distorted perceptions of changes in the body, which
should be gently confronted through reality-testing with an
experienced professional as well as significant others66.
Another emotion sometimes generated by disfiguring
surgery is elation. The feeling that the “bad part” is
removed improves the individual’s sense of self and iden­
tity66. Some may see it as a learning and growth experience
that leads to a deeper self-awareness and stronger self-
reliance76.
The effects of disfiguring surgery on children are even
greater than on adults. Studies of children and families of
children with craniofacial defects reveal an underlying
association of physical attractiveness with goodness and,
conversely, ugliness with badness66. Facially deformed
children are much more likely to be considered unintelli­
gent, uncooperative and unfriendly and are more likely to
be treated harshly. Given these findings, it is predicted that
children with disfiguring surgeries will have a much more
difficult time socially than other children77.
Sexuality can also be affected by alterations in body
image. Unfortunately, there are few studies on this topic in
head and neck cancer populations. An excellent overview
of sexual dysfunction in cancer patients in general is
presented by Auchincloss78. Grinker states: “The dread of
exposing oneself to one’s spouse as crippled, damaged,
incomplete or dying may cause sexual inhibition or absti­
nence. Intimacy and sexual bodily functions may be af­
fected by shame and embarrassment”79. Due to the high
prevalence of alcoholism and the physical and psychologi­
cal debility from the presence of the tumor, many head and
neck cancer patients are likely to have a preoperative
prevalence of sexual dissatisfaction or dysfunction80. En­
couraging patients to discuss their sexual concerns prior to
surgery can be helpful81. It will facilitate dialogue through­
out the treatment course, which is very important for the
patient’s adjustment.
7
Patients often feel they can no longer function sexually
because of their disfiguring surgery. In one study, about a
third of the laryngectomy patients described their sex lives
as “changed” and 40% “wished for improvement”82. Pa­
tients should be encouraged to experiment in their intimate
and sexual behavior, and to identify new routes for erotic
expression. Communication is an important tool in over­
coming changes in body image and sexuality. Therefore,
patients should also be encouraged to speak with their
partners, and with their physician about questions or con­
cerns81. Referral to mental health professionals who spe­
cialize in sexual dysfunction is very appropriate.
During the postoperative period, Dropkin describes 2
primary behavioral manifestations of the coping process as
self-care and resocialization75. Both of these behaviors are
important in adjustment to disfigurement. Self-care refers
to independent performance of basic hygiene with a spe­
cific emphasis on caring for those areas which were
operated on. Days 4 to 6 are pivotal. The patient should
begin to adjust to the defect and commence self-care during
this time frame. This step indicates reintegration and
evolution in the patient’s value system toward placing less
importance on physical attractiveness, and greater empha­
sis on internal characteristics versus external features.
Resocialization, defined as social interaction and go­
ing out in public, is very crucial to adjustment and coping73.
Generally, patients seek to routinize their daily interactions
to allow people to become accustomed to their altered
appearance76. Often they will allow people to see them at a
distance prior to close observation. Sometimes the patient
can become comfortable with a small network of friends
and never venture outside of this group. Social interaction
facilitates the process of refinement and redefinition of
self-presentation75. The interaction helps the person feel
less isolated, and can provide new input leading to behav­
ioral changes and healthy coping strategies. Acceptance
seems to come with controlled exposure to reactions of
others to body alteration.
Another major influence on how the patient adjusts is
how they are accepted by their treatment team83. The
treatment team is the first “social” exposure the patient
experiences and he/she is acutely sensitive to their reac­
tions. The greatest difficulty occurs when others do not
reveal their reaction to the patient’s surgical outcome and
appearance. Generally, imagination is worse than reality, so
an honest yet compassionate discussion is usually the best
approach.
Overall, most patients adjust well to their disfigure­
ment. In one study, more than 86% reported good adapta­
tion84. The support the patient receives from both family
and friends and the treatment team is crucial to adjustment.
8 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
Mental Disorders
Depression
Clinical depression is not uncommon in cancer pa­
tients. It is estimated that 20-25% of patients will experi­
ence a major depression during their illness85, and this
disorder is even more likely to occur in patients with head
and neck cancers49-86. Two studies have shown that upon
initial evaluation for their cancer, a substantial proportion
of head and neck patients exhibit depression. Davies found
that 29% of the patients with oral cancer met the criteria for
depression at the time of their evaluation87, and Baile
reported a 40% prevalence86. Thus, even prior to treatment,
these patients have a higher likelihood of depression.
David and Barrit defined an “expectable pattern” of severe
postoperative depression, which can have an extended
course80. Morton found that 40% of patients with oropha­
ryngeal cancer met the criteria for depression 6 months
after treatment88.
The unipolar depressive mood disorders fall into 3
groups; namely, major depressive disorder, dysthymic dis­
order, and depression not otherwise specified (DNOS)—
which are distinguished from bipolar disorders by the fact
that there is no history of having a manic, mixed, or
hypomanic episode32. An important differential diagnosis
for cancer patients is an adjustment disorder with a de­
pressed mood. The disease is the precipitating stressor. The
disorder occurs within 3 months of stressor onset and has a
duration of 6 months at most. The symptoms constitute an
incomplete depressive syndrome (e.g., depressed mood,
fearfulness, and feelings of hopelessness), but are judged in
excess of a normal and expectable reaction32.
It is critical to emphasize that individuals often experi­
ence an initial catastrophic reaction to a cancer diagnosis,
accompanied by shock and denial, then followed by gen­
eral emotional turmoil with anxiety, dysphoria and distur­
bances in cognitive and behavioral functioning85. This is
part of a normal adjustment period, which can occur both
pre- and post-surgery, as patients begin to live with their
diagnoses and alterations in appearance. Most patients do
feel depressed shortly after surgery. Depressive symptoms
persisting for more than 2 weeks may meet the criteria for a
major depression89. It is important to consider the grada­
tions in severity to help patients understand what they are
experiencing. The type o f symptoms, their severity and
duration dictate when referral to a mental health profes­
sional is appropriate.
The clinician should be aware of the signs and symp­
toms of major depression. The essential feature is either a
depressed mood most of the day, or diminished interest or
pleasure in all or almost all actvities which occur over a
period of at least 2 weeks, and at least 4 of the following
symptoms are present: (1) significant weight gain or loss
when not dieting, or appetite change, not related to the
illness; (2) insomnia or hypersomnia; (3) psychomotor
agitation or retardation; (4) fatigue or loss of energy not
related to the illness; (5) feelings of worthlessness or
excessive or inappropriate guilt; (6) diminished ability to
think or concentrate, or indecisiveness; and (7) recurrent
thought of death or suicide32.
Given these signs and symptoms, diagnosing depres­
sion can be problematic in patients who are already having
difficulty with sleep, speech, swallowing and appetite.
Other signs to look for specifically with head and neck
cancer patients include: excessive neediness, anger, with­
drawn behavior, limited eye contact, feeling hopeless and
helpless, excessive pain, and unwillingness to cooperate
with the medical regimen66. The more subtle, nonverbal
cues expressed in both gestures and expressions further
indicate the mood of the patient.
The etiology of depression has been found to be
multifactorial90. There can be tumor related factors, indi­
vidual differences in stress levels, individual differences in
coping resources and preexisting psychopathology as well
as depression due to withdrawal from alcohol or tobacco.
Patients with a history of depression are at much higher
risk of becoming depressed after surgery49. Compounding
the problem is the significant alcohol and/or tobacco
history of many head and neck cancer patients, who may
have less ability to cope with stress without using liquor
and/or cigarettes, at least temporarily49. Patients must ad­
just and learn to cope with many changes in speech,
swallowing, vision, smell, taste, and hearing, and with
facial disfigurement. All of these factors can contribute to
feelings of depression. Pain, discomfort and interference
with daily functions may also result in depression. Westin
evaluated head and neck cancer patients with significant
weight loss and found that 30% of them showed signs of
depression, suggesting an association between depression
and malnutrition91.
Suicide is a real danger with depressed head and neck
cancer patients. Farberow found that patients with malig­
nant lesions of the larynx, oral cavity and pharynx had
more than twice the risk of committing suicide than
patients with cancer in all other sites except the lung49.
Factors related to increased risk of suicide are as follows:
prior suicide attempts; presence of a plan and the means to
cany it out; persistent thoughts of suicide; having a family
member who has committed suicide; substance abuse cur­
rently or in the past; and “perpetual feelings of hopeless­
ness and despair”89. Additional risk factors particularly
relevant to head and neck cancer include increased age, low
social support, delirium, advanced disease, and disfiguring
 Behavioral and Psychosocial Issues in Head and Neck Cancer
disease or surgery85. It is important to assess a depressed
patient’s suicide potential because this information may not
be freely volunteered. Patients generally feel relieved to
have the issue raised. It makes them feel safer and cared
about, and demonstrates your concern.
Although the causes of depression are multifactorial,
treatments which have proven to be effective with head and
neck cancer patients include psychotropic medication, es­
pecially antidepressants66. Supportive psychotherapy and
cognitive therapy are effective in mobilizing patients and
helping to create healthy coping strategies. Support from
both the family and the medical treatment team are thera­
peutic as well49-92.
Anxiety
There are many factors that contribute to anxiety
disorders in patients undergoing disfiguring surgeries. It is
important to differentiate 2 different categories of anxiety
disorders. One is anxiety related to the illness. This is
commonly called an adjustment disorder with an anxious
mood, which is characterized by symptoms of anxiety (e.g.,
nervousness, worry, or jitteriness) that exceed the normal
reaction to a stressful illness32-49. The other category refers
to anxiety disorders that existed prior to the illness, includ­
ing a generalized anxiety disorder, panic disorder or pho­
bia. This second category can account for major complica­
tions during treatment and rehabilitation49.
There are many symptoms associated with anxiety
aside from patients’ reports of feeling anxious. Frequently,
patients do not realize they are anxious, but have other
anxiety related symptoms such as: “difficulty in falling
asleep, nightmares, restlessness, tremulousness, sweating,
dry mouth, pressured speech, frequency of urination, ta­
chycardia, lightheadedness, fear of fainting, palpitations,
generalized fatigue, vague aches and pains, shortness of
breath (especially a sighing respiration), and paresthesias.
The patient may also feel fearful, nervous and panicky for
no apparent reason; he may have feelings of impending
doom, be convinced that he is ‘falling apart,’ and have a
constant and excessive need for reassurance”89. In a study
at Memorial Sloan-Kettering Institute, half of the head and
neck patients had symptoms that met criteria for adjust­
ment disorder with anxious mood, underscoring its preva­
lence in this population of cancer patients and the impor­
tance of assessing for it49.
The sources of anxiety are different for different stages
of the illness. Preoperatively, patients may have fears about
the procedure and whether it will go well. They may have
fears about the anticipated cosmetic defect and facial
alteration and they may fear the loss of function if a critical
part of their face is to be resected49. In this case it may be
9
helpful for the patient to speak to another patient who has
been through the same procedure. The patient can ask
questions and learn that having the surgery will not destroy
their life and that people do adjust well to these proce­
dures49. Better adjustment in laryngectomy patients, for
example, has been related to preoperative counseling by a
laryngectomee93.
During the postoperative period, patients are focused
on the discomfort and pain, the inability to speak or
swallow, their appearance, how people will react to them
and how they will adapt to their disfigurement49. These are
the issues that patients carry with them out of the hospital
and into the rest of their lives. Patients may feel an
increased sense of vulnerability as well as separation
anxiety regarding the loss of a particular part of the face.
Finally, they may fear abandonment from friends and
family66. Satisfaction with social support is a key determi­
nant of postsurgical adjustment in laryngectomees93, and
the level of support from family and friends can influence
social reentry94.
In this vein, it is important to realize that anxiety can
lead to perceptual distortion of the body image. Patients
may visualize an image that is worse than the actual
situation66. This can be a problem, in particular, for people
who already feel damaged. It is important to intervene
quickly in this situation lest it lead to further distortion and
isolation for the patient. It is helpful to have realistic
opinions from other people to help the patient evaluate his
or her appearance in a mirror. Support from professionals,
as well as from others with the same cancer, facilitates
adjustment. For example, professional speech therapists
and rehabilitated laryngectomees can provide training in
communication skills, and the opportunity for social com­
parison and feedback for skill improvement94.
Several psychological treatment methods are helpful in
reducing anxiety. First is relaxation training, in which the
patient learns how to relax through breathing and muscle
contraction and relaxation. Patients mastering this tech­
nique often feel that they can regain some degree of mental
and physical control over their situation. Imagery is a
second form of relaxation and distraction that can help
patients relieve some anxiety and improve their body
image. Desensitization provides another means for patients
to overcome their anxiety through gradual exposure to
fearful or anxiety provoking thoughts, images and actual
stimuli while practicing relaxation. The combination helps
patients master their fears and also learn about relaxation.
Cognitive restructuring is another technique to assist anx­
ious patients by working with them on their thought
patterns. During therapy, patients describe and analyze
their cognitions to see if they are realistic. This evaluation
helps patients gain insight into their thought patterns and
10 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
teaches them how to rework their thoughts into a healthier
and more helpful schema. Finally, pharmacotherapy can be
helpful for patients who are too anxious to even begin these
or other exercises and can facilitate sleep and concentra­
tion66.
The anxiety that patients can experience is very real
and very critical in their adjustment to disfiguring and
dysfunctional surgeries. If anxiety persists it can contribute
to prolonged social isolation, phobic reactions and depres­
sion76. It is a relatively easy disorder to treat, and patients
experience significant relief when treated effectively. For
longer term adjustment, support groups may supplement or
serve as a viable alternative to individual therapy, provid­
ing emotional and environmental support information, so­
cial affiliation and mutual aid96.
Dementia and Delirium
Disorders due to brain dysfunction may occur postop-
eratively in head and neck cancer patients66. Two common
syndromes presenting postoperatively are delirium and
alcohol-related disorders. In addition, one may see demen­
tia, paranoia, and other severe personality changes. De­
mentia is characterized by the presence of multiple cogni­
tive deficits (e.g., aphasia), including memory impairment,
that may be caused by the physiological effects from a
general medical condition (e.g., head trauma, Alzheimer’s),
effects from a substance (e.g., alcohol), or a combination of
factors. Delirium is a form of encephalopathy, which may
be due to any one of a combination of factors, such as
systemic infections, metabolic disorders (e.g., hypoxia),
postoperative states, head trauma, and medications (e.g.,
analgesics and tranquilizers)32.
In dementia and delirium, alterations in brain function
affect several areas. Cognitive deficits can involve changes
in “relationship to reality, memory, intellectual capacity,
judgment, perception, level of consciousness, attention,
comprehension, capacity for abstract thought, ability to
synthesize, use of language, and capacity for self-evalua-
tion”. Behavioral disturbances can emerge which manifest
themselves as “impaired motor control, lack of impulse
control, and inability to control mood or feeling states.”
Mood and anxiety problems may lead to apathy, with­
drawal, poor cooperation with self-care, agitation, exces­
sive fatigue, weakness, subdued affect, and “disorganized
and uncontrolled emotional and motor discharge”89.
Because of the wide range of symptoms and behaviors
associated with dementia and delirium, it may be misdiag­
nosed by the physician. Using bedside testing, Adams
found that a high percentage of patients who were labeled
as depressed by their surgeon actually had substantial
neuropsychological deficits95. The syndromes vary both
across patients and within an individual over time; they
may coexist or present successively. The DSM IV32 pro­
vides examples that might well be found in a head and neck
cancer patient population; delirium superimposed on de­
mentia and thiamine-deficiency delirium (Wernicke’s
encephlopathy) followed by alcohol amnestic disorder
(Korsakoff’s syndrome)32. One basic distinction between
delirium and dementia is that dilirium primarily involves a
reduced ability to maintain and shift attention, and disorga­
nized thinking, accompanied by disturbances in perception,
sleep-wake cycle, psychomotor activity, orientation, and
memory function. Whereas dementia essentially features
short- and long-term memory impairment, accompanied by
disturbances in abstract thinking, judgement, or other
higher cortical functioning, and personality change32. In
dementia, the patient is typically alert. A hallmark of
delirium is that symptoms tend to fluctuate in severity,
becoming more severe as the day progresses
(“sundowning”), while, in dementia, symptoms (e.g., cog­
nitive impairments) tend to be relatively stable and tend to
persist unchanged for more than a few months32.
It can be difficult to assess altered mental status
initially because head and neck cancer patients often have
their speech impaired at least temporarily. Important signs
that can be clues to neurological deficits include the
inability to produce sound by covering the tracheostomy,
the inability to recognize that they cannot be understood
when mouthing words without vocalization, and the inabil­
ity to cooperate in writing responses to questions66. A
mental status examination could be difficult to administer
effectively since it requires verbal responses. A more useful
screening device is the Bender Motor Gestalt Test, which
involves copying geometric figures92. Another rough form
of assessment involves having the patient draw a clock
indicating a specific time66. These both require cognitive
and motor abilities and are useful preliminary screening
devices to determine whether further testing is necessary.
Treatment for mental syndromes (e.g., dementia and
delirium) involves identifying a treatable etiology for the
problem. Head and neck surgery patients are especially
vulnerable to aspiration pneumonia and wound infections
which can lead to changes in mental status66. Physical signs
of alcohol withdrawal may be present. Preexisting cogni­
tive deficits can be aggravated by prolonged surgeries. Low
dose antipsychotic medication therapy is helpful in manag­
ing agitation. However, it is most important to find the
cause of the changes in mental status and treat it directly89*92.
 Behavioral and Psychosocial Issues in Head and Neck Cancer
Conclusion
Cancers of the head and neck can be devastating in
their impact on physical structure and function of the
affected individual, leading to potentially severe compro­
mises in quality of life. Recent advances in treatment and
rehabilitation, particularly maxillofacial prosthetics, may
alleviate the sequelae of many disfiguring surgeries and
maintain good function. The major functional capacities
affected are eating, swallowing and speaking. Body image
is impacted significantly by surgical procedures and cos­
metic repair.
The 2 principal life-style behaviors that are etiologi-
cally linked to squamous cell carcinomas of the upper
aerodigestive tract are tobacco and alcohol use. Since these
are strongly addictive behaviors, they may be difficult to
treat. However, high quit rates for smoking have been
reported in this patient population. Physicians and dentists
should intervene when patients are receptive to discussion
of definitive treatments and participation in strategies for
optimal recovery. A similar approach can be taken to
alcohol abuse, perhaps relying more heavily on community
resources and ongoing treatment programs.
Psychological distress can be manifested in a variety
of mental disorders, primarily depression and anxiety.
Mental syndromes (e.g., dementia and delirium) may occur
postoperatively and require careful screening and treat­
ment. Acute or longer term therapy, with pharmacologic
intervention may be appropriate for the mood disorders.
Psychotherapeutic support can range from individual to
family-centered to community based groups. Such formal
and informal social support can be critical to the compre­
hensive rehabilitation of the head and neck cancer patient.
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Chapter 2
The Dental Clinician and
the Head and Neck Cancer Patient
Psychodynamic Interactions
B.R. Ross
A prosthodontist’s office is the setting. One patient is
consistently abusive and hostile towards the clinician and
staff, who dread this patient’s appointments. Another pa­
tient is cooperative, but weepy and melancholic—the staff
is bewildered. A third patient is superficially pleasant, but
demanding and manipulative. A fourth does not follow the
recommended oral hygiene program; her neglect is not due
to lack of understanding. Two questions arise: Why do
these patients behave as they do? and How can the prosth­
odontist and his staff appropriately respond?
These examples illustrate the human element in health
care and, in particular,, problems commonly seen with
patients with functional deficits or cosmetic deformity
secondary to the treatment of head and neck tumors.
Specific, concrete services are offered by the clinician as
part of a total program of comprehensive care for the
patient, but often this goal is not achieved. Consider for a
moment 2 patients. One has a well-fitting prosthesis and
yet becomes a social isolate. The other, in an apparently
apathetic mood, refuses prosthodontic services that could
be beneficial. Neither patient represents an outcome in
which the members of the health care team may honestly
take pride.
Cancer is a potentially life-threatening disease with
both physical and psychological components. Both compo­
nents require careful assessment and intervention if the
patient’s recovery is to be maximized. To overlook the bio-
behavioral interactions involved with this disease is to
provide less than optimal management for the patient. A
key point to remember is that the patient is a person in a
social support system.* The treatment program cannot
deny or ignore the influence of this support system if
comprehensive service is to be delivered.
* The social support system refers to that group of people in the patient’s milieu who interact with him or her in a significant
relationship. They may or may not be relatives of the patient.
To answer the 2 questions posed earlier—why do
patients behave as they do and how can healthcare profes­
sionals respond appropriately—this chapter examines the
psychosocial experiences of the head and neck cancer
patient. The impact of cancer on the patient, on the
patient’s social support system, and on the oncology team
members will be explored.
Crisis Sets for the Head and Neck Cancer
Patient
In our society, the patient with head and neck cancer
may be confronted with 3 sets of crises. The first set is
generated because he is ill. The second set of crises
develops because the specific illness is cancer. The third
group of crises are related to the deformity associated with
the necessary therapeutic measures—surgery, radiation
therapy, or chemotherapy.
Illness
Any person confronted by an illness may undergo a
transformation simply because he is ill; he adapts to the
sick role. Illness may provide a person with a socially
approved, justifiable reason to abdicate his usual adult
responsibilities—work, household management, and so
forth—and to accept having his dependency needs met. He
may be pampered by tender, loving care. These are second­
ary gratifications or indirect by-products of illness, which
may be enjoyable experiences for the patient. Because he is
ill, efforts are made (1) to keep him as physically and
emotionally comfortable as possible and (2) to overlook or
excuse irascibility on his part. In fact, he may become so
16 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
comfortable in this egocentric position that he uncon­
sciously engages in manipulative behavior in order to make
the most of his illness. His caretakers also adapt to the
patient’s new role and may obtain gratification from being
in a position of dominance or control in relation to the
patient.
On the other hand, some people may become ex­
tremely anxious in the sick role because they have great
difficulty in accepting their need to be dependent and
nurtured. The experience may be viewed by such patients
as weakness and, therefore, as anathema. Such an indi­
vidual will have greater difficulty in accepting medical
recommendations that limit usual activities and he or she
may offer greater resistance to recognition and acceptance
of the illness. Such a patient, especially one with milder
symptoms, presents a greater challenge for both the social
support system and the medical team.
In addition to secondary gratifications, role reversals,
and inability to accept illness, the patient may have to
surrender certain rights and privileges in adjusting to the
structure of medical care. Shontz suggests that the sick role
requires passivity, dependence upon medical authority, and
submission to treatment regimens*.
Cancer as the Illness
Fear of Death and Dying
We cannot perceive our own mortality. The most
fundamental crisis for a cancer patient is the realization of
mortality and the possibility of imminent death. For many
people, cancer is synonymous with death. Fear of death and
of dying, along with other common psychological re­
sponses such as anxiety, frustration, rage, denial, and
depression, may continue throughout the course of treat­
ment with varying degrees of intensity (see Chapter 1).
These responses may often disrupt the plan for physical
management. Hollingsworth and Pasnau write of the fear of
death as: “The understandable apprehension that one day
we shall cease to be, and although we must all die, we do
not fear death to the same degree or in the same way. In the
phenomenon of death, man, with all his cleverness, is
powerless. He may postpone death, he may relieve its
physical pains, he may rationalize away or deny its very
existence, but he cannot escape it”2.
In a group of patients who correctly anticipated their
deaths, Weisman and Hackett describe the fear of death and
the fear of dying as 2 distinct experiences3. The fear of
death is identified as a specific attitude toward the process
of dying and is not related to the fact of death. The fear of
death pertains to a sense of imminent disintegration, col­
lapse, or dissolution. Thus, it is more closely related to
primary anxiety or panic than to the transfiguration brought
about by actual death. Few human beings are free of the
fear of dying, but they dread the impairment of illness far
more than they fear death. Weisman and Hackett believe
that the fear of dying is evidently a necessary condition to
the fact of living and that it emerges whenever life is
threatened3.
The treatment of cancer and its associated physical
traumas can exacerbate the patient’s death-fear panic. Cure
or containment of disease may demand drastic measures.
Rather than helping the patient feel better and providing
objective evidence that his or her health is improving,
treatment may produce aversive side effects, such as pain,
nausea, weakness, inability to masticate, alopecia, nasal
regurgitation, facial disfigurement, and so forth. These
sequelae help to create an atmosphere of impending doom.
Fear of Stigma and Ostracism
A second potential crisis for cancer patients may arise
from the stigma attached to this disease. The social support
system may withdraw from physical contact with the
patient. Samuelson and Samuelson suggest that this group
may fear the possibility, of becoming infected themselves
because they are exposed to the disease4. They may be
reluctant to touch the patient, his or her personal belong­
ings, or even the dishes, towels, and other things the patient
may have used. One patient related in a UCLA group
meeting that after the departure of guests from her home,
she found homemade cookies in the wastebaskets. The
guests had accepted the cookies but apparently could not
eat them. Cancer patients may be ostracized by subtle and
more obvious means and may feel that they are social
outcasts5.
Fear of Abandonment
Related to both the stigma of cancer and to the death-
dying fear, a nonetheless separate phenomenon can be the
patient’s fear of abandonment. The patient may entertain
the fantasy of dying alone. Consequently, the patient may
attempt to mask the intensity of his or her fear and anger to
avoid the alienation of familial and professional caretakers.
The prospect of death means a permanent separation from
everything and everyone the patient knows. The patient
fears that people may withdraw from him, and this fear
may become a reality.
Individual members of the social support system may
find it increasingly difficult to interact with the patient as
deterioration progresses, to stifle their anger towards the
inevitable separation and to overcome a flood of guilt for
acts they should or should not have committed. Orcutt
 The Dental Clinician and the Head and Neck Cancer Patient: Psychodynamic Interactions
describes the readjustment process for the family of a dying
patient as an additional burden that can cause an “emo­
tional overload”6. The situation may be especially difficult
when interpersonal conflict and poor communication exist
between the patient and the family. Arndt and Gruber
describe accepting and adjusting to death as a family
problem7. The family’s attitude toward death influences the
patient’s, and their behavior may ease or increase the
patient’s anguish as they experience anticipatory grief.
Concurrently, the treatment staff may be coping with
their feelings of impotence, inadequacy, and helplessness.
Lasagna suggests that the behavior of the doctor toward the
seriously ill patient is inevitably affected by the physician’s
own biases and prejudices about the patient and the dis­
ease8. Finesinger describe how the physician is so affected
by the cancer patient’s distress that he tends to avoid the
patient, while still providing medical care9. They noted that
such avoidance compounds the patient’s distress and is
often interpreted as a rejection.
John Conley, head and neck surgeon of world renown,
believes that head and neck cancer is a very special
problem for the clinician10. His remarks describe aptly the
doctor’s dilemma of helplessness, and may apply to any
member of the treatment and rehabilitation team:
“H e’s asked to attack a disease that will kill, and his
method of attack is...mutilative. Imagine the emotional
involvement of a sensitive surgeon. Unlike cancer of the
stomach or cancer of the lung, his work is constantly on
exhibition and he’s frustrated. His patients not only die,
they get recurrent cancers. H e’s failing, the patient’s com­
ing apart, the family is after him, the community is after
him, and on the whole he is literally running away from the
patient because he can’t absorb the gigantic deluge of
emotional feeling which is coming from his lack of suc­
cess. This is why I think many surgeons like to be busy;
they want only 2 minutes for the patient who’s dying so
that they can go to the next patient. This is a built-in
emotional ego phenomenon which I think the surgeon
should try to analyze. Perhaps we are so mired down, not so
much by lack of technical efficiency as by emotional
involvement with failure, of mutilation or potential mutila­
tion.”
From the previous quote, it can easily be seen why the
patient’s fear of abandonment may become a reality.
Fear of Punishment
A fourth experience for the cancer patient may be the
conviction that his disease is punishment for past or present
behaviors, real or imagined, which warrant atonement.
Guilt may be associated with these transgressions, and the
patient may feel that he or she can survive the disease by
17
making appropriate or substitute reparations. One group,
participating in a study of the emotional problems of the
cancer patient, observed that feelings of inferiority and
worthlessness accompanied the guilt-punishment theme11.
Patients involved in this study described these reactions
with unexpected ease. The basic feeling seems to have
been, “It is my fault that I have cancer; I must have done
something wrong.” Their reaction likened cancer to vene­
real diseases; it was foul and they were ashamed to have it
and to talk about it. This guilt-stricken group of patients
especially dreaded rejection.
Lederer12 and Cobb13 are among the authors who have
explored the relationship between illness and feelings of
guilt by the patient. Lederer writes of a continuing folk
tradition existing in some areas. Its premise is that illness is
the just dessert of the sinner. People who hold this belief
feel guilty when they are ill; they may even feel compelled
to malinger health because illness is equated with immoral­
ity. Cobb’s study produced a group of cancer patients who
believed that the specific and personal threat of cancer was
punishment for their sins.
Anxiety, Inferiority, and Chronicity
The emotional equilibrium of the cancer patient may
be grossly disturbed when confronted with the diagnosis.
The patient can be overwhelmed by severe anxiety, depres­
sion and denial (see Chapter 1). He may need a significant
length of time to absorb and integrate this reality, despite
previous symptoms and suspicions.
Cancer may be equated by the patient with chronic
debility, the loss of general functions, the loss of self-
determination or self-control. The patient may perceive
himself as becoming a helpless, hopeless and worthless
burden. The possibility of recurrence means that he or she
will be labeled as a cancer patient “for life”. Cobb suggests
that with a cancer diagnosis, the patient can experience an
almost intolerable state of “biological defenselessness”13.
She adds that since medical science has no simple physi­
ological explanation for cancer, there can be no firm
assurance of recovery. Thus, the patient may come face to
face with a threat that is congruent with his individualized
perception of the meaning of cancer.
Maxillofacial Cancer:
Factors in the Adjustment Process
Physical trauma, Body Image, and Self Esteem
The head and neck cancer patient, while sharing
similar fears and anxieties, remains uniquely distinct
within the total population of cancer patients, as the
18 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
medical interventions currently in use (surgery, radio­
therapy, chemotherapy) may result in significant functional
disability and facial disfigurement.
The person who suffers from functional impairment or
disfigurement, not only suffers the inconvenience of a loss
in performance, but also a psychological loss4. As others
pity and devalue him, he devalues himself. If he feels
repulsive to others, he will likely become repulsive to
himself and, as a result, social relationships may be dis­
rupted. Some patients with physical and psychological
losses may never reach the point of fully accepting them
and may equate personal loss with personal worth.
Patients who undergo mastectomy, colostomy or ileo­
stomy provide prime examples of patients undergoing
physical and psychological losses. They also serve as
models for bio-behavioral interdependence. Mastectomy
patients endure a painful exercise program to prevent
muscular atrophy and edema-induced limb immobilization.
The ostomy patients have to cope daily with an altered set
of behaviors, such as bagging, irrigations, and stoma care,
related to the elimination of waste. In addition to gross
mutilation, both groups of patients face emotional adjust­
ments concerning their deformity, sexual relationships,
self-image and identity.
Facial Disfigurement
Without minimizing the magnitude of difficulties for
mastectomy and ileostomy patients, they in one sense have
a very real advantage over head and neck cancer patients.
Disfigurement secondary to mastectomy or ileostomy is
concealed and protected by their clothing; this is not true
for the head and neck cancer patient, whose mutilation is
easily visible. It is therefore easy to perceive why body
image can be so profoundly affected by head and neck
cancer (see Chapter 1).
The significance of the face in the development of
personality and identity and in social interactions has been
studied extensively by MacGregor14-15. They suggest that
psychosocial factors are of foremost importance in creating
and augmenting the problems of facially deformed
people14. A society’s attitudes toward physical appearance
help identify what constitutes a facial deformity and help
determine the extent to which such a disfigured individual
is or is not accepted by the group. Anyone who looks
different is set apart by the group because it is often
assumed that he is different. This assumption leads to his
being treated as different, and in this context “different” all
too frequently means inferior.
The facially deformed person tends to see himself as
defined by others. He is likely to feel more or less isolated.
He discovers that he is seen as a social inferior and
assigned marginal status, minority status, or both. Opportu­
nities available to non-disfigured people are denied to him.
Social participation, employment, prestige, interpersonal
relationships, personality framework, and a host of cultural
activities may be affected. To summarize MacGregor: “In
such familiar and trite expressions as ‘the face is the mirror
of your soul,’ ‘your face is your future,’ and ‘his face is an
open book,’ social significance is exemplified, becoming
even more meaningful when the face happens to be a
misfortune”15.
Several authors (MacGregor, Kiibler-Ross, Samuelson
and Samuelson, and Shontz) have noted that American
culture seems preoccupied with youth and physical perfec­
tion14’15-16. It may not be too surprising, therefore, that some
facially disfigured cancer patients, who find themselves
unable to cope with such rejection, do become social
isolates. Wearing a hat, scarf, and coat with the collar
turned up in an effort to hide as much of the deformity as
possible, one patient ventures out once a week in the wee
hours of the morning to buy groceries at an all-night
market. This is the only outing for the patient, who lives
alone, other than for leaving home to keep medical appoint­
ments.
Individual Differences in Patient Response
The diagnosis of cancer is one critical point for the
patient; another is the reality of treatment and its sequellae.
Regardless of how carefully the patient and the social
support system have been prepared for the morbidities of
therapy, the reality is always a shock 13. The emotional
support needed in the early post-treatment days is great.
MacGregor suggests that whether the disfigurement is
minor or severe, each patient uses his or her characteristic
pattern in adapting to the deformity and to his social
support system’s response to it. It is the unique quality of
personality structure that explains the variations in attitudes
and responses from one patient to another.
The background of 2 patients illustrates how indi­
vidual difference influences adjustment to facial deformity.
Both of these patients underwent orbital exenteration and
maxillectomy. One had exceptional difficulties in the ad­
justment process following the operation, whereas the
other exhibited little difficulty. Background history indi­
cated that from childhood and through early adulthood, the
first patient had received marked reinforcement based on
physical attractiveness and had worked professionally as a
live and photographic model. The second patient, on the
other hand, had been facially disfigured earlier in life due
to an accident and seemingly had resolved any internal
feelings about appearing significantly different from pre­
vailing physical standards. Thus, the mutilation of surgery
 The Dental Clinician and the Head and Neck Cancer Patient: Psychodynamic Interactions
was a greater calamity for the first patient, who was more
accustomed to being admired and who personally placed
greater importance on physical appearance. The socializa­
tion process, the mechanism by which the values and
expectations of a group are transmitted to an individual
member, helps to explain the difference in these patients’
responses.
Extent and Location of Defect
It may seem logical that maxillofacial cancer patients
with expansive defects experience greater emotional agita­
tion than do patients with smaller defects. However, this is
not always true. Often patients whose disfigurements are
relatively slight may have greater expectations for their
appearance. Therefore, they may be more disappointed,
since their conscious and unconscious hopes are unrealisti-
cally high. Patients with larger defects may be more easily
pleased to have a prosthesis which gives them a semblance
of normalcy. Patients whose defects are not centrally
positioned on the face, however, tend to have less traumatic
adjustment problems. The loss of an ear, for example, may
be less noticeable because of its lateral location and
because it may be covered by the patient’s hair.
The extent and location of the patient’s defect in some
cases is such that it is extremely difficult to create a well
sitting, effective prosthesis. This difficulty is not a reflec­
tion of the clinician’s skill; it is simply reality. Functional
disabilities for these patients may remain undiminished.
Age and Sex
It does not appear that age alone is of major impor­
tance in a patient’s readjustment and rehabilitation process.
It is true that often older patients may be less concerned
with their appearance than younger ones. However, our
experience suggests that another variable may be more
influential than age: the patient’s perception of the impor­
tance of physical appearance and physical admiration. In
terms of sex differentiation, female patients do not neces­
sarily have more difficulties in adjusting than do male
patients. Vanity is not a variable linked only to women. The
variable, regardless of sex, remains the patient’s evaluation
of the importance of physical appeal and attractiveness in
combination with the degree to which his employment
demands public contact.
Functional Disabilities
In addition to facial deformity, the patient treated for
head and neck tumors may endure functional deficiencies
that affect social interaction. Examples o f such problems in
physical function follow.
19
1. Inability to control saliva
2. Inability to make lip closure
3. Inarticulate speech
4. Uncontrollable nasal leakage of fluids
5. Compromised swallowing
6. Mandibular deviation
7. Inefficient mastication
8. Xerostomia
Depending on the degree of dysfunction, patients
demonstrate a variety of response patterns. Some refuse to
engage in social activities beyond their social support
system. Others withdraw from the social support system
and refuse to take their meals in the presence of anyone.
Depression may be a factor in the patient’s self-imposed
isolation.
Depression
The crisis of illness in general and of cancer in
particular contribute to a head and neck cancer patient’s
depression (see Chapter 1). Considering their combination
of functional problems and facial disfigurement, it is not
surprising that selected patients say, “If I had known it
would be like this, I never would have agreed to the
operation.” At that moment, the patient’s statement is an
accurate appraisal of his current feelings. In light of the
accompanying disabilities, the patient is unable at that time
to appreciate the prospect of continued life. Attempts to
argue against these expressed feelings or to give positive
assurances may only serve to convince the patient that the
listener, who is facially whole and without these functional
handicaps, simply does not understand.
The Social Support System
The patient’s social support system changes in reaction
to the patient and to his or her illness. Cancer presents a
problem that needs to be handled by the entire social
support system. Some of the crises experienced by mem­
bers of the support group are the same or similar to those
experienced by the patient. Family members, for example,
may experience depression, anger, anxiety and fear that the
patient may die. Reorganization is necessary for the family
as a social unit17.
Olson suggests that all families are subject at times to
events that throw them rapidly into disequilibrium. Serious
illness can be one such event. Preexisting rules and roles
may be insufficient to maintain sensible organization when
a family member suddenly is removed from the home, is in
danger of dying, is unable to function in his usual capacity,
or makes new demands on the family. Olson believes that
20 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Fig. 2-1. The Cancer Concerns Circle: Some of the overlapping psychosocial concerns and fears of the head and neck cancer
patient. The surrounding units would vary in size, being either larger or smaller, and in representing the intensity of an
individual patient’s reaction in that particular area.

the results of the crises and the necessary reorganization
may be even more functionally and emotionally disruptive
for other family members than for the patient.
A vicious circle may result and further complicate
interpersonal relationships for the patient in the social
support system. Individuals in the system may feel resent­
ment towards the patient since the changes are caused by
his illness. Yet they feel guilty for feeling resentment and
are resentful of feeling guilty.
The Response of the Prosthodontist
General Response
Thus far, this chapter has identified and examined
some of the variables that may operate in a patient’s
psychosocial reaction to head and neck cancer and in the
response of his social support system. These variables are
not discrete components and may overlap (Figure 2-1).
The patient goes to the prosthodontist for rehabilitation
services and for restoration of facial integrity and func­
tional losses. The material in this section discusses some
of the factors which may influence the clinician’s re­
sponse to his patient.
Psychological Influences
Cobb observes that the emotional impact on the physi­
cian is tremendous when a program for cure or control of
cancer causes disfigurement13. Conley’s statement offers a
striking illustration of a psychological by-product for the
head and neck surgeon10. If it is a valid premise that head
and neck cancer and its treatment programs create stresses
for the physician as well as for the patient and the social
support system, this principle applies also to the prosth­
odontist, whose responsibility it is to mitigate the cosmetic
and functional disabilities.
It is suggested that the physician, depending upon his
or her personality and coping mechanisms, may experience
some psychological discomfort in creating the patient’s
handicap. What, then, may be the burden or emotional
overload for the prosthodontist, who is expected to perform
the impossible—to remove the handicap by replacing in
artificial form what has been surgically removed? Substi­
tute prostheses do not function as well as the original
structure of bone and soft tissue. The clinician in this
subspecialty, with a modicum of sensitivity, may face the
difficult adaptation task of adjusting emotionally to death,
disfigurement, and patient demands for the impossible.
 The Dental Clinician and the Head and Neck Cancer Patient: Psychodynamic Interactions
Disruptive Influences
The potential for emotional reactions from the staff
providing patient services and the possibility of communi­
cation problems between staff and patients are reasons why
teamwork is especially important in cancer care. Too
frequently, the medical “team” managing the patient is
more of an ideal abstraction than a working reality.
Healey describes the patient’s experience with the
medical team as being more like a series of discrete
individuals, with quite different and sometimes conflicting
concerns, than a connected group of professionals cooper­
ating in a coordinated effort to improve his or her welfare10.
Perhaps this criticism is true; however, it is worthwhile to
remember that, like the patient, the “team” are people.
Professional people have feelings and, to better address
patient concerns, there may need to be a provision for the
release of the emotions that are held properly in check by
the professional in certain work-related situations.
Positive Influences
Clinical social workers are among the allied health
professionals with a valuable contribution to offer the
cancer care team. They have specialized skills and training
for the management of stress and conflict. Early identifica­
tion and elimination of distress points can prevent the
disruption of the physical management program.
Clinical social workers are available not only in public
and private hospitals but also in private practice (usually
state-licensed) to provide psychosocial interventions on 2
levels: (1) direct service to patients and social support
systems and (2) consultation service to health care profes­
sionals in their interactions with their patients. Whereas
many patient-family groups experience fewer hurdles in
adapting to the psychological and social trauma of cancer
and its sequelae, they still need assessment by a social
worker, even when they are “doing all right.” First of all, if
masking (concealment of emotional distress) is operative,
it may not be recognized by a health care professional
whose expertise lies in another specialty or discipline. The
social worker is professionally qualified to differentiate the
extent of psychological disease. Second, although the pa­
tient may be “doing well” at a given time, this fact does not
preclude the possibility that later difficulties may develop
in the course of the disease and treatment procedures. If
initial contact has been established between the patient and
a psychosocial support agent, it is easier to manage prob­
lems as they arise. Even with “only minor” maladjustment
problems, the worker can offer:
21
1. An outlet for ventilations that the patient feels he
cannot or should not express within his social
support system.
2. An outlet for members of the social support
system regarding those feelings that they may be
keeping from the patient and that become a stum­
bling block.
3. An outlet for the dental clinician, or any other
health team member, who may have interactional
difficulties with the patient or the social system
members in providing physical management ser­
vices.
The Patient’s Death
A cancer patient’s illness has 2 possible outcomes:
either the patient survives physically (emotionally well or
not) or he dies. Many theorists have expounded the psycho­
logical component of care for the terminal patient and his
social support system, among them Kubler-Ross18 and
Shneidman19. Regardless of the theoretical orientation to­
wards the phenomena of dying, death, and bereavement,
the underlying theme seems to be that psychological care is
also necessary during this period. It follows that the
responsibility of the oncology treatment team does not end
because the prognosis is poor. The contribution of an
analytical, psychosocial support agent at this point for the
patient, his social system, and the oncology team can be
crucial.
Specific Response
It seems appropriate to offer some simple and perhaps
obvious suggestions which might be useful to the dental
clinician in relation to his practice with cancer patients.
1. Recognize the existence of the emotional compo­
nent of illness for the head and neck cancer patient
and for the health care professional. Also, the
patient’s resistance to following the recommended
treatment programs may be caused by psychologi­
cal barriers.
2. Make an effort to listen to what the patient does
and does not say. Do not assume that no difficul­
ties exist because the patient offers none.
3. Establish a routine office practice of referring the
patient to a clinical social worker or other quali­
fied therapeutic agent for psychosocial evaluation
and treatment, and consultation services as
needed. Talk to the worker personally in making
the referral.
22 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Closing Comment
The subject matter in this chapter may present a
difficult challenge for dental clinicians. The profession of
dentistry, in general and in sub-specialties, prepares its
practitioners to provide very specific physical services. Yet
physical management is only 1 component of a dual
responsibility in all health care services. The other compo­
nent, the psychological one, involves theoretical constructs
used to explain observable behavior. No one can see or
touch an ego, a defense mechanism, or a personality
structure, but these constructs influence human interac­
tions, especially during crises such as illness. Colloquially,
they “come with the territory” of health care services, and
they cannot be ignored. If health care professionals sub­
scribe to the premise that the treatment goal is to maximize
the patient’s function, bio-behavioral interdependence fol­
lows as a necessary corollary. Recognition of this relation­
ship may aid in making comprehensive dental health care a
reality rather than an abstract ideal. The problem patients
mentioned in the opening paragraph of this chapter will not
disappear, but they may receive a better quality of service.
Patient Resources
birth defects, injuries or disease who may apply for finan­
cial assistance for non-medical costs. Support is offered on
the basis of financial and medical need for such expenses as
travel, lodging and food when traveling to a craniofacial
center for reconstructive surgery.
FACES
Box 11802
Chattanooga, TN 37401
(615) 266-1632
Let’s Face It
The United States branch of an international organiza­
tion dedicated to helping people with facial difference, their
loved ones, the professionals who care for them, and the
communities in which they live, to understand and to solve
the problems of living with this disability. It is an indepen­
dent, non-profit support network. '
Let’s Face It
P. O. Box 711
Concord, MA 01742-0711
(508) 371-3186

A number of resources are available that may help Cleft Palate Foundation
your patients through their most difficult time. They in­
clude support organizations, as well as books and articles A non-profit support network for cleft lip and palate
devoted to this very specific subject. patients, parents and family.

Organizations
Cleft Palate Foundation
AboutFace 1218 Grandview Avenue
Pittsburgh, PA 15211
An international information and support organization (412) 481-1376
for people with facial difference and for their families.
Includes a bimonthly newsletter, parent support training, Books
books, videos and a lending library. AboutFace has 40
chapters in North America. Face Value
This book about coping with facial disfigurement is by
U. S. Office: Canadian Office: Linda R. Shafritz. An excellent book providing valuable
AboutFace AboutFace insight and advice to patients and their families about
P. O. Box 737 99 Crown’s Lane coping with facial deformity. Available by writing to:
Warrington, PA 18976 Toronto M5R
3P4 Face Value
800-225-FACE 800-655-FACE P. O. Box 45854
Los Angeles, CA 90045
Faces

Faces is a part of the National Association for the

Craniofacially Handicapped. It is a nonprofit organization
for people with craniofacial deformities resulting from
 The Dental Clinician and the H ead and N eck Cancer Patient: Psychodynamic Interactions 23

Let’s Face It 11 Finesinger J, Shands H, Abrams R: Managing the emotional

This book, by Christine Piff, describes the experience problems of the cancer patient. In: Clinical Problems in
of a patient who underwent a maxillectomy and orbital Cancer Research. New York, 1952; Sloan-Kettering Cancer
exenteration. Available by writing to: Center.
12 Lederer H: How the Sick View Their World. In: Patients,
Let’s Face It Physicians, and Illness. Jaco E, ed. Glencoe, 1958; The Free
P. O. Box 711 Press.
Concord, M A 01742-0711 13 Cobb A: Medical and Psychological Problems in the Reha­
bilitation of the Cancer Patient. In: Counseling and Rehabili­
Autobiography o f a Face tating the Cancer Patient. Hardy R, Cull J, eds. Springfield,
A n autobiography by Lucy Grealy describing the emo­ 111., 1975; Charles C. Thomas.
tional and physical pain caused by resection o f a mandibu­ 14 MacGregor F, et. al.: Facial Deformities and Plastic Surgery,
lar neoplasm and the subsequent attempts at reconstruction. Springfield, 111., 1953; Charles C. Thomas.
Available through: 15 MacGregor F: Transformation and Identity. New York, 1974;
Quadrangle/New York Times Book Co.
Houghton Mifflen 16 Kubler-Ross E: Death: The Final Stage of Growth, Englewood
215 Park Avenue South Cliff, 1975; Prentice-Hall, Inc.
New York, N Y 10003 17 Olson E: The Impact of Serious Illness on the Family
System. Postgrad Med. 47:169;1970.
References 18 Kubler-Ross, E: On Death and Dying, New York, 1969;
Macmillan Co.
1 Shontz F: The Psychological Aspects of Physical Illness and 19 Shneidman E: Deaths of Man. New York, 1973; Quadrangle/
Disability. New York, 1975; Macmillan Publishing Co., Inc. New York Times Book Co.
2 Hollingsworth C, Pasnau R: Death Following Terminal
Illness. In: The Family in Mourning: A Guide for Health
Professionals. Hollingsworth C, Pasnau R, eds. New York,
1977; Greene and Stratton, Inc.
3 Weisman A, Hackett, T.P. 1976. Predilection to Death. In:
Death and Identity, Rev. Ed. Fulton R, ed. Bowie, 1976;
Charles’ Press Publishers, Inc.
4 Samuelson K, Samuelson C: Rehabilitation and Cancer. In:
Counseling and Rehabilitating the Cancer Patient. Hardy R,
Cull J, eds. Springfield, HI., 1975; Charles C. Thomas.
5 Shafirtz L: Face Value. Los Angeles, 1994; Linda R. Shafritz
(self-published).
6 Orcutt B.A. 1977. Stress in Family Interaction When a
Member is Dying: A Special Case for Family Interviews. In:
Social Work with the Dying Patient and the Family. Prichard
E, et. al., eds. New York, 1977; Columbia University Press.
7 Arndt H, Gruber M: Helping Families Cope with Acute and
Anticipatory Grief. In: Social Work with the Dying Patient
and the Family. Prichard E, et. al., eds. New York, 1977;
Columbia University Press.
8 Lasgna L: Physicians’ Behavior Toward the Dying Patient.
In: The Dying Patient. Brim O, Freeman H, Levine S, Scotch
N, eds. New York, 1970; Russell Sage Foundation.
9 Finesinger J, Shands H, Abrams R: Managing the Emotional
Problems of the Cancer Patient. In: Clinical Problems in
Cancer Research. New York, 1952; Sloan Kettering Institute.
10 Healey J Jr: Ecology of the Cancer Patient. Washington,
D.C., 1970; Interdisciplinary Communications Associates,
Inc.
Chapter 3
Cancer Chemotherapy
Oral Manifestations, Complications, and Management
Perry R. Klokkevold
An estimated 1.2 million Americans will be diagnosed
with malignant cancers this year, and the incidence contin­
ues to rise1. The medical management of a majority of these
malignancies will involve surgical excision, alone or in con­
junction with other forms of therapy. Anti-neoplastic thera­
pies that may be employed when surgery is not indicated nor
desired include radiation, chemotherapy and bone marrow
transplantation. Radiation and chemotherapy may be admin­
istered independently or in combination depending on the
pathology, location and severity of the lesion. Bone marrow
transplantation is a treatment modality that utilizes an ag­
gressive combination of chemotherapy and total body irra­
diation. Although initially developed to treat malignancies
of the hematopoietic system as a last resort, bone marrow
transplantation has recently been used with success to treat
non-hematopoietic neoplasias.
Surgery and radiation remain the primary modes of treat­
ment for most tumors. Surgical resection of a tumor has the
advantage of physically removing the bulk of malignant tis­
sue, while radiation has the advantage of localizing morbid­
ity to the specific area of the body. Both modalities have
adverse effects on normal tissues, such as cellular changes
and reduced vascularity, but the morbidity is usually limited
to the tumor area.
Cancer Chemotherapy
Although chemotherapeutic treatments are unable to
match the success of surgery and/or radiation, these agents
are being used more and more for palliative care, for prolon­
gation of life and, in some cases, with a curative intent. Che­
motherapy is a key factor responsible for the increased long­
term survival of patients with acute lymphocytic leukemia,
Burkitt’s lymphoma, choriocarcinoma, Hodgkin’s disease,
Wilm’s tumor and others. Approximately 50% of all cancer
patients are treated with chemotherapeutic agents during
some phase of their cancer therapy2’3-4.
Oral complications occur in nearly half of the patients
receiving chemotherapy for non-head and neck cancers and
in most patients treated for head and neck malignancies5.
Those patients with oral complications often have multiple
episodes corresponding with multiple courses of chemo­
therapy. Some chemotherapy-induced oral changes are as­
ymptomatic and may not be considered complications. Thus,
the incidence of reported oral “complications” may not be
representative of the number of oral “changes” that occur
for each patient with each course of chemotherapy.
When compared to resective surgery and radiation
therapy, the adverse effects of cancer chemotherapy are ini­
tially less noticeable to healthcare providers due primarily
to their internal location and to their relatively non-deform­
ing nature. Nonetheless, complaints of oral or pharyngeal
problems manifested by chemotherapy agents often become
the primary concern for a patient in the midst of therapy.
Oral manifestations of cancer chemotherapeutics include mu­
cositis, xerostomia, bleeding and infections. Some of these
effects are the result of direct toxicity to the tissues of the
oral cavity while others result indirectly from toxicity to dis­
tant tissues. An understanding of the effects of the chemo­
therapeutic agents being used enables the dentist to follow
the course of treatment and to anticipate potential oral com­
plications.
26 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTTC CONSIDERATIONS
Chemotherapeutic Effectiveness
The effectiveness of chemotherapy agents is based on
their ability to non-specifically destroy or slow the growth
of rapidly dividing tumor cells. Unfortunately, normal cells
are also vulnerable and subject to the destructive effects of
these agents. Chemotherapeutic agents are unable to distin­
guish normal dividing cells from malignant dividing cells.
The normal cells most adversely affected by chemothera­
peutic agents are those found in bone marrow and those lin­
ing the oral cavity and gastrointestinal tract. These tissues
have high proliferation rates, making them more susceptible
to.the damaging effects of chemotherapy than quiescent tis­
sues. Bone marrow contains a multitude of stem cells that
are constantly differentiating and multiplying to replenish
circulating hematopoietic cells and to continue the stem cell
line. The epithelial basal cells lining both the oral cavity and
the gastrointestinal tract have a high cell division rate in or­
der to replace old and damaged lining tissues. The oral mu­
cosa is particularly vulnerable to breakdown because it is
constantly subjected to traumatic injuries such as those caused
by mastication, brushing, and chemical and thermal stimuli.
In addition, the oral cavity hosts a milieu of microorganisms
with the potential for infection and delayed healing, making
it a major site of chemotherapeutic toxicity.
Adjuvant chemotherapeutics has not become the pana­
cea that some thought it might become. There are several
theories that have attempted to explain this lack of success:
kinetic resistance, tumor cell dormancy, biochemical hetero­
geneity, and pharmacogenetic variability. The cell kill hy­
pothesis is perhaps the best known and most discussed theoiy.
Simply stated, chemotherapy fails to eradicate the last of the
neoplastic cells because they are either intrinsically resis­
tant or become resistant to the cytotoxic drug being used.
Cell kinetics partially explains this limited effectiveness.
Patients with widespread cancer may harbor as many as 1012
cancer cells. If a drug is capable of killing 99.0% of these
cells, it would reduce the number of cancer cells only by the
3rd order of magnitude (i.e. from 1012to 109 cells). Accord­
ingly, chemotherapy is administered at the maximum toler­
ated dose (MTD) to achieve the highest degree of fractional
cell kill of the sensitive tumor cells.
The theory of tumor cell dormancy supports the cell kill
hypothesis. Large tumors are more likely to have a greater
number of cells in G0 phase and therefore are thought to be
more resistant to cytotoxic drugs. Cellular and/or biochemi­
cal variation within the tumor may explain resistance of some
cells to chemotherapy. The pharmacogenetic variability takes
into account the dynamics necessary for drugs to interact
with and to cross cell membranes at proper concentrations
and helps explain why chemotherapeutic dosages must be
adjusted individually. Cytotoxic agents must achieve a mini­
mal concentration over a minimum period of time to be ef­
fective.
The Goldie-Coldman hypothesis is a newer concept that
is receiving attention. This hypothesis is based on the con­
cept that chemotherapy fails to eradicate all tumor cells be­
cause drug resistant neoplastic cells arise from mutations,
and thus drug resistance can be inherited and propagated6.
The Goldie-Coldman hypothesis is highly analogous to the
effectiveness and/or failure of antibiotics with infections. Like
bacteria, tumor cells with high mutation rates will have a
greater possibility of mutating towards increased resistance.
The implication is that tumors with both a high mutation
rate and a large number of tumor cells will have the prob­
ability of producing at least 1 resistant cell. The Goldie-
Coldman hypothesis supports the idea that chemotherapy
should be started as soon as possible in order to impact upon
neoplastic cells before they have mutated.
The truth is probably an amalgamation of all these con­
cepts. Unfortunately, curative chemotherapeutics likely will
never be that hoped for panacea. The major limiting factor
for any chemotherapy regimen is its adverse effects on nor­
mal cells. Toxicity to normal tissues as well as limitations in
chemotherapy effectiveness led to the use of chemothera­
peutic agents in combination. Agents with different activity
profiles are combined in therapy to increase their anti-neo­
plastic effectiveness. Regretfully, many chemotherapeutic
agents share similar toxicities, thus complicating the use of
drug combinations.
Bone Marrow Transplantation
Bone marrow transplantation is a procedure that effec­
tively utilizes multiple chemotherapeutic agents in combi­
nation with total body irradiation. The basic concept of bone
marrow transplantation is rather simple. Destruction of ma­
lignant cells is accomplished without regard for marrow tox­
icity. Normal donor, autogenous or allogeneic marrow is in­
travenously transfused into the bone marrow suppressed pa­
tient, and marrow function is restored following subsequent
engraftment. The aim of treatment is to achieve a maximum
anti-cancer effect without the limitations imposed by mar­
row toxicity. In short, the transplantation replaces marrow
destroyed by the therapy used to destroy malignant cells.
The complications of the bone marrow transplantation
procedure are generally more severe than for other forms of
chemotherapy. The epithelial lining of the oral cavity and
the gastrointestinal tract suffer the greatest consequences of
combination chemotherapeutic cytotoxicity. Oral complica­
tions include but are not limited to mucositis, xerostomia,
bleeding and secondary infections. Although avoiding mar­
row toxicity, bone marrow transplantation carries significant
 Cancer Chemotherapy: Oral Manifestations, Complications, and Management 27

risks not shared by chemotherapy alone. The process risks

fatal infection during a period of total immunosuppression,
pending marrow engraftment, yet improves the ability of
therapy to achieve elimination of the cancer.
Patients receiving allogeneic bone marrow transplants
have the added complication risk of graft versus host dis­
ease (GVHD). Graft versus host disease occurs when the
donor tissue (marrow with donor immunologic memory) re­
jects the recipient (host antigenic) tissues and mounts an in­
flammatory response. A graft versus host reaction can mani­
fest in any tissue or organ but often occurs intraorally. Acute
GVHD occurs within the first 100 days after transplantation
and manifests intraorally as mucosal desquamation, erythema
and ulceration. The tongue is often the first and most sensi­
tive intraoral site to be affected. Later, chronic GVHD ap­
pears intraorally in a variety of forms. The most common
manifestation is denudation of mucosa with a glossy erythema
with associated white areas (Figure 3-1 and Figure 3-2). Pa­
tients suffering from GVHD may be placed on additional
chemotherapy or anti-inflammatory agents to suppress the
process.
b
Cancer Chemotherapy Agents
Fig. 3-1. Chronic graft versus host disease manifesting on
Anti-neoplastic agents can be divided into those that are oral mucosa following bone marrow transplantation, a: Note
cell cycle specific and those that are cell cycle non-specific. palatal lesions, b: Manifestation of graft versus host disease
The cell cycle specific drugs are useful primarily in tumors on tongue in same patient. Glossitis and denudation of tongue
which demonstrate rapid growth, such as certain leukemias epithelium results in glossy erythema, loss of papilla on tongue,
and lymphomas. They often act competitively with impor­ with some areas of leukoplakia. (Courtesy: Sol Silverman, Jr.)'
tant naturally occurring biomolecules. Examples of drugs that
preferentially effect rapidly proliferating cell populations in­
clude 6-mercaptopurine, 5-fluorouracil, vincristine, vinblas­
tine and bleomycin. The cell cycle non-specific drugs typi­
cally act by complexing the DNA and usually do so regard­
less of whether the cell is dividing. Examples include cyclo­
phosphamide, doxorubicin and dactinomycin.
A more empirical method of grouping anti-neoplastic
drugs is to categorize them as alkylating agents, antimetabo­
lites, antitumor antibiotics, plant alkaloids, hormones and
miscellaneous agents. A brief description of these categories
and specific chemotherapy agents within each category will
be discussed with respect to mode of action, indications and
toxicities (Table 3-1). The stomatotoxic effects of specific Fig. 3-2. Chronic graft versus host disease response of buc­
agents will be mentioned when applicable (Table 3-2). cal mucosa in patient undergoing maintenance chemotherapy
following bone marrow transplantation.
Alkylating Agents

Alkylating agents (busulfan, cyclophosphamide) are the

nitrogen analogs of the well known vesicant war gas, mus­ act by transferring an alkyl group to biologically important
tard gas. They are called alkylating agents because they are cell constituents such as amino, carboxyl, sulfhydryl or phos­
capable of reacting with or alkylating a number of chemical phate groups whose function becomes impaired. Studies have
groupings, many of which are vital to cell functions. They suggested that these reactions cross-link bases in the DNA,
28 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Table 3-1. Specific action of chemotherapeutic agents.

Cell Cycle Specific Mode of Action

Alkylating Agents
Busulfan Non-specific Impairs function of biologically important cell constituents.
Cyclophosphamide Non-specific Impairs function of biologically important cell constituents.
Inhibits DNA synthesis.

Antimetabolites
Methotrexate S-phase specific Inhibits dihydrofolate reductase; Inhibits a variety of biochemical reactions.
5-Fluorouracil S-phase specific Inhibits pyrimidine synthesis; Inhibits DNA synthesis.
6-Mercaptopurine S-phase specific Inhibits purine synthesis; Inhibits DNA synthesis.

Antitumor Antibiotics
Bleomycin G2-phase specific Inhibits DNA repair.
Doxorubicin Non-specific Inhibits DNA-dependent RNA synthesis and DNA-dependent DNA synthesis.
Dactinomycin Non-specific Inhibits DNA-dependent RNA synthesis.

Plant Alkaloids
Vincristine M-phase specific Arrests mitosis; Inhibits RNA synthesis
Vinblastine M-phase specific Arrests mitosis; Inhibits RNA synthesis

Hormones
Androgens Not cytotoxic Androgenic.
Estrogens Not cytotoxic Estrogenic.
Adrenocorticosteroids Not cytotoxic Inhibition of lymphoid proliferation.

Miscellaneous
Cisplatin Non-specific Inhibits DNA synthesis
Hydroxyurea S-phase specific Inhibits DNA synthesis

probably guanine, thus inhibiting replication. Alkylating
agents also inhibit glycolysis, protein synthesis, and impair
a number of cell membrane functions.
The alkylating agents have been used successfully in
the treatment of Hodgkin’s disease, Burkitt’s lymphoma,
chronic myelocytic leukemia and other similar neoplasms.
This group has not been employed successfully in the treat­
ment of solid tumors of the head and neck region. The major
toxicides of alkylating agents include leukopenia, thromb­
ocytopenia, anorexia, and diarrhea. Complications that may
affect the oral cavity are bleeding and secondary infections.
Occasionally, alkylating agents will cause the oral mucous
membranes to desquamate.
Antimetabolites
The antimetabolites are organic substances that inter­
fere with the function of essential metabolites through com­
petition with the latter during a biochemical process. The 3
major groupings of antimetabolites are anti-folic acid com­
pounds, anti-purines and anti-pyrimidines. These drugs act
by interfering with the synthesis of nucleic acids which are
essential in the formation of DNA and RNA. Antimetabo­
lites are typically cell cycle specific due to their interference
with nucleic acid synthesis.
Folic acid is required in the de novo synthesis of pu­
rines, conversion of uracil to thymidine and for a number of
other cellular biochemical reactions. Methotrexate is the most
widely utilized and well known of the folic acid antagonists.
Its principle effect is to bind and inhibit the activity of the
enzyme, dihydrofolate reductase, that catalyzes the conver­
sion of folic acid to tetrahydrofolic acid. Tetrahydrofolic acid,
a key precursor in the synthesis of the purines and pyrim­
idines, is required for nucleic acid synthesis. Dihydrofolate
reductase combines more readily with methotrexate than with
folic acid and its intermediaries. As a result, synthesis of
purines, pyrimidines and ultimately DNA and RNA is inhib­
ited.
Clinically, the major role of methotrexate has been in
the treatment of acute lymphoblastic leukemia in children. It
 Cancer Chemotherapy: Oral Manifestations, Complications, and Management 29

Table 3-2. Chemotherapeutic agents with adverse effects on oral cavity and gastrointestinal tract.

severe/frequent = (+++); moderate/common - (++); mild/occasional - (+); mild/rare = (+/-); insignificant/never = (-]

Mucositis Xerostomia Thrombocytopenia Leukopenia Nausea/Vomit Diarrhea

Alkylating Agents
Busulfan +/- +/- ++ ++ - -
Cyclophosphamide ++ m +/- ++ ++ ++

Antimetabolites
Methotrexate +++ +/- ++ ++ - +++
5-Fluorouracil ++ +/- ++ ++ ++ ++
6-Mercaptopurine + +/- + ++ + +/-

Antitum or Antibiotics
Bleomycin +++ +/- - - ++ -
Doxorubicin ++ +/- + ++ ++ ++
Dactinomycin ++ +/- ++ ++ ++ ++

Plant A lkaloids
Vincristine +/- + A + - -
Vinblastine +/- + +/- ++ ++ +

Hormones
Androgens - - - - - -
Estrogens - - - - +/- -
Prednisone - - - - - -

Miscellaneous
Cisplatin +/- ++ ++ +++
Hydroxyurea +/- ++ +++

has also been useful for introducing long term remissions
and sometimes cures for choriocarcinoma. Methotrexate has
been used in the treatment of breast carcinoma, bronchogenic
carcinoma, non-Hodgkin’s lymphoma, osteogenic sarcoma,
squamous cell carcinoma of the head and neck, and testicu­
lar carcinoma. The most frequent manifestations of methotr­
exate toxicity include bone marrow depression, extensive oral
ulcerations, diarrhea, and skin rash. The incidence and se­
verity of oral mucositis induced by methotrexate is higher
than that observed with other stomatotoxic agents7. Severe
stomatitis can become a cause for interruption of methotrex­
ate therapy.
Five-fluorouracil (5-FU) is the principal pyrimidine an­
tagonist and is the anti-metabolite that enjoys the greatest
popularity in the treatment o f solid tumors. Its usefulness is
enhanced by the fact that uracil is utilized to a higher degree
by tumor cells than by normal cells. Five-fluorouracil alters
cell function by its effect on DNA and RNA synthesis. The
products of the fluorinated pyrimidines inhibit the activity
of thymidylate synthetase, an enzyme active in the produc­
tion of a DNA precursor thymadylic acid. Five-fluorouracil
has been used successfully to eradicate superficial basal cell
and squamous cell carcinomas of the skin when applied topi­
cally. Some clinicians have employed it to remove hyperk-
eratotic lesions in the oral cavity. It is also indicated in the
treatment of colorectal carcinoma, gastric adenocarcinoma
and pancreatic adenocarcinoma. Five-fluorouracil toxicity
includes thrombocytopenia, leukopenia, anemia, oral as well
as gastrointestinal ulcerations and diarrhea. Leukopenia oc­
curs within 7-14 days after the initial dose.
Six-mercaptopurine (6-MP) is the prototype for the pu­
rine antagonists. Its primary action involves its conversion
into 6-methylmercaptopurine, which is a potent inhibitor of
de novo purine biosynthesis. It has been used in the treat­
ment of acute myelogenous leukemia, acute lymphoblastic
leukemia, and chronic myelogenous leukemia. Its principal
use has been in the treatment of acute leukemia in children.
The major toxic side effect is bone marrow depression in­
cluding thrombocytopenia, leukopenia and anemia. Oral ul­
cerations are only seen occasionally.
30 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
Antitumor Antibiotics
The mechanism of action, indications for use and toxic­
ity profiles of antitumor antibiotics differ for each agent.
Some of the more common drugs used as antineoplastic
agents in this group are bleomycin, dactinomycin and doxo­
rubicin.
Bleomycin is cell cycle specific. It consists of numer­
ous antibiotic peptides that inhibit both mitosis and DNA
synthesis. It inhibits DNA repair by marked inhibition of
DNA ligase. Bleomycin has been used for squamous cell
carcinomas of the head and neck, often in combination with
radiation therapy. It is also indicated in the treatment of
Hodgkin’s disease, non-Hodgkin’s lymphoma, testicular car­
cinoma and uterine cervix carcinoma. The principle side ef­
fects include pulmonary fibrosis, alopecia, hyperpigmenta­
tion, desquamation of hands and feet with hardening and ten­
derness of the fingertips, nausea, vomiting and stomatitis.
The oral ulcerations are quick to develop and can be quite
severe (Figure 3-3).
Fig. 3-3. Oral desquamations secondary to bleomycin can
be quick to develop and severe.
Both dactinomycin and doxorubicin are cell cycle non­
specific and inhibit DNA-dependent RNA synthesis by in­
tercalating between DNA base pairs. They are indicated and
useful in the treatment of Ewing’s sarcoma, osteogenic sar­
coma, rhabdomyosarcoma and Wilm’s tumor. Doxorubicin
enjoys a wider spectrum of indications, including acute leu­
kemia, bladder carcinoma, breast carcinoma, Hodgkin’s dis­
ease, non-Hodgkin’s lymphoma, soft tissue sarcomas and thy­
ro id carcinom a. T he g astro in testin al side effects of
dactinomycin and doxorubicin include anorexia, nausea,
vomiting (usually within hours of administration), diarrhea,
stomatitis, glossitis, chelitis and proctitis. Bone marrow de­
pression results in thrombocytopenia and leukopenia within
7 days of therapy. Alopecia, erythema, desquamation and
hyperpigmentation may also be noted after administration.
In addition to these adverse effects, doxorubicin turns urine
red (not hematuria) and may cause diffuse cardiomyopathy
with congestive heart failure. Cardiomyopathy becomes the
dose limiting factor in the utilization of doxorubicin.
Plant Alkaloids
Vincristine and vinblastine, the 2 plant alkaloids, are
derivatives of the periwinkle plant (Vinca rosea). These drugs
interfere with the formation of the microtubules of the mi­
totic spindle during metaphase, thereby arresting cell divi­
sion. These plant alkaloids are used in the treatment of
Hodgkin’s disease, breast carcinoma, non-Hodgkin’s lym­
phoma and acute lymphocytic leukemia. The principal side
effects include alopecia, peripheral neuritis, muscle weak­
ness and mild to moderate bone marrow depression. The
oral mucous membranes are rarely affected directly by the
plant alkaloids.
Vinblastine is a cell cycle specific agent. It arrests mito­
sis by binding the cytoplasmic precursors of the spindle. It
also inhibits RNA synthesis by binding DNA-dependent RNA
polymerase. Vinblastine is indicated in the treatment of breast
carcinoma, choriocarcinoma, Hodgkin’s lymphoma, non-
Hodgkin’s lymphoma and testicular carcinoma. Gastrointes­
tinal toxicities include nausea, vomiting, abdominal pain and
diarrhea. Leukopenia occurs in 5-10 days but recover occurs
after 7-14 days. Thrombocytopenia is uncommon. Vincris­
tine has the same action as vinblastine. The indications for
use and the drug toxicities are also similar. However, vinc­
ristine therapy is associated with severe jaw pain, loss of
deep tendon reflexes, ataxia and muscle wasting. The sever­
ity of these latter effects will determine dose limitations of
vincristine therapy.
Hormones
Sex hormones (androgens, estrogens, etc.) and adreno-
corticosteroids have been used extensively in the treatment
of neoplastic disease, especially in those tumors derived from
normal tissues sensitive to hormonal influences. Mammary
and prostate gland tumors tend to retain the properties of the
original tissue and may be inhibited or stimulated by changes
in sex hormonal balance. The adrenocorticosteroids have also
been used in the treatment of acute leukemia, lymphomas
and myelomas. These steroids produce lysis of lymphocytes
and particularly compromise delayed hypersensitivity. Prin­
ciple side effects of hormonal chemotherapeutic agents in­
clude fluid retention, masculinization or feminization, and
hypertension. There is a minimal amount of cytotoxicity of
normal tissues and the oral mucous membranes are rarely
affected by hormone therapy.
 Cancer Chemotherapy: Oral Manifestations, Complications, and Management 31

Miscellaneous Agents
Cisplatin is a cell cycle non-specific agent that inhibits
DNA synthesis. Cisplatin cross-links complementary strands
of DNA with a preference to binding guanine. It has been
used in the treatment of bladder, head and neck, lung, ova­
rian, testicular and uterine cervix carcinoma(s). Renal insuf­
ficiency is the dose limiting toxicity of cisplatin. Damage to
renal function is cumulative and must be recovered before
continuing with treatment. Other toxic effects include nau­
sea and vomiting (often severe), pancytopenia and periph­
eral neuropathy. Cisplatin may cause ototoxicity (cumula­
tive) and occasionally anaphylactic type reactions. The oral
mucosa is not affected by cisplatin chemotherapy.
Hydroxyurea is cell cycle specific. It inhibits the func­
tion of ribonucleotide reductase, an enzyme required in the
synthesis of DNA. Hydroxyurea has been widely used in the
treatment of chronic myelogenous leukemia. It has also been
used to treat carcinoma of the head and neck and ovarian
carcinoma. Major toxicities include leukopenia, thrombocy­
topenia and anemia. Leukopenia induced by hydroxyurea
becomes the dose limiting factor in its administration. Occa­
sionally hydroxyurea will cause impairment of renal tubular
function. Stomatitis is rare.
Oral Manifestations and Complications
As a result of chemotherapeutic treatment, approxi­
mately 400,000 cancer patients will develop oral manifesta­
tions. Adverse effects may be acute or chronic in nature5.
The oral manifestations of chemotherapy result directly from
tissue necrosis and desquamation, indirectly from a decreased
number and function of platelets and neutrophils, and may
be exacerbated by preexisting conditions unrelated to can­
cer, such as periodontal disease, tooth decay and defective
restorations. Direct oral complications of cancer chemo­
therapy are usually dose dependent and present as mucosi­
tis, xerostomia and pain with corresponding neurologic symp­
toms. Indirect oral complications that may present in the
chemotherapy patient are bleeding, infection and nutritional
deficiency.
Oral Mucositis
Sonis found that 39% of patients receiving chemotherapy
developed oral complications2. The most prevalent compli­
cation in this study was oral mucositis. Oral mucous mem­
brane changes, such as discoloration, desquamation, and ul­
ceration are most often seen in drug protocols involving the
antimetabolites and the alkylating agents8-9. Antibiotics, such
as bleomycin, have a particularly adverse effect on squa­
mous epithelium and may cause serious mucosal ulceration.
The antimetabolite, methotrexate, is associated with severe
mucositis710. The severity of methotrexate mucositis was
thought to be related to its excretion in the saliva. However,
in a study of salivary concentrations, methotrexate levels did
not correlate with the degree of oral mucositis10.
Lockhart and Sonis found thinning and atrophy of the
epithelium and marked degeneration of collagen in a histo­
logic study of oral changes induced by chemotherapy in hu­
mans". Chemotherapy irreversibly destroys or damages the
rapidly dividing basal cells of the oral epithelium. Damage
and destruction of basal cells results in an inability to main­
tain continuity of the oral mucosa. Desquamation and ulcer­
ation result when the damaged cells migrate toward the mu­
cosal surface. This process, initially seen as leukoplakia of
the oral mucosa, progresses over a 2-week period to erythema,
ulceration and denudation (Figure 3-4). Mucosal surfaces
become sore and sticky. Oral hygiene compliance diminishes.
Subsequently, the denuded surface collects debris and be­
comes vulnerable to secondary infections. Overgrowth of
microorganisms around breaks in the mucosa prolongs heal­

a
Fig. 3-4. a and b: Chemotherapy induced mucositis seen as generalized ulceration. Sloughing of thickened oral epithelium
without compensatory renewal by basal cell division results in thinning and erythema of oral mucosa. Subsequent desquamation
and ulceration result when the damaged basal cells migrate toward mucosal surface unable to maintain tissue integrity. Ulcer­
ated mucosal surfaces become sore and sticky with greatly diminished capacity for oral hygiene. Denuded surface collects
debris, invites microbial invasion and prolongs healing. (Courtesy: Sol Silverman, Jr.)
32 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
ing and invites microbial invasion that potentially leads to
severe systemic infections. Lockhart found that oral compli­
cations correlated with the rise and fall of peripheral blood
cell counts12. They found that healing of oral ulcerations in
the chemotherapy patient corresponds with the rise in white
blood cells. Likewise, healing in the bone marrow transplant
patient usually follows engraftment, with a concomitant rise
in white blood cells13.
Several grading systems have been developed by indi­
viduals and organizations to score the level of oral mucosi­
tis14-1^ . Some have multiple gradations while others simply
have 3 or 4 grades. Schubert suggests that an ideal mucositis
grading system should rate subjective complaints (pain, taste,
dryness), functional performance (speech, chewing and swal­
lowing) and objective changes (edema, atrophy, pseudomem­
brane, ulceration)16. He and his colleagues developed and
tested the Oral Mucositis Rating Scale (OMRS), which at­
tempts to consider, in detail, changes in the oral mucosa dur­
ing therapy, along with subjective complaints and functional
performance. None of the systems seem to have been adopted
universally. The more detailed scoring systems appeal to re­
searchers, while the simpler, less cumbersome scoring sys­
tems tend to be more applicable for clinicians.
Xerostomia
Dry mouth is thought to be caused by the effects of che­
motherapy on major and minor salivary glands. Lockhart and
Sonis found that minor salivary glands degenerated in 50%
of the patients examined histologically11. If degeneration oc­
curs to the same extent in major salivary glands, it would
explain the xerostomia seen clinically. Chemotherapy in­
duced xerostomia tends to be much less severe and usually
more transient than radiation induced xerostomia. (See Chap­
ter 4 for a discussion on radiation induced xerostomia.)
Xerostomia increases the pain and discomfort associ­
ated with oral mucositis. The soft tissues of the tongue, floor
of the mouth, palate, buccal mucosa and oropharynx cling to
one another, the teeth and any prosthetic appliances. Xeros­
tomia contributes to oral pain caused by chemotherapy in­
duced neuralgia. Neurologic side effects present as pain and
paresthesia in the head and neck region and are most com­
monly seen with the administration of the plant alkaloids. In
addition to the loss of lubrication for comfort, xerostomia
causes a decrease in the amount of IgA secreted in saliva17.
Decreased salivary flow results in diminished protective con­
stituents, limited natural cleansing, and alterations of the oral
environment which render the patient at increased risk of
secondary infections.
The effects of chemotherapy on the oral mucous mem­
branes and salivary glands, and the induced pain contribute
significantly to the patient’s outlook on and tolerance of treat­
ment. Oral mucositis, pharyngitis and/or esophagitis are pain­
ful, often rendering the patient dysphagic. Severejnucositis,
xerostomia and pain render the patient unable or unwilling
to verbally communicate, perform oral hygiene or to con­
sume food. As a result, patients regress and become more
vulnerable to the indirect effects of cancer chemotherapy such
as bleeding, infection and nutritional deficiencies.
Oral Hemorrhage
The frequency and severity of hemorrhage is directly
related to the degree of thrombocytopenia. Thrombocytope­
nia results from inadequate and insufficient production of
megakaryocytes and can be manifested by a disease, such as
acute leukemia, aplastic anemia and idiopathic thrombocy­
topenic purpura, or associated with anti-neoplastic chemo­
therapy.
A quantitative diagnosis of thrombocytopenia is based
upon the concentration of circulating platelets. Normal plate­
let counts range from 150,000 to 400,000 platelets per cubic
millimeter. Thrombocytopenia, with platelet levels below
60.000 platelets per cubic millimeter, put the patient at in­
creased risk of bleeding. At 25,000 platelets per cubic milli­
meter or below, there is a 75% chance of spontaneous or
induced severe, possibly uncontrollable hemorrhage. The risk
drops to 41% at a level of 25,000 to 60,000, and 16% above
60.000 platelets per cubic millimeter18. Therefore, accurate
monitoring of platelet levels is critical prior to the initiation
of any potentially traumatic procedure. The need to gain con­
trol of a spontaneous hemorrhage may necessitate platelet
transfusion when the patient is thrombocytopenic.
The clinical signs of hemorrhage include petechiae, ec-
chymosis and bleeding. Petechiae are characterized by pin­
point red spots on the tissue that are 1-3 mm in size (Figure
3-5). Damage to cells lining small vessels in the submucosa
allow erythrocytes to escape into the connective tissues. Ec-
chymosis is more diffuse and results from submucosal bleed­
ing and microvascular incompetence (Figure 3-6). Bleeding
persists when the integrity of the small vessels is more se­
verely damaged and platelets are inadequate to maintain he­
mostasis. Petechiae and/or ecchymosis seen intraorally in
patients should be used as an indicator of potential bleeding
problems (Figure 3-7). Hemorrhage most often occurs from
areas of traumatic injury or ulceration. The trauma can be
physical (toothbrush injury), chemical (strong mouth rinses),
thermal (hot food or drink) or microbial (endogenous or ex­
ogenous in origin). Ulcerations may be visible breaks in the
oral mucosa or microscopic breaks in the sulcular epithe­
lium.
Spontaneous intraoral bleeding is most common from
the gingival crevice. The increased vulnerability stems from
the fact that the epithelium in the sulcus is only a few cell
 Cancer Chemotherapy: Oral Manifestations, Complications, and Management
Fig. 3-5. Petechiae are characterized by pinpoint red spots
on tissue. Petechiae are most evident on the soft palate, as
seen in this patient undergoing chemotherapy.
Fig. 3-6. Ecchymosis is more diffuse than petechiae and
results from submucosal bleeding and microvascular incom­
petence. Ecchymosis is commonly seen on the soft palate in
thrombocytopenic patients.
Fig. 3-7. This patient bled continuously through gingival sul­
cus while thrombocytopenic. Bleeding persists when integrity of
small vessels is more severely damaged and platelets are
inadequate to maintain hemostasis. (Courtesy: Sol Silverman, Jr.)
33
layers thick. When inflamed, as in gingivitis or periodontal
disease, the sulcular epithelium thins and has many micro­
scopic ulcerations. Gingivitis and periodontitis increase the
risk for gingival bleeding due to the weakened sulcular bar­
rier caused by inflammation. Sulcular microulcerations be­
come points of spontaneous bleeding in the thrombocytopenic
patient. The sulcular epithelium may also be more suscep­
tible to chemotherapy induced ulceration than the oral epi­
thelium because the former is thinner and has a slightly higher
mitotic rate. This may also explain the increased incidence
of bleeding from the gingival sulcus.
Infection
Infection is the most common and potentially the most
serious complication in chemotherapy patients with bone
marrow suppression. Chemotherapy induced immunosup­
pression renders the patient susceptible to infection by mi­
croorganisms that would normally be controlled. By defini­
tion, leukocytes are reduced, rendering the host unable to
resist colonization, invasion and infection by opportunistic
microorganisms.
Profound immunosuppression places the patient at ex­
treme risk of infectious complications. Three factors con­
tribute to the high incidence of and increased host suscepti­
bility to infection in the immunosuppressed patient. They
are the impaired host defenses, the indiscriminate use of broad
spectrum antibiotics19, and the presence of opportunistic oral
microbes. Impaired host defenses may be manifested by dis­
ruption of an intact integument, alteration of cellular immu­
nity, inhibition of the maintenance of proper titers of pre­
cipitating and hemagglutinadng antibodies, and the lack of
normal gamma globulin.
As previously mentioned, many chemotherapeutic
agents cause mucositis as a direct side effect, with ulcer­
ations that become portals of entry for microorganisms into
the underlying connective tissues. Ultimately, microorgan­
isms gain access to the systemic vasculature in hosts with
compromised cellular and humoral immunity. Continual bac­
terial seeding (bacteremias) leads to septicemias that are
potentially fatal in the compromised patient.
The oral mucositis ulcerations induced by chemotherapy
are not solely responsible for infections seen in compromised
patients; the immune response must also be compromised.
This is evidenced by the fact that normal patients with oral
ulcerations (traumatic, idiopathic or viral induced) do not
become infected like immunocompromised patients. The
potential for infection is very low at levels greater than or
equal to 1500 white blood cells per cubic millimeter18. Also,
a patient who responds to an infectious assault with increas­
ing granulocyte levels usually has a favorable prognosis with
respect to warding off the infection. Polymorphonuclear leu-
34 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

kocytes (neutrophils) make up 50 to 70% of the circulating The lesions are necrotic and enclosed by a reddened halo
white blood cells. These are the most numerous of all blood with a dry whitish-yellow center that turns purple to black.
cell types found in the acute phase of the inflammatory reac­ Ultimately, the necrotic core sloughs off to expose a bright
tion and the most important in preventing infection. Many red shiny bed of granulation tissue. These organisms are re­
chemotherapeutic agents interfere with the action and num­ sistant to most conventional antibiotics and are extremely
bers of neutrophils, thereby inhibiting phagocytosis19. difficult to treat, especially in the immunosuppressed patient.
Antineoplastic drugs lower patient immunity to infec­ The most common indigenous microorganisms seen in oral
tion by induction leukopenia, inhibiting antibody responses19, infections in these patients are the Bacteroides species. An­
blocking the mononuclear phase of the inflammatory reac­ other indigenous group of microorganisms, gram negative
tion and compromising delayed hypersensitivity20. Leuko­ enteric rods, can be particularly destructive in the
penia is defined as any situation in which the total number immunocompromised patient as they are capable of necrosing
of circulating granulocytes or polymorphonuclear leukocytes large areas of tissue (Figure 3-9) as well as causing osteo­
is less than normal. The normal granulocyte level varies with myelitis.
the individual, but generally falls within the range of 5,000
to 6,000 cells per cubic millimeter.
Adrenocorticosteroids and most of the cytotoxic drugs
adversely affect lymphocyte populations. Consequently, de­
layed hypersensitivity is impaired, thus increasing host sus­
ceptibility to intracellular parasites and further reducing host
resistance. These drugs also adversely affect macrophage
function and diapedesis of granulocytes.
In some cases, the primary disease process is also re­
sponsible for lowering host resistance. Acute leukemia pa­
tients undergoing chemotherapy are particularly susceptible
to frequent and severe infections. The propensity for infec­
tion is increased by the presence of immature, incompetent
myeloblasts. In some patients, lymphocyte function may also
be impaired, as are the number of circulating B and T lym­
phocytes.
There are many sources of microorganisms for oppor­ Fig. 3-8. Typical long-standing ulceration in patient under­
tunistic infections. The most common are the endogenous going intensive chemotherapy. Cultures revealed Escherichia
oral and skin microbial flora. Microorganisms that are nor­ coli.
mally kept in check by other microorganisms and the func­
tioning immune system become pathogenic when there are
changes in the microbial balance and a loss of immune func­
tion. The hospital environment is a source of potentially le­
thal exogenous microorganisms that may infect the
immunocompromised patient. These microorganisms often
have resistance to many antibiotics and can be extremely
challenging to manage.

Bacterial Infection

The most common exogenous microorganisms which

contribute to infections in these patients are the gram nega­
tive bacillary opportunistic aerobes21-22, Serratia, E. coli, En-
terobacteriaceae, Klebsiella, Pseudomonas aeruginosa, and
Proteus. Except for Pseudomonas, gram negative oral infec­
tions present clinically as creamy white, raised, nonpurulent
lesions, and form ulcerations on a reddened base (Figure 3- Fig. 3-9. Destruction of gingiva and mucosa from teeth and
8). Pseudomonas present with a classic bluish-red halo im­ alveolus in patient undergoing intensive chemotherapy. Op­
mediately surrounding the necrotic sections of the lesion23. portunistic enteric organism suspected.
 Cancer Chemotherapy: Oral Manifestations, Complications, and Management 35

Viral infection

Outbreaks of viral infections occur typically in patients

with previous exposures. Meyers reported an 82% incidence
of oral herpes simplex virus infections in seropositive (HSV
antibody titer) bone marrow transplantation patients24. Con­
tracting exogenous viral infections are less common. Her­
petic infections are particularly troublesome in patients un­
dergoing intensive chemotherapy. Herpes simplex virus is
the most common cause of oral ulceration in the bone mar­
row transplant patient population25. The oral and circumoral
lesions can be particularly widespread and quite symptom­
atic. Resolution of these lesions may require 5-6 weeks, de­
pending on host defense and medical management. Antibody
titers are usually only of academic interest. The circumoral Fig. 3-10. These crusty lesions were confined primarily to cir­
lesions present as circular crusty ulcerations which may form cumoral region. Cultures revealed herpes simplex virus.
large painful lesions when they coalesce (Figures 3-10). The
oral lesions are likewise quite painful and can be widespread,
although most are confined to the keratinized mucosa (Fig­
ure 3-11). Treatment is often palliative since viral lesions
tend to run their course regardless of therapeutic interven­
tion. In the immunocompromised patient, this course is typi­
cally longer than what occurs in the healthy host and may
persist until immune function has recovered.

Fungal Infection

Opportunistic fungal infections that afflict patients un­

dergoing chemotherapy include asperillosis, candidiasis,
cryptococcosis and mucormycosis. Candidiasis and mucor­
mycosis are seen most frequently; aspergillosis and
cryptococcosis are seen only occasionally.
Candidiasis is an opportunistic fungal infection most
commonly caused by Candida albicans. Since Candida spe­
cies are part of the indigenous oral flora in 40-60 percent of
the normal population, etiology is felt to be due to alterations Fig. 3*11. Lesions in this patient undergoing bone marrow
in floral balance as well as compromised inflammatory and transplantation are not confined to keratinized mucosa.
immune mechanisms.
Candidiasis infections are commonly found in the oral
cavity of the immunosuppressed patient. A Candida infec­
tion may present as pseudomembranous, erythematous (atro­
phic) or hyperplastic candidiasis. In pseudomembranous can­
didiasis, white creamy plaques (Figure 3-12) can be rubbed Although not a common finding, fungal infections in
off the mucosal surface. The plaques are foci of fungal or­ the severely immunosuppressed patient can invade tissues
ganisms. In erythematous candidiasis, there are few obvious (Figure 3-14). Systemic fungal infections are very difficult
fungal organisms, but there is diffuse redness of the oral mu­ to manage and potentially fatal in the immunosuppressed
cosa (Figure 3-13). Hyperplastic candidiasis is less common patient. Mucormycosis is a locally destructive infection with
and presents as tenacious white plaques on mucosal surfaces. an often fatal outcome (Figure 3-15). Those who survive usu­
Lesions in severely immunosuppressed patients can be quite ally suffer facial disfigurement secondary to local tissue loss
extensive, with all forms presenting at the same time. The (Figure 3-15). Most patients with mucormycosis suffer from
most common complaint from patients with oral candidiasis concomitant diabetes millitus and control of this fungal dis­
is a burning sensation. ease is dependent on controlling the diabetes.
36 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Fig. 3-12. a, b, and c: Typical white plaques of candidiasis on oral mucosa of immunosuppressed patient during chemotherapy.
White plaques could be rubbed off, exposing an erythematous base. (Courtesy: Sol Silverman, Jr.)

Fig. 3-13. Inflamed, erythematous mucosa of denture

bearing surfaces in patient undergoing chemotherapy in­ a
dicative of erythematous candidiasis. Although little evi­
dence of plaques are seen, culture revealed fungal or­
ganisms.

Fig. 3-14. Invading fungal infection in severely immuno­ Fig. 3-15. a and b: This patient, although cured of mu­
suppressed patient undergoing bone marrow transplan­ cormycosis, suffered severe facial deformity.
tation. Culture revealed Candida albicans.
 Cancer Chemotherapy: Oral Manifestations, Complications, and Management
Management of Oral Complications
Prevention and Treatment Prior to Chemotherapy
Diagnosis and treatment of oral conditions in the
prechemotherapy patient are oriented towards prevention.
The most important conditions to diagnose and treat are in­
fections or conditions that involve a potential to become in­
fected. A complete oral examination, including appropriate
radiographs, is essential, for any patient scheduled to receive
chemotherapy, in order to identify any condition that may
complicate therapy. Without a thorough examination, oral
problems can go unrecognized and may unnecessarily com­
plicate the clinical course of the disease and its therapy to
the point of being life threatening. Chronic dental infections
such as periodontitis and endodontic lesions are often as­
ymptomatic and not recognized by the patient. Thus, it is
important for the clinician to identify all potential sources of
infection and render treatment in order to prevent induced or
spontaneous oral complications during chemotherapy. Den­
tal treatment such as prophylaxis, dental restorations, root
canal therapy, surgical debridement or extraction may be
indicated. If sufficient time is available prior to the start of
chemotherapy, all identified problems should be treated de­
finitively to prevent exacerbation during chemotherapy.
Carious teeth should be treated by excavation and res­
toration. If the dental pulp is exposed during excavation, ap­
propriate endodontic care should be provided. Rough sur­
faces and sharp edges can become major sources of injury
and therefore must be smoothed and eliminated, whether on
teeth, restorations, or prostheses. During immunosuppres­
sive chemotherapy, the oral mucosa will become more vul­
nerable to ulceration and irritation.
Prosthetic appliances should be thoroughly examined
for proper fit, function and smoothness. Inadequacies and
defects in prostheses that the patient has previously adapted
to may become the source of problems during chemotherapy.
Complete and/or partial dentures should be adjusted, relined
if indicated, or new dentures should be fabricated. Dentures
that do not have appropriate vertical dimension, occlusion,
stability, fit and function should be removed to prevent trau­
matic ulcerations26. Following recovery between courses of
chemotherapy, adjustments, relines or new dentures can be
provided.
Teeth that are diagnosed with endodontic problems
should be definitively treated whenever possible. Non-vital
pulp chambers and/or canals that are non-vascularized “dead
spaces” can provide a nidus for infection. Teeth that are symp­
tomatic and periapically infected should be definitively
treated with root canal therapy. Some patients may present
with asymptomatic teeth that show signs of infection such
as abscess formation, fistula and/or purulent drainage. En­
37
dodontic treatment can and should be completed for these
patients, if time permits, prior to chemotherapy. If the infec­
tion cannot be resolved with endodontic therapy prior to che­
motherapy, extraction should be considered. An asymptom­
atic tooth with a radiographic lesion but no other signs of
infection should probably be treated endodontically. How­
ever, studies have not been reported that compare the risk of
treatment with no treatment. For those patients without ob­
vious signs of infection that cannot have endodontic therapy
prior to chemotherapy, the endodontic treatment can be com­
pleted between courses while the patient is minimally sup­
pressed. The appropriateness of root canal therapy versus
extraction in symptomatic patients requires further investi­
gation27.
For cases in which the patient will undergo total immu­
nosuppression, such as bone marrow transplantation, some
clinicians prefer extraction of pulpally involved teeth. The
premise for such a preference is that removal of the tooth
eliminates the potential source of infection while endodon­
tic therapy may fail to completely eliminate the infection.
This risk of endodontic failure is of greater concern in the
immunosuppressed patient because resistance to infection is
compromised. The decision to extract or treat endodontically
remains an empirical choice of the treating dentist and phy­
sician. Studies have not defined the risk of extraction versus
the risk of infection following endodontic therapy in the im­
munosuppressed patient.
Dental extractions should only be performed when re­
tention of the tooth or teeth carries the risk of systemic in­
fection. Extractions should be done at least 7 days prior to
the start of chemotherapy for proper organization of the
wound. Wounds should be closed primarily if possible. This
may require a slight alveolectomy and flap manipulation.
Teeth that should be considered for extraction include ab­
scessed teeth, severely periodontally involved teeth, partially
erupted wisdom teeth and grossly carious teeth. If time does
not permit extractions prior to chemotherapy, treatment can
be rendered between courses of chemotherapy, during peri­
ods of minimal suppression. The objective is to reduce the
potential of infection during periods of profound immuno­
suppression.
Periodontal disease should be controlled and potential
problem areas such as deep pockets should be treated ag­
gressively in order to decrease inflammation, improve gin­
gival health and minimize gingival bleeding and infection
during periods of thrombocytopenia and leukopenia28*29. The
gingival sulcus harbors millions of microorganisms that may,
given the opportunity, cause infection in the
immunocompromised patient.
A thorough oral prophylaxis and oral hygiene instruc­
tions should be provided for all patients scheduled to receive
cancer chemotherapy. Patients should be instructed to use a
38 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
soft or extra soft bristle toothbrush unless bleeding, pain or
infection becomes evident. Patients should be instructed not
to use dental floss unless they floss on a regular basis and
show excellent manual dexterity. Improper use of dental floss
can cause serious injury that leads to bleeding and/or infec­
tion. If tooth brushing begins to cause excessive bleeding,
pain or infection, patients should immediately discontinue
brushing with a bristle brush. An alternative hygiene aid,
such as a cotton swab, gauze pad or a Toothette* should be
instituted to avoid additional injury. The alternate oral hy­
giene aid should be soft, sterile and disposable. Oral hygiene
practices can be augmented with a mouth rinse to reduce
microbial colonization.
Over-the-counter mouth rinses have some beneficial ef­
fects when used for oral hygiene. However, most are alcohol
based and contribute to drying and irritation of mucous mem­
branes. Previous reports have advocated the use of hydro­
gen peroxide as an oral irrigant to reduce microbial
growth3031. However, it is now felt that the less desirable
drying effects of hydrogen peroxide outweigh its antimicro­
bial benefits32.
M outh rinses with antim icrobial agents, such as
chlorhexidine or betadine, can be used as adjuncts to oral
hygiene to effectively decrease oral microbes and lessen the
potential for infection. Peridex** contains 0.12%
chlorhexidine in an alcohol base which is very irritating to
ulcerated mucosa. For this reason, compliance with Peridex
mouth rinse in the patient with oral mucositis is reduced.
Peridex has been reported to decrease the incidence of oral
Table 3-3. Treatment risk assessments based on blood counts.
(In thousands) N o rm a l R ange L o w R is k
N e u tro p h ils 3-5 1.5+
P la te le ts 150-400 60+
O ral H yg ie n e Normal OH Normal OH
R e s to ra tio n s Normal Tx Normal Tx
E n d o d o n tic s Normal Tx Normal Tx
E x tra c tio n s Normal Tx Normal Tx
MD Consult
Antibiotics
* Toothettes, Halbrand, Inc. Willoughby, OH
* * Peridex, Procter and Gamble, Cincinnati, Ohio.
mucositis when used as a prophylactic rinse in patients un­
dergoing bone marrow transplantation33. Subsequent studies
have not substantiated these results. Although not currently
available in the United States, chlorhexidine has been for­
mulated in a non-alcohol base. This formulation is thought
to be less irritating to ulcerated mucosa and may improve
compliance.
Risk Assessment
Prior to rendering any of these dental treatments, the
patient’s medical condition and ability to tolerate the pro­
posed procedure(s) must be assessed in consultation with
the patient’s physician. The primary disease status and sec­
ondary medical conditions should be discussed, along with
their implications with respect to treatment. The basic quan­
tifiable risk assessment values are white blood cell and plate­
let counts. They provide a relative assessment for the risk of
developing infection or bleeding, respectively (Table 3-3).
Since polymorphonuclear leukocytes (neutrophils) provide
the primary cellular immune defense against invading mi­
croorganisms, the absolute neutrophil count (ANC) should
be used to assess the risk of developing infection and/or bleed­
ing. If the risk is excessively high, no treatment may be the
option of choice. Preventive management of the patient with
reduced immune capacity (low white blood cell count) may
include premedication with antibiotics or transfusion with
granulocytes. In patients with thrombocytopenia, preventive
management may include transfusion with platelets and/or
M o d e ra te R isk H ig h R is k
0.5-1.5 <0 .5
20-60 <20
Alternate OH Alternate OH
Modified Tx No Tx
Modified Tx No Tx
Modified Tx Emergency only
MD Consult MD Consult
Platelets Platelets
Antibiotics Antibiotics
 Cancer Chemotherapy: Oral Manifestations, Complications, and Management
admission to the hospital for observation and management
of anticipated bleeding.
Oral Mucositis
The pain and irritation of oral mucositis caused by can­
cer chemotherapy can only be managed palliatively. Numer­
ous remedies have been advocated for relief of pain. A mouth
wash of 50% kaopectate and 50% benadryl can provide oral
relief. However, the kaopectate may leave a chalky film that
is especially troublesome for patients with profound xeros­
tomia.
Symptoms of pain, from oral mucositis, is more often
relieved by analgesics. Non-narcotic or narcotic analgesics
can be administered by mouth or intravenously as needed
for alleviation of pain. Topical anesthetics may also be used
to alleviate the pain associated with oral mucositis. This is
especially useful prior to eating and performing oral hygiene.
Some patients find it comforting to keep their mouths cold
with ice. They can keep ice water and/or ice chips nearby for
frequent sipping and soothing. Water and ice should be puri­
fied to eliminate the risk of exogenous microorganisms. Re­
movable dental prostheses should be removed to reduce in­
jury, facilitate oral hygiene and improve comfort.
Oral dryness, ulceration and pain associated with oral
mucositis compromises oral hygiene which, in turn, leads to
accumulation of debris and microorganisms. Secondary bac­
terial, viral or fungal infections may develop and require an­
timicrobial therapy.
In severe cases of oral mucositis, chemotherapeutic dos­
ages may be reduced or discontinued. Difficulty and/or re­
fusal to consume nutrients orally may necessitate total
parenteral nutrition. Severe oral mucositis pain, especially
when infected with herpes simplex virus, may require a mor­
phine-type narcotic analgesic administered via a patient-con-
trolled administration (PCA) intravenous pump to control
pain.
Xerostomia
Xerostomia (oral dryness) may be a complaint of pa­
tients undergoing chemotherapy and is often a complaint of
patients undergoing radiation therapy. In the irradiated pa­
tient, xerostomia is often more permanent and the long-term
effects can be devastating to the dentition. One of the most
important functions of saliva is protecting the teeth. Acids
generated by bacteria are buffered by saliva and saliva aids
in remineralization of tooth structure. In the patient with long
term xerostomia, the use of fluoride to protect against dental
caries and demineralization is essential. Radiation patients
are instructed on the daily application of fluoride gel. How­
ever, fluoride application may not be necessary for the pa­
39
tient with short term xerostomia induced by chemotherapy.
If patients experience long term xerostomia following che­
motherapy, fluoride treatments should be initiated.
Fortunately, xerostomia is usually a mild, transient con­
dition for the chemotherapy patient. Thus, management of
xerostomia can be directed toward symptomatic relief. Pa­
tients can be advised to sip water frequently for the relief of
dry mouth. Saliva substitutes may provide longer periods of
relief from symptoms and require fewer applications. Saliva
stimulants such as chewing gum, sour candies or pharma­
ceuticals may also be useful. It is important to avoid using
products with sugar ingredients due to the increased suscep­
tibility to dental caries. Chewing gum and candies must be
sugarless. Pharmacologic saliva stimulants such as pilo­
carpine can stimulate viable salivary glands to increase pro­
duction of saliva and may be beneficial for some patients.
(See Chapter 4 for a detailed discussion on the management
of xerostomia and the application of fluorides and saliva sub­
stitutes.)
Oral Hemorrhage
Bleeding in the oral cavity results from thrombocytope­
nia. The occurrence of bleeding varies with the degree of
bone marrow depression. In the suppressed bone marrow,
megakaryocytes are reduced, resulting in a decreased num­
ber of platelets and subsequent bleeding.
Monitoring the various blood values prior to any rou­
tine or emergency dental procedure is necessary. This per­
mits a more accurate assessment of the necessity of the den­
tal procedure versus the potential for oral bleeding or other
complications. Platelet levels below 25,000 cells per cubic
millimeter may indicate potentially severe or even fatal hem­
orrhage, either spontaneous or induced, and may require
transfusion of platelets. The average half life of host plate­
lets is 8-10 days, while that of donor platelets is only 4-5
days after being stored for several days. For this reason, che­
motherapy patients with thrombocytopenia often require
multiple platelet transfusions to avoid hemorrhage.
Local management of bleeding in the thrombocytopenic
patient can be difficult. Any potential cause of bleeding such
as sharp edges on prostheses or abrasive tooth brushing
should be eliminated or modified. Identification of the site
of hemorrhage is essential. All blood clots and debris should
be gently removed from the mouth. Suction is helpful to re­
move pooling blood and saliva while attempting to visualize
the bleeding site. Adequate light and proper positioning of
the patient are also essential to find the source of hemor­
rhage.
The size and location of the bleeding area will delineate
the appropriate management. Large diffuse areas that are dif­
ficult to isolate can be managed with topical hemostatic
40 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
agents such as thrombin or Avitene*. Small, pinpoint areas
of bleeding can be controlled with direct application of pres­
sure for a prolonged period (30 minutes or more). Cooling
the tissues with intraoral ice packs, gauze and pressure will
reduce blood flow to the area and may aid in hemostasis. If
traumatic injury has caused a significant wound or if bleed­
ing is from previous extraction sites, management may ne­
cessitate local anesthesia and suturing. However, most cases
of bleeding in the thrombocytopenic patient will not benefit
from suturing. In fact, suturing and local anesthetic injec­
tions may be contraindicated in these patients because the
needles can create additional sites of bleeding. If the gingi­
val sulcus is identified as the bleeding site, pressure should
be applied over the facial and lingual or palatal gingiva with
cold gauze. Management of bleeding from the gingival sul­
cus can be very trying and time consuming. The tissues within
the sulcus are very thin, highly vascularized and often ulcer­
ated from chemotherapy and/or previous gingivitis or peri­
odontitis. Pressure to the area should be gentle yet firm and
consistent. Beware that neither periodontal dressings nor well
intentioned patients apply sufficient pressure for the extended
periods necessary to stop gingival sulcus bleeding. Topical
hemostatic agents can be used in the gingival sulcus to aid in
hemostasis. However, it can be perplexing to get topically
applied agents to the site of hemorrhage within the gingival
sulcus. Ultimately, correction of thrombocytopenia with
platelet transfusion and/or recovery is necessary for control
of hemorrhage.
Infection
Even when all potential dental sources of infection have
been treated and oral hygiene measures have been taken, pa­
tients with immunosuppression may become infected. Im­
balances of the indigenous oral flora can permit pathogenic
species to inhabit and invade the oral tissues, leading to po­
tentially serious oral infections and subsequent septicemias.
The potential for infection from any source is minimal
at granulocyte levels of 1500 or more mature cells per cubic
millimeter. The incidence of infection increases at granulo­
cyte levels below 1500, and the response to antibiotic therapy
is lessened. Many hospitals place patients in isolation to pro­
tect against infections when their white blood cell count drops
below 500 cells per cubic millimeter.
Surveillance cultures are not necessary for routine pa­
tient management. However, cultures should be obtained for
suspicious lesions or in patients that show signs of infection.
Signs and symptoms of infections of the oral cavity typi­
cally include fever, malaise, chills, pain, swelling, and
erythema, and may be associated with bleeding gingiva.
* Avitene, Avicon, Inc., Fort Worth, TX.
However, the immunosuppressed patient may exhibit few or
possibly none of these signs. When patients are unable to
mount a normal immune response against invading micro­
organisms, classic signs and symptoms of infection are of­
ten absent.
Therefore, cultures, wet smears, and serologic diagnos­
tic procedures should be implemented whenever infection is
suspected and the source and type of organism is not readily
discernible. Appropriate antibiotic therapy should be insti­
tuted as soon as possible when an infection has been diag­
nosed. Intravenous antibiotics are more efficacious than oral
antibiotics in immunosuppressed patients. Reduction in the
dose of the cytotoxic drugs and/or administration of granu­
locytes may be warranted to control infections.
Bacterial Infections
Identification of the infecting organism(s) is essential
to treating a bacterial infection. Bacterial infections in the
immunocompromised patient have the potential to be severe,
and therapy with antibiotics can be perplexing. Treatment
should begin as soon as possible, but should not be attempted
without sensitivity and resistance testing. The knowledge and
facilities to manage serious and potentially fatal side effects
must be available. Typical antibiotics and dosages are often
abandoned in favor of late generation broad spectrum agents
and intensified dosing schemes. Granulocyte transfusions
may be needed to augment and facilitate antibiotic therapy.
Viral Infections
Treatment of viral infections in the chemotherapy pa­
tient is sometimes limited by drug toxicity. In normal pa­
tients, viral infections typically run an average course of 2-3
weeks regardless of therapy. In the immunosuppressed pa­
tient, the duration and nature of viral infections is often longer
and more extensive. The typical infection can last 5-6 weeks
or more. If the viral infection is excessively prolonged or if
it becomes debilitating, antiviral agents such as acyclovir
can be administered (5 mg/kg every 8 hours) intravenously
for 7 days. This dosage can be repeated if infection persists.
Acyclovir can be used as a prophylactic agent in selected
patients identified as herpes simplex virus antibody positive.
Reactivation of this infection is extremely common, and can
be prevented with prophylactic use of acyclovir. Although
efficacious, Acyclovir is used with care in chemotherapy
patients because of its toxicity to vital organs. Acyclovir can
be nephrotoxic and neurotoxic especially in patients exposed
to other chemotherapy agents with similar toxicities.
 Cancer Chemotherapy: Oral Manifestations, Complications, and M anagement
Fungal Infection
Acute oral candidiasis is treated with nystatin supposi­
tories used as an oral lozenge. Patients are advised to dis­
solve 3 to 5 lozenges per day for 7 days (or longer) in order
to effectively expose the fungal microorganisms to the drug.
In the immunocompromised patient, fungal infections
may becom e invasive and enter the systemic vasculature.
Am photeracin B is the drug o f choice for systemic candidi­
asis. It is slowly administered intravenously, with dosage (20-
30 mg/day) depending on the nature o f the infection. In pa­
tients with mucormycosis, surgical debridem ent o f locally
involved areas may also be necessary. Generally, as with
many antibiotics, immunosuppression must be recovering
before this drug becomes truly effective. Invasive aspergillo­
sis does not respond well to am photeracin B.
References
1 Boring C, Squires T, Tong T: Cancer statistics, 1994. CA: Can­
cer J fo r Clinicians. 44:1; 1994.
2 Sonis S, Sonis A, Lieberman A: Oral complications in pa­
tients receiving treatment for malignancies other than of the
head and neck. / Amer Dent Assoc. 97:468;1978.
3 DePaola L, Peterson D, Overholser C, et al.: Dental care for
patients receiving chemotherapy. JADA. 112(2): 198; 1986.
4 Rosenberg S: Oral care of chemotherapy patients. Dent Clin
Nor Amer. 34:2; 1990.
5 Wingard J: Infectious and non-infectious systemic conse­
quences. Oral complications of cancer therapies. NCI Mono­
graphs. 9:21; 1990.
6 Goldie J, Coldman A: A mathematical model for relating the
drug sensitivity of tumors to their spontaneous mutation rate.
Cancer Treat Rep. 63(11-12): 172; 1979.
7 Dreizen S, McCredie K, Keating M: Chemotherapy-induced
oral mucositis in adult leukemia. Postgrad Med. 69:2; 1981.
8 Greenwald E: Cancer Chemotherapy, 2nd ed. New York, 1973;
Medical Examination Publishing Co.
9 Frei E: Clinical use of actinomycin. Cancer Chemother Rep.
58:49;1974.
10 Oliff A, Bleyer W, Poplack D: Methotrexate-induced oral mu­
cositis and salivary methotrexate concentrations. Cancer
Chemother Pharmacol. 2:225;1979.
11 Lockhart P, Sonis S: Alterations in the oral mucosa caused by
chemotherapeutic agents: A histologic study. J Dermatol Surg
Oncol. 7:12;1981.
12 Lockhart P, Sonis S: Relationship of oral complications to pe­
ripheral blood leukocyte and platelet counts in patients re­
ceiving cancer chemotherapy. Oral Surg. 48(1):21;1979.
13 Seto B, Kim M, Wolinsky L., et al.: Oral mucositis in patients
undergoing bone marrow transplantation. Oral Surg, Oral
Med, Oral Pathol. 60:493;1985.
41
14 Dyck S, Brett K, Davies B, et al.: Development of a staging
system for chemotheraopy-induced stomatitis. Cancer Nurs.
14(1):6;1991.
15 Donnelly J, Muus P,Schattenberg A, DeWitte T, Horrevorts
A, et al.: A scheme for daily monitoring of oral mucositis in
allogenic bmt recipients. Bone Marrow Transplant.
9:403; 1992.
16 Schubert M,Williams B, Lloid M, et al.: Clinical assessment
scale for the rating of oral mucosal changes associated with
bone marrow transplantation. Cancer. 69(10): 2469;1992.
17 Main B, Caiman K, Ferguson M, et al.: The effect of cyto­
toxic therapy on saliva and oral flora. Oral Surg. 58:545; 1984.
18 Bodey G, Buckley M, Sathie Y, et al.: Quantitative relation­
ships between circulating leukocytes and infection in patients
with acute leukemia. Annal Inter Med. 64:328; 1966.
19 Armstrong D: Infectious complications in cancer patients
treated with chemical immunosuppressive agents. Transplant
Proc. 15:1245;1973.
20 Hersh E: Causes of death in acute leukemia. JAMA.
192:105;1965.
21 McCreadie K: Platelet and leukocyte transfusion in acute leu­
kemia. Hum Pathol. 5:699; 1974.
22 Greenberg M, Cohen G, McKitrick J, et al.: The oral flora as
a source of septicemia in patients with acute leukemia. Oral
Surg. 53(1): 32; 1982.
23 Driezen S, Bodey G, Rodriquez V: Oral complications of can­
cer chemotherapy. Postgrad Med. 58:75; 1973.
24 Meyers J, Flournoy N,Thomas E: Infection with herpes sim­
plex virus and cell mediated immunity after marrow trans­
plantation. J Infect Dis. 142:338; 1980.
25 Montgomery M, Redding S, LeMaistre C: The incidence of
oral herpes simplex virus infection in patients undergoing can­
cer chemotherapy. Oral Surg, Oral Med, Oral Pathol.
61:238; 1986.
26 DePaola L, Peterson D, Leupold R, et al.: Prosthodontic con­
siderations for patients undergoing cancer chemotherapy.
JADA. 107(1):48;1983.
27 Peterson D, Overholser C, Williams L: Endodontic therapy in
patients receiving myelosuppressive chemotherapy. Proc J
Dent Res. 61:276; 1982.
28 Suzuki J, DePaola L, Nauman R: Periodontal therapy in a pa­
tient undergoing cancer chemotherapy. JADA. 104(4):473-
475; 1982.
29 Overholser C, Peterson D, Williams L, et al.: Periodontal in­
fection in patients with acute non-lymphocytic leukemia:
prevalence of acute exacerbations. Arch Intern Med. 142:551;
1982.
30 Fattore L, Baer R, Olsen R: The role of the general dentist in
the treatment and management of oral complications of che­
motherapy. Gen Dent. 374; 1987.
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31 Naylor G, Terezhalmy G: Oral complications of cancer che­

motherapy: prevention and management. Spec Care Dent. 150-
156;1988.
32 Liebman M: Oral care. Pract Corner, ONF. 19(6): 939; 1992.
33 Ferretti G, Ash R, Brown A, et al.: Chlorhexidine for prophy­
laxis against oral infections and associated complications in
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Chapter 4
Radiation Therapy of
Head and Neck Tumors
Oral Effects, Dental Manifestations, and Dental Treatment
John Beumer III, Thomas A. Curtis, and Russell Nishimura
In recent years, radiation therapy has been used with in­
creasing frequency in the management of neoplasms of the head
and neck region. A majority of patients with such tumors will
receive radiotherapy at some time during the course of their
disease. In some tumors, it is the preferred treatment whereas in
others it is employed in combination with surgery or sometimes
with chemotherapy. The therapist’s intent in most patients is to
cure, but in some instances radiation provides useful palliation.
Postradiation sequelae are significant, well known, and may
result in needless morbidity.
Significant advances have been made in the last 15 years
that have resulted in a decreased incidence of radiation caries
and osteoradionecrosis, but many questions are left unanswered,
and much research needs to be done. The literature regarding
evaluation of dentition, extraction of teeth, treatment of osteo­
radionecrosis, and restorative maintenance of the dentition re­
mains indeterminate and confusing. It is the intent of this chap­
ter to summarize and collate the available data and clinical ex­
perience of those active in this field in order to present an orga­
nized, rational approach to evaluation, care, and maintenance
of the oral health of patients undergoing cancericidal doses of
radiation therapy to the head and neck region.
Radiation Therapy of Head and Neck Tumors*
Physical Principles
Radiation therapy is defined as the therapeutic use of ion­
izing radiation. Two broad categories of radiation are available:
electromagnetic and particulate. Electromagnetic waves of wave
lengths less than 1 angstrom are called photons. They have nei­
ther mass nor charge. Their energy is measured in electron volts
and varies from several thousand electron volts, kiloelectron
volts (KeV), to several million electron volts or mega electron
* Section on radiation therapy of head and neck tumors contributed by Kenneth T. Shimizu.
volts (MeV). By definition, photons that haye an energy supe­
rior or equal to 1 MeV are called high energy photons, x-rays
and gamma rays are types of photons which are, in fact, identi­
cal in nature. The difference between them lies in how they are
produced, x-rays are generated by electric devices (x-ray ma­
chines, linear accelerators, betatrons, and so forth) in which an
electron beam of high energy bombards a target, usually of tung­
sten or gold. Gamma rays are produced by radioactive disinte­
gration of unstable radioisotopes (cobalt 60, cesium 137, iri­
dium 192, and so forth).
Particulate radiations, which have mass, are charged nega­
tively (electrons, pi-mesons), positively (protons, alpha par­
ticles), or are neutral (neutrons). The particulate radiations most
commonly used are electrons and neutrons. Electrons are small
negatively charged particles. These can be accelerated to high
energy levels by means of the same electrical devices used to
produce x-rays. Neutrons are particles with a mass similar to
protons (hydrogen nuclei) but with no charge. Neutrons can be
produced by fission or by means of a cyclotron. The pi-meson
is a particle with a mass 273 times that of an electron. It has
provoked some interest because of the theoretical dosimetric
advantages that apparently would make it valuable in the treat­
ment of deeply situated tumors.
All of these radiations act similarly when producing bio­
logic effects insofar as they produce ionization within tissues.
Most ionization occurs when these rays give up energy by col­
liding with and ejecting electrons from atomic orbits.
Interactions of Radiation and Tissues
Radiation absorption by tissues is either directly or indi­
rectly ionizing. When charged particles have sufficient energy,
they are directly ionizing. Li other words, as they pass through
the target matter, they disrupt the atomic structure by producing
44 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
chemical and biological changes. On the other hand, photons
and uncharged particles (neutrons) are indirectly ionizing as they
give up their energy to produce fast moving charged particles.
Photons entering tissues interact with orbital electrons and
can be absorbed in 3 different ways, by the photoelectric effect,
by the Compton effect, and by pair production. In the photo­
electric effect, the photon’s entire energy is employed to eject
an electron from its orbit. This type of absorption prevails for
low energy photons (orthovoltage) and increases with the atomic
number of the absorber. The Compton effect prevails for high
energy photons at 1 to several MeV (cobalt 60, linear accelera­
tor). In the Compton effect, 1 electron is ejected and the rest of
the energy of the incident photon will generate a low energy
photon.
Pair production is seen when very high energy photons
entering matter materialize into 2 charged particles of opposite
signs, 1 negative electron and 1 positive electron (positron).
The positron is short-lived and reacts with another electron to
produce a photon.
Unlike photons, which primarily produce secondary elec­
trons, neutrons are essentially absorbed by colliding with hy­
drogen nuclei, which are most numerous in tissue. The neutron
interactions set in motion fast recoil protons, alpha particles and
heavier fragments. Ionization is then produced by the second­
ary protons that are set in motion by the incident neutrons.
Biologic Effects
The primary effects of radiation occur within the nucleus,
since it is 100 to 1000 times more sensitive to radiation than the
cytoplasm. After irradiation, there is only a small amount of
immediate cellular death from direct effects (e.g., damage to a
key segment of the cellular metabolism). Most of the damage is
confined to intranuclear structures, such as the DNA and the
mitotic apparatus. Hie best available evidence indicates that
this damage accounts for most cell deaths following irradia­
tion. Damage to these structures may be lethal (irreparable) or
sublethal, and may not be apparent until at least 1 cellular divi­
sion is attempted. If enough time passes between the sublethal
event and cellular division, the damage may be corrected. While
the repair time will vary with different tissues, a minimum safe
clinical interval of 6 hours is necessary. This process is known
as repair o f sublethal damage*. Lethal and unrepaired, suble­
thal damage are manifest as chromosomal abnormalities at the
time of mitosis, when genetic material in daughter cells may be
altered or lost. Occasionally, bridges occur between daughter
cells, preventing completion of cell division.
The biologic effects of radiation can occur through either
direct or indirect action. Direct action results when secondary
particles (i.e., recoil electrons and protons) interact with the tar­
get molecule, while indirect action results from interaction with
water to produce free radicals (hydroxyl and hydrogen), which
in turn interact with the target molecule by oxidation reduction
reactions. In radiation biology, the target molecule is the DNA
which has a key role in cellular life. However, DNA molecules
are relatively scarce as compared to the surrounding molecules
of water. Therefore, photons have a higher probability of caus­
ing damage to DNA through indirect action. On the other hand,
densely ionizing radiations, like neutrons, interact primarily
through direct action.
These biologic actions on target tissues are dependent on
the level of oxygenation. When tissues are anoxic, they may be
up to 3 times more resistant to radiation effects than they would
be under full oxygenation. The role of oxygen can be explained,
at least in part, by its combination with organic free radicals (R)
to produce non-restorable organic peroxides (R02) of the target
molecule. This reaction leaves more hydroxyl free radicals which
can then interact with target molecules that would otherwise
react with hydrogen to form inactive molecules of water. Thus,
indirect action of radiation treatment, primarily in photon beam
therapy, is dependent on oxygen in its fixing of organic free
radicals. Therefore, it appears that the biologic effects in hy­
poxic tumors treated with photon beam therapy are dependent
on treatment strategies that increase the transport of oxygen to
the tumor, a radiobiologic concept known as reoxygenation2.
On the other hand, heavy particles like neutrons have high ki­
netic energy, and the energy transferred per linear unit of track
or linear energy transferred (LET) is sufficiently great to cause
irreversible damage to the cells by direct action which happen
to be on the track and perhaps “over-kill” them. Consequently,
with these radiations, the oxygen effect is not as pronounced as
it is for photons or light particles, and thus may be more effec­
tive in treating large, hypoxic tumors.
The effect on individual cells may vary according to the
position the cell occupies in the cell cycle at the time of irradia­
tion. It has been well demonstrated that cells are not uniformly
radiosensitive during the different phases of their cycle. They
are most vulnerable during G1 and in mitosis, and relatively
radioresistant at the beginning and end of DNA synthesis.
Most cell populations, whether malignant or normal, are
asynchronous (i.e., the individual cells are in different phases
of the cell cycle). If synchrony could be produced in neoplastic
cells and radiation given during the most sensitive phase, in­
creased cell killing would result. This is known as redistribu­
tion of cells within the cell cycle3. Theoretically, this can be
accomplished with some chemotherapeutic agents known as
cell cycle dependent agents (e.g., vinca alkaloids and hydrox­
yurea), or with timed fractionation of radiation therapy. How­
ever, to date there is no practical clinical way to produce syn­
chrony and thereby take advantage of the phasic variation of
cell sensitivity.
A fourth radiobiologic principal is known as repopulation.
This means that, given enough overall treatment time,-cells in
irradiated tissue can proliferate and repopulate. In recent years,

this seemingly simple concept has been modified by the obser­
vation that any cytotoxic agent, including radiation, can trigger
clonogenic surviving cells in a tumor to divide faster than be­
fore4. This is called accelerated repopulation and is estimated
to occur about 4 weeks after the initiation of treatment, when
the tumor mass is coincidentally shrinking. Thus, in order to
keep pace with the more rapid growth rate of tumor cells, a
more rapid delivery of treatment may be needed.
Biologically Equivalent TYeatment Schedules—Isoeffect
Models
Clinical experience has shown that as dose increases, tis­
sue changes become more profound and irreversible, leading to
an increased incidence of complications. For more than half a
century, radiation therapists have been trying to predict dose-
outcome effects through isoeffects modeling. A number of meth­
ods have been developed over the years to devise treatment
schedules to improve tumor control yet limit side effects. The
number of fractions, dose per fraction, total dose and the time
period over which the therapy is delivered are all important
variables to be considered when evaluating the biologic effect.
Strandqvist produced the first clinical isoeffect curves5.
They were for skin cancers and skin reactions using parameters
of total dose and overall treatment time. A third parameter, num­
ber of dose fractions, was introduced by Fowler and Stem6. In
the late 1960’s, the nominal standard dose (NSD) was intro­
duced7, and it is still the best known isoeffect formula. It was
also based on data from skin cancers and skin reactions. From
this formula, theTDF (time, dose, fractionation) tables and CRF
(cumulative radiation effect) formulas were derived. This in­
dex was an attempt to account for the variables of delivery to
indicate more accurately the true biologic response. Theoreti­
cally, normal tissue tolerance in the head and neck has been
postulated to be in the range of 1800 rad therapeutic equiva­
lents (rets). In the following decade, it became apparent that the
NSD formula was not applicable to the late damage of normal
tissues and that tissue specific parameters were needed. Fur­
thermore, the time factor for tumors was underestimated and
the size of the dose per fraction was found to be more signifi­
cant than the number of dose fractions for isoeffect relation­
ships.
In the mid-1970’s, Withers showed that when plotting iso­
dose effects against dose per fraction the curves for acutely re­
sponding tissues (like mucosa and skin) differed from late re­
sponding tissues (like spinal cord and dermis)8. These survival
curves for late responding tissues consistently had steeper curves.
In other words, more cell kill could be achieved in late respond­
ing tissues with an increase in the size of the dose per fraction­
ation, presumably due to different repair capacities. This dis­
covery led to the linear quadratic formula and equations for
comparison of isoeffects, such as the following:
Radiation Therapy o f Head and Neck Tumors 45
D1 _ a/b2 + d 2
D2 “ a/b, + d 1
(where D = Total dose for isoeffect, d = dose per fraction, and
subscript numbers represent doses for each respective isoeffect)
Alpha (a) describes slope of the initial (single-hit) portion of
the cell survival curve while beta (b) describes the terminal multi­
hit portion of the curve. The a:b ratio is small for late effects
tissues (on the order of 2 to 4 Gy) and is larger for acute re­
sponding tissues (8 to 12 Gy). This formula does not consider
the time factor and assumes complete repair with no prolifera­
tion between dose fractions. When these conditions are not met,
modifications can be applied, but they make the formula more
complex.
Fractionation
Radiation therapy is delivered in a series of treatments or
fractions. Curative treatment regimens for squamous cell carci­
nomas of the head and neck region can vary. In the United States,
“conventional fractionation” prescribed by most radiation
oncologists consists of a total dose of 6500 to 7200 centigray
(cGy) in daily fractions of 180 to 200 centigray (cGy) fractions
given Monday through Friday over a 7-week period. The final
total dose is limited by the radiation tolerance of critical normal
tissues within the treatment volume. This tolerance is determined
by total dose, dose per fraction, overall treatment time, and fre­
quency of dose fractions. Clinical experience has enabled the
radiation therapist to establish the relationships between these
treatment parameters and the severity of acute and late side ef­
fects.
A tremendous amount of work has been done in radiobiol­
ogy aimed at understanding phenomena that were empirically
and intuitively established by experienced radiotherapists. This
effort has been rewarded with some gain in therapeutic ratio. In
fact, fractionation remains the most significant breakthrough in
radiation therapy and its usefulness is apparent from the fol­
lowing lines of evidence. First, fractionated radiation allows
the regular reoxygenation of the tumor during the course of treat­
ment. In tumors, significant portions of the cell population are
probably severely anoxic. Presumably, in fractionated radiation
therapy, the death of oxygenated cells allows oxygen to reach
hypoxic cells, which therefore become more radiosensitive. Fail­
ure of reoxygenation may account for the resistance of some
tumors to radiation. Second, fractionation offers more opportu­
nities for the radiation to affect more tumor cells during the
radiosensitive phase of their cell cycle. Third, normal cells seem
to recover more completely between fractions from sublethal dam­
age than do tumor cells. Fourth, experience has shown that it works.
46 MAXILLOFACIAL REHABILITATION: PROSIHODONTIC & SURGICAL CONSIDERATIONS
Altered Fractionation Schemes
L i e conventional treatments, altered fractionation schemes
a e Smiled by acute reactions and late sequelae of therapy. How-
d c tlh e expected dose effects that have been established through
c x f o l clinical observations with conventional radiation therapy
Hay not apply to altered fractionation treatments. Clinical and
qpaimental radiobiological experience has shown that the se­
verity o f acute reactions are more dependent on the rate of dose
■rrnnfotion: namely, the size of dose per fraction and the fre-
q ra c v of dose fractions. Late effects are more sensitive to the
s k o f dose per fraction, the interval between fractions (time
farsabiethal damage repair) and total dose. This dissociation of
anne and late effects is described by the linear quadratic for-
a n b discussed previously. Altered fractionation schemes in-
c U e fayperfractionation and accelerated fractionation sched-
afles.
H yperfractionation The treatment parameters in
kfpofiactMxiation may be defined relative to conventional frac-
iioEiaDon. There is an increased total dose, total number of frac­
tions, and number of fractions per day, while decreasing the
dose per fraction and keeping the overall treatment time rela-
Ihefy unchanged. The dose per fraction is typically 115 to 120
cGy,given twice per day. This means that the rate of dose accu-
zmlaoon and, therefore, of acute reactions increases, becoming
A e dose-limiting side effect. However, the advantage with
hyperfkactionation is the increased tolerance of late effects with
Ae use o f smaller dose fractions and the ability to increase the
mnidose delivered to tumor. It is critical that a sufficient amount
o f time elapses between fractions to allow repair of sublethal
damage. Clinical experience indicates that an interval of at least
6 bows between fractions appears to be adequate. Other ration­
ales for the use of hyperfractionation is the redistribution of
cefc within die cell cycle and reoxygenation.
Clinical results from the University of Florida9, the
BORIC10, the RTOG11, as well as from India12have shown no
dgfrirnce in late effects and an increase in acute effects when
compared to conventional fractionation. As expected, the late
effects were shown to be dependent on the interval between
factions and die overall dose. Additionally, there was signifi-
c a n improvement in local control as long as an adequate total
dose was delivered, and survival rates improved as well.
Acceleratedfractionation Relative to conventional frac­
tionation, accelerated fractionation offers a decreased overall
treatment time and a slight decrease in dose per fraction, while
iw rasing the number of fractions per day and keeping the over-
a l dose the same or slightly decreased. The dose per fraction is
typically 140 to 160 cGy and given twice or thrice daily. As
n d i hyperfractionated treatments, there is an increased rate of
dose accumulation with dose-limiting acute reactions, hi fact,
this accumulation can be so rapid as to necessitate unscheduled
treatment breaks or require planned breaks. The advantage of
accelerated fractionation is to decrease the overall treatment time
and to increase tumor control probability by maintaining an
accumulated dose rate to the tumor that will keep pace with
accelerated repopulation. Again, redistribution and
reoxygenation may play important roles.
Three basic accelerated fractionation schemes have been
reported. Mt. Vemon Hospital used a short-course intensive
accelerated fractionation scheme delivering 3 fractions per day
of 140 to 150 cGy each, over 12 consecutive days'3. The acute
reactions limited total doses to 5040 to 5400 cGy and many
patients required hospitalization. Significant late toxicity was
also encountered, including unexpected radiation myelopathy14.
Needless to say, this strategy requires further investigation de­
spite high tumor control rates.
The second scheme, accelerated split course fractionation,
was used extensively by Wang at Massachusetts General Hos­
pital15. It delivered 160 cGy fractions twice daily, with a planned
2-week treatment break (for anticipated acute reactions). A to­
tal dose of 6400 to 6720 cGy was given over approximately 6
weeks. Local-regional control rates were significantly improved
over conventionally treated historical controls, with late com­
plications reportedly comparable with the expected increase in
acute effects.
The M. D. Anderson Hospital reported on a third scheme
with concomitant boost accelerated fractionation, in which ac­
celerated fractions of 150 cGy were added to a basic conven­
tional scheme of5400 cGy given over 6 weeks, using 180 cGy
daily16. These additional fractions were given either in the first
2 weeks, last 2 weeks or throughout the 6 weeks of therapy, for
a total dose of 6900 to 7200 cGy. Preliminary tumor control
data favors the boost given in the last 2 weeks of therapy17when
accelerated repopulation by the tumor would be expected. Again,
there was no increase in late complications but there was an
increase in acute reactions.
Dosimetry
The purpose of dosimetry is to evaluate the amount of en­
ergy absorbed by the tissues subjected to radiation. The stan­
dard unit of the absorbed dose is the gray, which is defined as
“the energy absorption of 1 joule per kilogram of tissue.” This
has replaced the rad, which corresponds to an energy absorp­
tion of 100 ergs/gm. Therefore, 1 rad = 1 centigray. The term
roentgen is no longer used as it is a measure of exposure based
on ionization in air and is not indicative of the dose absorbed by
different tissues. A millicurie is the unit of activity of a radioac­
tive isotope which measures the number of disintegrations per
second (I mCi = 3.7 x 107disintegrations per second).
 Radiation Therapy o f Head and Neck Tumors 47

In addition to standardizing terminology, accurate treat­

ment planning must consider the beam characteristics for the
different types of radiations used in clinical practice, such as
photons and electrons. These characteristics will vary with type
and the energy of the radiation applied and can vary signifi­
cantly between machines used to generate these beams. These
distinctions include the penetration depth of the maximum dose
(Dmax), the buildup region, the fall off region* and the isodose
curves. When a radiation beam penetrates tissue, the dose de­
creases with depth of penetration after the maximum dose level
is reached. The region from the surface to the depth of maxi­
mum dose is called the buildup region, while the region beyond
is called the fall-off region. The depth dose curves are visual­
ized on a plane running along the axis of the beam where the
points of equal dose are connected, yielding curves known as
isodose curves (Figure 4-1).

Isodose Curves for Photon Radiation

Single Beam For photons, as the energy of the beam is

increased, the buildup region and Dmax extend to a greater depth.
When using low energy x-rays like orthovoltage, Dmax is lo­
cated on the surface, making this an excellent treatment modal­
ity to treat superficial skin lesions. As photon energy increases,
the surface dose decreases, the buildup region increases and
Dmax is located further from the surface (Figure 4-1). For ex­
ample, with a cobalt beam, the Dmax is located at 4 to 5 mm
and, as the photon beam becomes more energetic, it is located
at greater depths (e.g., Dmax for 4 MeV photons is 10 mm and
for 10 MeV photons is 25 mm). Thus, with higher energy pho­
tons, there is a surface sparing effect, more popularly described
as the “skin sparing effect” The major advantage of high en­
ergy photons, however, remains the increased percentage of
depth dose. The fall off for photons is gradual, especially when
compared to electron beams.
Multiple Beams When a tumor is located deep, it becomes
necessary to use 2 or more beams (radiation ports) in order to
deliver a dose to the tumor equal to or higher than the dose
delivered to normal tissues (Figure 4-2). The goal of these field
configurations is to maximize the tumor dose and to minimize
the dose to normal tissues such as sensitive tissues like the spi­
nal cord. Varying amounts of normal tissue are frequently treated
to doses near or higher than the prescribed tumor dose, but with
modem equipment, this variation should seldom exceed 5%.
Large dose inhomogeneities not only increase the total dose,
but also increase dose per fraction and therefore increase the
biologic dose especially with regard to late effects. Thus, treat­
ment planning is essential.
Fig. 4-1. Isodose curves of photon beam (Co60). Note pro­
gressive falling off of tissue dose and that maxi­
mum dosage level (100%) is attained below skin
surface.
In an attempt to spare normal tissues, multiple beams with
varying configurations can be applied. Beam configurations can
vary from 2 simple opposed fields, to angling 2 fields with re­
spect to one another (wedge-pair fashion), to using 3 or more
fields with different beam angles. The most common arrange­
ment in irradiation of head and neck tumors involves the use of
parallel opposed lateral fields. In addition, different beam ener­
gies can be used to manipulate the coverage of regions of inter­
est. For example, if superficial areas such as lymph nodes need
treatment, lower energy photon beams are applied. However, if
the primary concern is for dose levels to deeply situated struc­
tures, then higher energy photons should be used.
Isodose Curves for Particulate Radiations
The dose distribution for an electron beam is similar to that
of photons in that, the higher the energy used, the greater the
depth of penetration; however, electron beam dose distribution
differs from that of photons in 2 significant ways. First, the elec­
tron beam exhibits a rapid falling off of the dose beyond the
80% to 90% isodose line (Figure 4-3). This permits treatment
of superficial structures like lymph node bearing areas, yet spares
48 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Reference isodose curve
where maximum tumor
dose is given
Fig. 4-2. Concentration of dose by using two converging photon beams and
wedges (tumor of ethmoid and maxillary antrum).
deep structures like the spinal cord. Hence, electron beam therapy
is widely used in treatment of the posterior neck during the “off
cord” portion of therapy. The second difference applies to the
buildup region; as the energy of the electron beam increases,
the depth to Dmax decreases and a greater dose is deposited to
the skin, so there is less skin sparing.
As an alternative to orthovoltage therapy, one can take ad­
vantage of these 2 qualities of electron beam therapy and treat
cutaneous lesions. However, caution must be used not to
underdose superficial structures when using lower electron en­
ergies. A surface bolus described later in this chapter can be
used to increase the dose level of the skin. An additional char­
acteristic of electron therapy is that, as the energy increases,
there is constriction of the isodose curves such that the actual
volume covered by the 90% and 100% isodose lines may physi­
cally lie inside the edge of the beam. Therefore, there is the
potential to underdose at the edges of the treatment volume.
For heavy, charged particles, such as protons, the secondary
ionizations are more concentrated at the end of the trajectory
where the speed of the initiating particle has decreased. Thus,
the Dmax occurs near the end of this trajectory, and a relatively
sharp peak can be obtained deep in the tissue (Bragg peak ef­
fect). Neutron beams have a similar depth dose curve as 4 MeV
photons.
Beam Mixing and Beam Weighting
Thus far, we have only discussed the use of different field
configurations and individual beam energies to reduce dose in­
homogeneities and to improve the coverage of the treatment
* Med-Tec, Inc., Dallas, TX.
volume. One can imagine further refinements in treatment plan­
ning are possible through beam mixing (the use of different
radiation energies or types) and differential beam weighting (the
unequal emphasis of one field over another). For example, to
achieve adequate dose to a lateral lesion, such as a lesion of the
anterior tonsil pillar, while sparing contralateral normal tissues,
such as the parotid gland, one can treat this tumor with a single
lateral beam. This procedure may spare the contralateral pa­
rotid, but the therapist will not have homogeneous tumor cov­
erage. To compensate for this shortcoming, a second, equal
opposed lateral field may be added, which not only provides
adequate coverage to the tumor, but also gives a significant dose
to the parotid gland concerned. The dose to the tumor can be
increased and the dose to the parotid gland decreased by in­
creasing the amount of radiation delivered from the first field
(increase its weighting) while reducing the contribution from
the contralateral field. Alternatively, one can use a single lateral
field, but mix the treatment beams. By using a combination of a
high energy photon beam (adequate coverage of the tumor with
reduction of ipsilateral skin reaction) and high energy electron
beam (adequate coverage of the tumor and reduced dose to the
parotid gland), our goal of delivering an adequate tumor dose
but sparing normal tissue (parotid gland and skin) has been at­
tained. Further sparing of contralateral tissue may be achieved
with the use of intraoral radiation stents (described later) of
Cerrobend alloy* with acrylic resin and wax coatings to absorb
the back scatter of electrons. The thickness of these shields will
vary with the type and energy of the radiation prescribed (pho­
ton and higher energy beams require thicker shielding).
 Radiation Therapy o f Head and Neck Tumors 49

CM

— 1

— 2

— 3

— 4

— 5

9 MeV electrons
100 cm SSD
Field size: 10 cm x 10 cm

Fig. 4-3. Isodose curves of electron beam. Note rapid falloff of tissue dose.

Brachytherapy In addition to this physical advantage, low-dose-rate (LDR)

Brachytherapy is a method of radiation treatment in which
sealed radioactive sources are used to deliver the dose a short
distance by interstitial (direct insertion into tissue), intracavi­
tary (placement within a cavity), or surface application (molds).
This method takes advantage of the rapid decrease in dose with
distance from a radiation source (inverse square law). The in­
tensity of radiation at a distance from the point source is in­
versely proportional to the square of the distance from the source.
For example, if the dose received 1cm from the source is 3600
cGy, then at 3 cm it would be approximately 400 cGy (one-
ninth). Thus, a high radiation dose can be given to the tumor
while sparing surrounding normal tissues (Figure 4-4).
brachytherapy has other theoretical biologic advantages. Be­
cause the dose rate is low relative to external beam therapy, it
can be considered a highly fractionated form of irradiation with
an infinite number of small individual doses. If the dose rate is
low enough, then all sublethal damage can be theoretically re­
paired; however, if the dose rate is too low, cell proliferation
(repopulation) can occur during radiation18. This critical dose
rate level has yet to be determined, but at the clinical dose rates
used, the concern of repopulation in not felt to be very impor­
tant. Additionally, experimental data suggests continuous, low-
dose-rate irradiation tends to synchronize the cell cycle such
that there is an accumulation in the sensitive G2/M phases of
the cell cycle19.

tl N0; SC'CA' rl':O C K OF

' OF 1MPCAMI 8

Fig. 4-4. a: Isodose curves of iridium implants positioned

in floor of mouth. Note rapid falloff of tissue dose
as distance from sources increase, b: Radiation
mucositis is also localized.
50 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
There are also potential disadvantages with this technique.
The major concern is the potential for inhomogeneity of dose
throughout the implanted volume. This can occur if the radio­
active sources are spaced too closely together (“hot spot”) or
too far apart (“cold spot”). Therefore, brachytherapy, particu­
larly interstitial implantation, requires the operator to have ad­
equate technical and conceptual skills to achieve good dose dis­
tribution. Furthermore, there is the need for general anesthesia
and hospitalization as well as potential exposure to operating
room personnel and to therapists, especially with the use of ra­
dium needles. An additional problem unique to radium is the
emission of potentially harmful radon gas.
Currently, the most commonly used radioisotope in the head
and neck region is iridium 192, which has an average photon
energy of 0.38 MeV. Other isotopes used include cesium 137
and radium 226, which have average energies of 0.66 MeV and
0.83 MeV, respectively. Generally, multiple sources are used,
with their geometric arrangement dictated preoperatively by the
clinical circumstances of a particular lesion. The sources are
ordered and received prior to the procedure and then placed
surgically.After a prescribedperiod of time, the radiation sources
are usually removed. They may be in the form of needles, nar­
row tubes, wires or small seeds. Direct implantation of radium
needles or radioactive seeds have been successful in the past
and still have merit. However, this technique has been super­
seded by afterloading techniques which are more flexible and
accurate. In addition, afterloading avoids unnecessary exposure
to radiation during the preloading period. Iridium 192 is the
most commonly used radioactive isotopefor afterloading inter­
stitial therapy.
Some of the inherent problems with LDR implantation can
be resolved with the recent advancements in high-dose-rate
(HDR) afterloading brachytherapy, where the implantation tech­
nique is virtually the same as for LDR. The difference is in the
overall shorter time of delivery so the delivery can be more
precise. HDR radiation is given through a single source located
at the end of a cable that is computer controlled. After the cath­
eters are placed, their positions are digitized by computer, and
an ideal, homogeneous plane can then be obtained through dif­
ferentiated dwell times of the source at any point along the im­
plant catheters. In other words, areas that would have potential
“hot spots” with LDR treatments could have decreased dwell
times, reducing the overall dose delivered to these areas. Addi­
tional advantages include decreased exposure to personnel.
Despite these advantages, HDR has not been routinely used in
the treatment of head and neck tumors as there is still the need
for hospitalization and general anesthesia.
Modalities Available
Radiation therapy may be delivered via an external source,
or a radioactive material may be surgically implanted locally
within the area encompassed by the tumor. Implantation tech­
niques usually result in less post-therapy morbidity because the
radiation is more localized, thereby sparing important structures
such as major salivary glands and the mandible (see previous
section on brachytherapy). External beam therapy must traverse
through these structures, necessarily compromising their bio­
logic integrity.
External Radiation Therapy
Photon therapy There are 3 categories of energy that are
commonly available for treatment:
(1) Superficial (50 keV to 150 keV)—appropriate for the treat­
ment of small superficial tumors (skin lesions).
(2) Orthovoltage (150 keV to 500 keV, with most in the range
of200 keV to 300 keV)—can conveniently treat superficial but
thick tumors (bulkier skin lesions).
(3) Megavoltage (1 MeV or greater, like cobalt 60 units and
linear accelerators)—used to treat deeply located tumors while
sparring superficial normal tissues (“skin sparing”).
Particle therapy The primary particle widely available for
clinical use is electron beam therapy. The electron beam allows
the clinician to deliver high doses of radiation to tumors which
are located within 6 cm of the surface. The energy of the elec­
tron beam can be adjusted to the depth of interest, thus permit­
ting the therapist to concentrate the dose to the tumor volume
while sparing possible critical underlying structures. For ex­
ample, adenopathy of the upper part of the posterior triangle
can be treated adequately without injuring the spinal cord. Un­
like photon therapy, as electron energy increases, so does the
dose to superficial structures (skin). Other particulate beam thera­
pies (proton, neutron, etc.) are still considered investigational,
although some studies have shown advantages in tumor control
over photon therapy (e.g., neutron beam therapy for salivary
gland tumors20).
Brachytherapy
Interstitial and intracavitary radiation therapy is available
at virtually all radiation treatment centers. They can be used id
treat gross disease either as a boost for advanced tumors or pri­
marily for small lesions. For oral tongue and floor of the mooch
lesions, it is essential that treatment include interstitial implan­
tation or intraoral cone when primary radiation is used21. Lo»-
dose-rate after loading techniques with iridium 192 are most
commonly used today. Alternatively, radium needles and befc-
dose-rate methods are available.

Treatment Planning
With careful treatment planning and meticulous dose de­
livery, significant tumor doses can be given with little or no
significant resultant complications. The intent of the radiation
therapist is to deliver a curative dose to the tumor and to keep
the dose to the normal structures within their tolerance. When a
decision has been made to initiate therapeutic irradiation, the
physician must first determine the extent of disease and the tu­
mor volumes to be treated. This is done by performing a com­
plete physical examination and completing the appropriate labo­
ratory studies such as radiographs, scans, bone marrow biopsy,
and so forth. Treatment volumes are also determined by estimat­
ing the possible subclinical involvement of the tumor, knowing
the pattern of recurrences and the risk and site of regional lymph
node involvement. At this point, the patient should be seen by a
maxillofacial prosthodontist for dental evaluation and fabrica­
tion of intraoral shields and stents, if appropriate.
In general, a portion of the treatment must be given pro-
phylactically to the areas at high risk for direct spread and lymph
node involvement by subclinical disease. The remainder of the
treatment delivers a dose of radiation to the tumor bed (some­
times called the final boost field). In certain instances, this is
delivered using interstitial implantation or an intraoral cone. If
the tumor is small and risk of spread is minimal, then treatment
of the primary site alone may be adequate. Frequently, prescribed
doses (in conventional fractionation) to the prophylactic vol­
ume range from 4500 cGy to 5500 cGy, typically through op­
posed lateral fields. The total cumulative dose given to the final
boost volume range from 6500 cGy to 7200 cGy through mul­
tiple field arrangements, but most commonly through opposed
lateral fields as well. However, the prescribed doses vary with
the clinical situation and treatment techniques used. In the post­
operative setting where tissue is hypoxic or if interstitial im­
plantation is used, then the prescribed dose may be higher.
While delivering these cancericidal doses, consideration
must be given to the effects of radiation on normal tissue. Nor­
mal tissue areas (spinal cord, lens, mandible, and so forth) must
be spared to the extent possible, and careful consideration must
be given to the maximum permissible dose to these volumes.
This can be accomplished based on physical examination and
radiographic studies, with careful planning procedures, includ­
ing the simulation. The goal of the simulation is to simulate the
patient setup during actual treatment, while taking advantage
of fluoroscopy, quality diagnostic films, and customized im­
mobilization devices for consistency of the daily setup. It is
crucial during simulation that patient position be exacting and
reproducible. This is achieved through the use of face masks,
and laser and field lights, which are available in the simulation
and treatment rooms. First, the patient is positioned with the
appropriate oral stent or shield and a face mask is placed. Struc­
tures of interest are outlined—for example, wire placed around
* Cerrobend Alloy, Med-Tec Inc., Dallas, TX.
Radiation Therapy o f Head and Neck Tumors 51
palpable lymph nodes—then viewed under fluoroscopy. Fields
are determined and planning (simulation) films are then taken
(Figure 4-5a). Once the setup is deemed adequate for treatment
by the radiation oncologist, ink markings of setup points are
placed on the patient’s skin or on the mask to facilitate repro­
ducibility.
The standard beams produced by treatment machines are
rectangular. These fields can be converted into irregular shapes
to conform to the individual tumor and patient anatomy through
the use of beam shaping devices, most commonly customized
blocks. These blocks use a low melting point alloy*. The pro­
cedure calls for drawing the block outlines on the planning films.
The casts for the blocks are then cut in Styrofoam using an
electrically heated wire in a device that accounts for beam di­
vergence. Using a Lucite mounting txay, the Styrofoam cast is
then carefully aligned with the central axis and melted Cerrobend
is poured into these casts. Once the metal has cooled, the tray
with the mounted block can be placed on the head of the treat­
ment machine for treatment. Before actual treatment com­
mences, verification of setup and field blocking must be per­
formed by taking a radiograph of the patient with the blocks in
place on the treatment machine (port film) (Figure 4-5b). The
blocking can be modified during treatment as tissue tolerance
is reached. For example, spinal cord tolerance is around 4500
cGy, and shielding of this structure from opposed lateral pho­
ton beam treatment should be placed at that time (“off-cord
field”) (Figure 4-5c,d). The cord block coincidentally shields
the posterior neck. Treatment of the off-cord field can continue
with photon therapy, and should a dose be needed for the poste­
rior neck, then electron fields can be added to that area until an
adequate dose is delivered.
As the human body is not a flat plane, an incident radiation
beam on an irregular or sloping surface can skew isodose curves.
Significant differences in topography and thickness in a treat­
ment field require correction. This can be accomplished through
the use of tissue compensators. One method is to place tissue-
equivalent material directly on the skin, thereby reshaping ir­
regular contours and creating a flat surface. This is called a bo­
lus (see Tissue Bolus Devices). Obviously, this method removes
the buildup region and brings the dose towards the surface, which
may or may not be desirable. Another method involves placing
a device some distance from the patient, but within the path of
the beam to account for surface irregularities. Skin sparing is
achieved as long as the devices are at an adequate distance from
the skin (15cm to 20cm for megavoltage therapy). They can be as
simple as wedge-shaped metal devices (wedges) for compensa­
tion of sloping surfaces, or a complex as customized, 3-dimen-
sionally-shaped compensators for irregular surfaces.
In treatment of head and neck tumors, adjacent fields are
often used. This commonly occurs when treatment of the lymph
nodes in the entire neck as well as the primary tumor is re­
quired. This is almost always accomplished through opposed
52 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

pijiiijp mmm

c d

Fig. 4-5. a: Simulation film of patient to be treated for nasopharyngeal carci­

noma. b: Port film of same patient. This field was treated to a level of
5000 cGy. c: Port film of “off cord” field. Dose is carried to 5500 to 6000
cGy with this field, d: Port film of “boost” field. This field encompasses
a only the primary lesion and dose is brought to approximate 7000 c G y .

lateral fields to the primary and upper neck region along with a
single anterior field to the lower neck and supraclavicular fos­
sae areas. The concern with any adjacent field treatment is over­
dosing critical structures at the junction of die 2 fields; in this
case, the spinal cord. Different methods can be used to correct
for potential overdosage, including placing a gap between the 2
fields (which would underdose tissue in the gap), angling the
fields so that, theoretically, neither field contributes an overlap­
ping dose through divergence (assuming errorless setup and no
patient movement during treatment), or by simply placing a
small block over the spinal cord (cheater block) in whatever
field is appropriate (provided no target structure is denied the
prescribed dose).
On occasion, due to the location of a tumor with adjacent
critical normal structure, treatment planning can be rather elabo­
rate. In such situations, simple opposed lateral fields will not
suffice and angled or multiple fields are used. These setups re­
quire the use of several contours of the patient drawn at the time
of simulation, using stiff wire or molding rods, with subsequent
drawing of tumor and critical structures (determined from pre­
vious studies) onto the contour. Alternatively, this can be ac­
complished with a computed tomographic (CT) scan after simu­
lation. This latter method is preferred, as less estimation of lo­
cal critical structures and tumors is needed and planning can be
taken directly from the scan images with the patient in treat­
ment position. Armed with this information, the physicist and
the radiation therapist find the most appropriate technique (one
or several fields, open or wedged, fixed or rotational, mixed or
weighted beam). A computer is most helpful during this second
phase of planning, permitting close study of the dose distribu­
tion of as many techniques as desired during a short period of
time and allowing development of a highly individualized tech­
nique for each patient. Field verification is then performed on
the simulation machine and, finally, a port film is taken on the
treatment machine with subsequent ink markings or fixed tat­
toos.
The interaction between radiation therapist and radiation
physicist results in a treatment chart, which in effect is a pre­
scription noting the energy and type to be used, fields, loca­
tions, wedges, total dose, daily dose and fractionation. During
treatment, the patient should be followed closely not only to
monitor possible side effects (hair loss, mucositis, edema) but,
also, tumor response (including tumoritis reaction), so that the
treatment plan can be modified, if necessary. Reasonably fre­
quent port films are desirable to verify accuracy and reproduc­
ibility of the radiation fields. During the last part of the treat­
ment, the patient is reevaluated by taking into consideration the
response of the tumor, the tolerance of the normal tissues, and
the general condition of the patient. At this point, fields may be
modified, or a determination may be made as to the utility of a
radioactive implant or surgery.
Indications for TVeatment of Head and Neck Tumors
The large majority of malignant neoplasms of the mucosa
of the head and neck are squamous cell carcinomas of various
degrees o f differentiation and radiosensitivity. Prim aiy
lymphomas arising in the nasopharynx or tonsil, and adeno­
carcinomas of salivary and mucous glands are relatively rare.
The lymphomas are quite radiosensitive but the response of
adenocarcinomas is less predictable. Sarcomas and melanomas
are also rare and are primarily surgical diseases that require wide

margins. These margins may not be possible in the head and
neck region without undue morbidity, so treatment usually com­
bines surgery and postoperative radiotherapy. Unless otherwise
specified, the following comments apply to squamous cell car­
cinomas.
The decision regarding the use of radiation and/or surgery
for control of the primary lesion is a function of the location
and extent of the tumor. Maximum dose delivery with radiation
therapy is limited by tolerance of adjacent normal tissue. Local
control with radiation alone is unlikely for large, infiltrative tu­
mors, especially if bone is involved. The extent of surgical re­
section is also limited by surrounding critical normal structures
and by resultant functional and cosmetic deformity. Addition­
ally, if prophylactic radiation treatment of regional lymph nodes
is indicated, then there may not be any advantage to surgery in
terms of limiting morbidity from radiation. Therefore, radia­
tion alone may be warranted. The decision to use either modal­
ity is also dependent on the wishes of the patient.
Radiation therapy is generally the treatment of choice for
carcinomas arising in the nasopharynx, base of the tongue, and
soft palate because of surgical morbidity and/or difficult ac­
cess. Additionally, lesions in the nasopharynx, base of the tongue
and tonsillar fossa have a high risk of regional lymph node in­
volvement22 and may be better treated with radiotherapy than
surgery alone. Carcinomas of the alveolar ridge and salivary
glands (adenocarcinomas) should be treated surgically, due to
potential for bony infiltration, and then possibly followed by
radiation therapy. Early carcinomas of the tongue and glottic
larynx are equally well controlled by radiation or surgery, but
radiation usually offers the better functional result. Hard, deeply-
infiltrated carcinomas of the tongue are less likely to be con­
trolled by radiation, as are lesions causing fixation of the vocal
cords. Superficial or exophytic lesions usually have a higher
cure rate with radiation than do deeply-infiltrated lesions.
When the decision is made to treat with primary radiation
therapy, treatment can be with conventional fractionation or with
altered fractionation schedules. When conventionally fraction­
ated external radiotherapy is used, the doses are of the order of
6500 to 7200 cGy in 6 to 7 weeks. Hyperfractionated regimen
are generally reserved for bulkier lesions and doses can be up to
8050 cGy. Dosage levels from interstitial therapy may be even
higher. Lymph node metastases are fairly radiocurable when
they are less than 2cm in diameter. Hence, in many head and
neck tumors, the lymphatic drainage down to the clavicles is
included in the radiation fields. For specific lesions, radiation
therapy may be used for control of the primary and subclinical
neck disease, with the addition of surgery reserved for control
of bulky disease in the lymph nodes.
Tumors exhibiting deep invasion of soft tissue or exten­
sion into bone or cartilage are far less likely to be controlled
with radiation or surgery alone, and a planned combined ap­
proach with surgery followed by radiotherapy should be con­
Radiation Therapy o f Head and Neck Tumors 53
sidered. Other indications for postoperative radiotherapy include
positive surgical margins or residual gross disease, tumor spill­
age, perineural invasion, and lymphovascular invasion. Indica­
tions for this treatment approach to the neck include multiple
positive lymph nodes, extracapsular extension, and the known
recurrence pattern. Some studies in the literature indicate that
the interval between surgery and radiation should be no longer
than 7 weeks23, while others do not report a significant decrease
in control rates with delays up to 10 weeks.
Data from the literature suggests postoperative radiation
therapy (of5500 cGy or more) is superior to preoperative treat­
ment (of up to 5500 cGy) with respect to local control and,
probably, survival24,25. In addition to increased control rates,
postoperative therapy has the advantage of tailoring treatment
according to the true extent of the tumor and the ability to de­
liver higher doses of radiation, but its disadvantage is that higher
doses may be required due to hypoxia in the surgical bed and
the potential for accelerated repopulation after surgery. Addi­
tionally, there may be excessive delay in initiation of postop­
erative treatments due to prolonged surgical recovery. Even with
less favorable control rates, planned preoperative irradiation will
continue to be necessary for tumors with fixed lymph nodes, in
lesions that extend beyond the normal surgical boundaries and
thus require reduction in size, and in patients whose postsurgi-
cal recovery is anticipated to excessively delay initiation of
postoperative therapy. Also, “preoperative” therapy may be used
in patients who undergo planned radical radiation therapy, but
whose tumor response is poor after 5000 cGy and, hence, re­
quires surgical “salvage”.
In many sites, radiation may be tried as the primary treat­
ment modality, with surgery reserved as a true salvage proce­
dure. The majority (greater than 90%) of radiation failures oc­
cur in the first 2 years after completion of treatment, with time
to recurrence decreasing with increased tumor volume. The
exception may be true vocal cord lesions, which tend to recur
later than squamous cell carcinomas of other head and neck
sites26. The patient must be observed closely and surgery uti­
lized as soon as radiation failure is evident, provided the early
radiation reaction has subsided (usually after 4 to 6 weeks). This
delay in excision rarely affects the outcome adversely. With an
experienced surgeon and properly administered radiation, there
is little difference in morbidity rates from surgery performed as
primary treatment after preoperative irradiation or because of
failure of primary radiation therapy.
The 5-year disease-free control rates for radiation therapy
vary according to the primary site, tumor size and extent, and
distribution and size of involved lymph nodes. The control rate
for Stage I carcinoma of the true vocal cord is on the order of
90% with radiation alone, and with surgical salvage, it is about
97%. The smaller carcinomas of the border of the tongue, free
portion of the epiglottis, floor of the mouth without infiltration
into the tongue or mandible, and early localized lesions of the
54 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

soft palate, tonsil, and nasopharynx should be controlled by ra­ Hence, structures relatively radioresistant to therapeutic levels
diation in at least 80% of patients. Carcinomas of the pyriform of radiation therapy may suffer significant damage secondary
sinus, subglottic area and alveolar ridge are rarely controlled by to vascular compromise. Salivary glands and bone represent
radiation alone. Early lesions of the maxillary antrum, base of excellent examples of this phenomenon.
the tongue, hypopharynx, false vocal cords and laryngeal ven­ A second school of thought proposes that complications in
tricle have cure rates falling between these extremes. More ad­ late effects may be due to direct radiation effects on parenchy­
vanced lesions and those with lymph node metastases have lower mal or stromal cells28. During radiotherapy, the DNA of slowly
cure rates. dividing (late effect) tissues is impaired, and these injured cells
may sit dormant for months or even years. Therefore, cell death
General Tissue Effects is not expressed quickly. However, when the tissue is violated
traumatically or surgically, these cells are induced to proliferate
Any tumor can be destroyed by radiation if the dose deliv­ to repair the damage. At this time, they will undergo cell death
ered is sufficient. The limiting factor is the amount of radiation and the tissue can become necrotic. This induced proliferation
the surrounding and adjacent normal tissue will tolerate. Tis­ can also account for the difficulty and complications encoun­
sues which exhibit rapid turnover rates are more readily affected. tered with surgical procedures in irradiated tissues (Figure 4-6).
Reactions in the epithelium of the gastrointestinal tract and skin
appear very early, but, if the dose is not excessive, healing is
equally rapid. In tissues with slower turnover rates, damage may
not become evident for months or years after therapy.
Although specific cells may be fairly resistant to radiation
damage, they may indirecdy suffer significantchange. In muscle, High Dose Irradiation
for instance, individual cells are fairly radioresistant. However,
muscle wasting and atrophy in the field may be severe because Immediate cell death Reproductive DNA Damage
of the changes associated with the fine vasculature. Peripheral (interphase Death) (Functional Cell)
nerves are also considered fairly resistant, but fibrosis of sur­
trauma
rounding soft tissue has been reported to cause their compres­
sion, with resultant cranial neuropathies. In the oral cavity, be­
cause of compromised salivary production, severe caries may
occur even though the teeth so affected are not in the field of
radiation.
The etiology of long-term side effects may be vascular in
origin27. The fine vasculature responds to radiation in a more
sensitive fashion than do large vessels. An early radiation-in­ a
duced change is seen histologically as swelling, degeneration,
and necrosis of the inner endothelial lining of small and me­
dium sized capillaries. Loss of the endothelial lining permits
the formation of thrombi that may occlude small vessels. This
and other factors contribute to vascular congestion and increased
permeability of the vessel walls. The resulting increase in
perivascular fluid may exert an external pressure on the walls
of small vessels, further impeding blood flow. As a result of this
perivascular and subendothelial edema, metabolic support of
surrounding tissue is impaired, and significant fibroblastic ac­
tivity in the immediate area predominates. The process of fi­
brosis may continue for years, with resultant further narrowing
and obliteration of the lumens. These responses are more se­
vere and more permanent as the dose increases and in the post­
operative setting. Although there is some recovery by way of Fig. 4-6. a and b: Induced proliferation and cell death after
neovascular regeneration, there usually is a significant net loss irradiation.
of the fine vasculature after radiation. It follows that surgical
procedures within heavily irradiated tissues, such as extraction
of teeth, may be fraught with difficulty and complications.

Use of Prosthodontic Stents and Splints During
Therapy*
Patients with malignant neoplasms of the head and neck
that are treated with radiation therapy require customized treat­
ment plans. Several factors influence treatment planning, such
as the type, size, and anatomical location of the tumor and the
potential for the tumor to metastasize. The prosthodontist is
commonly consulted when custom prosthetic devices are needed
to facilitate the delivery of radiation therapy.
Prosthetic devices (frequently called stents, splints, shields,
carriers, or positioners) can be used to optimize the delivery of
radiation while reducing the associated morbidity. One type of
stent positions the anatomical structures to be irradiated into a
predictable and repeatable position while displacing and/or
shielding other normal structures. Another type of stent will
permit the radiation oncologist to correctly position the radia­
tion beam during the required multiple treatment sessions. A
third device, called a carrier, positions radioactive sources into,
or adjacent to, the tumor site. Complex tissue contours can be
repositioned and/or recontoured with a bolus, which simplifies
dosimetry calculations. Prostheses can also be fabricated that
shield adjacent non-diseased tissues from the radiation beam.
Many custom stents and splints actually incorporate several of
the above criteria into a single device.
Section on use of prosthetic stents and splints during therapy contributed by Harold Gulbransen.
Radiation Therapy o f Head and Neck Tumors 55
Fig. 4-7.
Stent positions the
tongue in constant
and repeatable posi­
tion and lowers radia­
tion field, a: Mounted
casts with wax block-
out. b and c: Com­
pleted stent. Note flat
plane must extend to
second molar area in
order to prevent base
of tongue from ex­
tending above occlu­
sal plane, d: Stent po­
sitioned intraorally.
Note hole for repro­
ducible tongue posi­
tion.
Positioning Stents
This type of stent may be used to rearrange tissue topogra­
phy within the radiation field and displace normal tissues out­
side the radiation field. Both objectives serve to simplify treat­
ment. Positioning stents are particularly useful for tongue and
floor of the mouth lesions treated with external radiation. With­
out the controlled depression of the tongue, the radiation field
extends from the inferior border of the mandible to the hard
palate. An inferior position of the tongue and mandible enables
the radiation therapist to lower the radiation field, thus sparing
significant amounts of the parotid gland from radiation, thereby
leading to higher levels of salivary output after therapy.
In the past, many radiation therapists used a cork with a
tongue blade taped to it to confine the tongue within the man­
dible. The dentist can fabricate a prosthesis which serves this
same purpose, but with more accuracy and comfort for. the pa­
tient. These stents are readily fabricated for dentulous patients.
An interocclusal stent is prepared that extends lingually from
both occlusal tables with a flat plate of acrylic resin. This serves
to depress the tongue within the lingual borders of the body of
the mandible. A hole is made in the anterior horizontal segment
and the patient is instructed to maintain the tongue tip in this
orientation hole during treatment. This will ensure a consistent,
reproducible tongue position during the treatment sequence
(Figure 4-7).
56 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 4-8. a and b: Tongue positioning device for edentulous patient with squamous carcinoma of floor of mouth, c: .Radio­
graph of stent in position.
For the edentulous patient, fabrication of the stent requires
maxillary and mandibular impressions. Casts are made, record
bases are constructed, and an interocclusal record is made at
approximately one-half to two-thirds of the maximum opening
exhibited by the patient (25 to 30 mm). Openings in excess of
this amount make it difficult for the patient to insert and re­
move the stent. The casts are mounted on a suitable articulator.
Two thicknesses of base plate wax are attached to the mandibu­
lar record base to form the portion of the stent which will de­
press the tongue. An occlusal index should be incorporated into
the record bases to ensure patient comfort, stability of the stent,
and a consistent position of the mandible. If the existing den­
tures are adequate, duplication of the dentures can be a quick
and easy way to begin fabrication. The duplicate dentures are
returned to the mouth, lined with a tissue-conditioning material
when necessary, and the tongue confining portion is fashioned
as previously described (Figure 4-8).
c
Some clinicians prefer to fabricate this stent intraorally using
a direct technique. The direct technique requires more clinical
experience to obtain acceptable results. Softened base plate wax
is formed within the patient’s mouth into the desired size and
shape. The wax is then indexed to the existing dentition (Figure
4-9). The resultant wax pattern is invested in a denture flask
and processed into methyl methacrylate resin.
A common problem observed during radiation is backscatter
from large metallic dental restorations. Backscatter may create
a more severe localized mucositis in adjacent tissues. This can
be prevented by having the patient wear fluoride trays during
therapy. This simple stent creates sufficient space between the
mucosa and metallic restorations to minimize the effects of back­
scatter. The intensity of the backscatter radiation decreases pro­
portionally to the inverse square of the distance (i.e., a small
separation greatly reduces the intensity).
Figure 4-9.
a and b: Positioner
be in g fa b ric a te d
using direct te ch ­
nique.

In certain tongue tumors, some radiotherapists prefer to
administer a moderate dose of external beam radiation therapy.
This is followed by a localized boost to the tumor site using
radioactive implants. If these radioactive implants are located
too close to the lingual aspect of the mandible, the mandible
can receive a significant dose of radiation. A simple but effec­
tive stent can be fabricated from autopolymerizing acrylic resin
or light cured resin. The stent is designed to rest between the
medial aspect of the mandible and the tongue. Since the effect
of radiation decreases rapidly with increased distance, this simple
device greatly reduces the absorbed dose to the lingual surface
of the mandible.
Peroral Cone Positioning Devices
Small superficial lesions in accessible locations in the oral
cavity may best be treated with a boost of radiation with a per­
oral cone. Using this technique, the patient receives a course of
external radiation beam therapy initially to a wider field. This is
followed with a boost of radiation delivered to the primary tu­
mor site through a peroral cone. The tumor site receives a higher
dose of radiation while sparing adjacent vital tissues such as the
mandible, teeth and salivary glands (Figure 4-10). Lesions that
are amenable to this technique should be small (usually T or T,
in size) and must be encompassed by one of the available cone
sizes. Most commonly, these lesions are located in the anterior
floor of the mouth, hard palate, soft palate, or oral tongue.
Fig. 4-10. Peroral cone was used to treat localized squa­
mous cell carcinoma. Note the well circumscribed
pattern of radiation mucositis.
Radiation Therapy o f Head and Neck Tumors 57
Fig. 4-11.
a and b: S tent to
p o s itio n p e ro ra l
cone in edentulous
patient. Note that
the stent positions
the tongue.
A custom docking device can be fabricated to orient the
peroral cone in a repeatable position. For an edentulous patient,
mandibular and maxillary record bases are fabricated. The ac­
tual peroral cone, or a cylinder of the same diameter as the cone,
is used to form an acrylic resin ring 5 to 6 cm in length. One
thousandth of an inch (0.00254 cm) thick tinfoil is wrapped
around the cone to insure its separation from the
autopolymerizing acrylic resin which is used to form the ring.
With the radiation therapist present, the acrylic resin cylinder is
attached to the maxillary record base with dental modeling plas­
tic, centering the acrylic resin cone over the lesion. This task is
best performed with the patient present, but the cast may be
used on occasion when the lesion is easily visualized. The treat­
ment cone should be inserted into the positioning stent for veri­
fication of position. If the dorsum of the tongue protrudes into
the end of the cone, a wax extension may be attached to deflect
or reposition the tongue (Figure 4-11). A beveled cone will usu­
ally serve the same purpose. For dentulous patients, maxillary
and mandibular occlusal indices are fabricated and the acrylic
resin cone attached in a similar fashion.
58 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Shielding
Judicious placement of cerrobend alloy can help reduce
radiation exposure to normal structures. Cerrobend alloy* is a
low fusing alloy (158°F) composed of 50% bismuth, 26.7%
lead, 13.3% tin and 10% cadmium. Shielding is helpful when a
patient is to receive a unilateral dose of radiation. Examples of
such anatomical sites are the buccal mucosa (Figure 4-12), skin,
and alveolar ridge (Figure 4-13). For example, the patient in
Figure 4-13 was scheduled to receive a unilateral field of radia­
tion for a lesion of the mandibular gingiva. The stent was de­
signed to displace the tongue away from the treatment area and
to increase the vertical dimension of occlusion. This increased
a alloy, c: Completed shield, d: Shield in mouth.
Fig. 4-12. a: Patient presents with squamous carcinoma of
buccal mucosa, b: Completed shield, c: Shield
positioned orally.
* Med-Tec. Inc., Dallas, TX.
a
c d
Fig. 4-13.
Shielding device. Patient presents with lymphoma of man­
dibular gingiva, a: Cast of overextended impression. Note
width of lingual flange area, b: Shield on cast with cerrobend
opening displaces the mandible inferiorly so the field of radia­
tion will encompass less of the parotid gland. On the medial
aspect of the mandible, an acrylic resin reservoir was devel­
oped. The walls of this reservoir should be at least 0.5 cm thick
to prevent backscatter to the mandible. The reservoir was then
filled with cerrobend alloy, and an acrylic resin cap was added
to seal the alloy in place. Ideally, the cerrobend alloy should be
1 cm or greater in thickness; however, this thickness is limited
by the displaceability of the tongue, determined while making
the impression (Figure 4-13). Cerrobend alloy is quite effective
in shielding an electron beam. It has been reported that a 1 cm
thickness of cerrobend alloy will prevent transmission of 95%
of an 18 MeV electron beam29.
Recontouring Tissues to Simplify Dosimetry
This type of stent is advantageous when treating skin le­
sions associated with the upper and lower lips. When the thera­
pist adjusts the beam for the midline, the dosage delivered will
be less at the comers of the mouth because of the convex curva­
ture of the lips and face in this region. A stent can be employed
to flatten the lip and comer of the mouth, thereby placing the
entire lip in the same plane. Such stents often are combined
with a shield. They are easily fabricated by forming dental mod­
eling plastic to the desired dimensions. This pattern is invested
and processed in acrylic resin.
 Radiation Therapy o f Head and Neck Tumors 59

Positioning a Radioactive Source
Brachytherapy is a technique used to deliver radiation over
a short distance, utilizing radioisotopes positioned into or close
to the tumor. A previously fabricated stent or radiation carrier is
used to position the radioactive sources (cesium 132 or iridium
192) near the tumor site. Radiopaque shields and/or tissue
positioners (stabilizers) can also be incorporated into the radia­
tion carrier to spare surrounding tissues from unnecessary ra­
diation exposure.
The radioactive sources may be either preloaded or
afterloaded into the radiation carrier. When preloading a car­
rier, the radioactive source (typically cesium) is positioned within
the prosthesis just prior to the earner being inserted. The medi­
cal staff receives some radiation exposure using this technique.
With afterloading techniques, the radiation carrier is designed
with hollow catheters in predesigned locations. Once the radia­
tion carrier is in position, radioactive isotopes (typically cesium
137 or iridium 192) are threaded into the hollow tubing. This
technique reduces radiation exposure to the medical staff.
The techniques for fabricating radiation carriers vary de­
pending on the anatomical site being treated. Generally, an im­
pression of the tumor site is made and a master cast is generated
from this impression. Occasionally, the master cast is made in 2
sections, such as in making an impression of the nasopharynx
or nasal cavity. Once the master cast is retrieved, the radiation
oncologist and/or radiation physicist determine the location of
the radioactive sources. They also determine the dosimetry based
upon source location and isotope strength. Armed with this in­
formation, the prosthodontist fashions the carrier from acrylic
resin or silicone. The completed carrier is positioned in the pa­
tient with dummy sources for simulation, and the final dosim­
etry is calculated by the radiation oncologist (Figures 4-14 and
4-15).

Fig. 4-14. Radiation carrier, a: Recurrence of previously irradiated squamous carcinoma, b: Master cast and acrylic resin stent,
c: Stent with polyethylene tubing, d: Tubing incorporated within stent, e: Completed stent with tubing and cerrobend shield, f:
Stent in position.

Fig. 4-15. a: Cast of squamous cell carcinoma of floor of mouth and alveolar ridge, b: Stent fabricated with polyethylene tubing
placed at prescribed distances from mucosal surface, c: Stent loaded with radioactive source after it has been positioned.
60 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Numerous articles have appeared in the literature describ­
ing the use of brachytherapy for treating a variety of anatomical
sites. Rosenstein described treatment of nasopharyngeal carci­
nomas with radiation carders30. With the patient under general
anesthesia, a silicone putty impression was made of the nasophar­
ynx. A silicone carrier was fabricated from the master cast. The
silicone carrier included some barium sulfate, which permitted
radiographic evaluation of the position of the carrier to facili­
tate dosimetry. The silicone carrier was preloaded with cesium
sources. Cano also described a technique for treating nasopha­
ryngeal carcinoma with brachytherapy31. A self-curing silicone
impression was made of the nasopharynx while the patient was
under general anesthesia. The silicone mold had hollow cath­
eters positioned appropriately so that the iridium source could
be afterloaded. Arksomnukit described the fabrication of a ra­
diation carrier to treat the nasal cavity32. The carrier was made
of silicone and had plastic tubing included for afterloading the
radioactive sources. This carrier also included a lead shield to
reduce exposure to adjacent structures. Meyer described the use
of a resin intranasal stent for stabilization and fixation of cath­
eters in predetermined locations in the nasal cavity33. The stabi­
lized catheters were then afterloaded with radioactive sources.
Randall used an afterloaded radiation carrier to treat a previ­
ously radiated carcinoma of the palate34. The prosthesis was
made of acrylic resin and incorporated afterloading catheters.
Cerrobend low fusing alloy was placed on the lingual surface
of the carrier to decrease radiation exposure to non-involved
but previously irradiated tissues. Cameron reported using
brachytherapy to treat tumors of the. lower lip35. The radiation
carrier was afterloaded with iridium 192. In addition, the car­
rier displaced the lip away from the alveolar ridge and incorpo­
rated a lead shield to protect the upper lip. This greatly reduced
the dose of radiation to the alveolus and upper Up. Herring and
Greene described the use of an existing mandibular denture as a
preloaded carrier (cesium) for treating the retromolar triangle,
floor of the mouth, and alveolar ridge36. Jolly and Nag described
using brachytherapy in the treatment of a recurrent maxillary
alveolar ridge carcinoma, a tracheal stoma recurrence, and re­
current disease along the medial canthus and medial aspect of
the orbit37.
Templates Used In Direct Implantation
Lesions of the tongue and anterior floor of the mouth often
are treated by direct implantation of a radioactive source in the
tumor. Occasionally, prosthodontic restorations are useful in
positioning the radioactive source. The radiation physicist and
radiation oncologist determine the position and placement of
the implant, and holes are drilled in the prosthesis to correspond
to the desired placement. The prosthesis aids not only in posi­
tioning the radiation source, but also in determining the proper
depth of insertion. Once the prosthesis is secured and the im­
plants have been placed, a tissue-conditioning material is flowed
over the implants to maintain them in proper position during
the treatment period.
Tissue Bolus Devices
Irregular tissue contours create uneven radiation dose dis­
tributions, and cause difficulty for the radiation oncologist. As
a result, some areas within the field of radiation may be un­
treated while other areas may develop isolated “hot spots”. A
bolus is a tissue-equivalent material placed directly onto or into
irregular tissue contours to produce a more homogeneous dose
distribution. The most commonly used materials for a bolus in
the head and neck region are saline, wax and acrylic resin.
Following orbital exenteration and maxillectomy, irregu­
lar contours and air spaces make it difficult to determine dose
distribution, particularly when the size of the air spaces result­
ing from these surgical procedures are larger than the entry points
through the orbit or palate. Tissues in greatest jeopardy of ra­
diation injury are skin grafts within the defects, broad areas of
thin mucosa over bone, and brain tissue, which is in close ap­
proximation to the posterior borders of the defect. Tissue sur­
faces which have been lined with split thickness skin grafts are
of particular concern during the first 3 weeks of radiation therapy,
when soft tissue reactions are most likely to occur. Loss of a
split thickness skin graft over tissues bordering the defect greatly
impairs the ability to restore function and cosmetic contours
with the obturator prosthesis.
A variety of methods have been employed for restoring
tissue density to facilitate radiation therapy. The placement of
thermoplastic materials, such as wax, within the defect is one
option. The physical properties of these thermoplastic materi­
als allow the clinician to develop the desired shape. However,
irritation of border tissues during insertion and removal, and
the unavoidable air spaces between the segments, make their
use time consuming as well as problematic. Gauze boluses
soaked in water can also be used to restore lost tissue density.
However, water seeps through nasal passages and down into
the pharynx, leading to discomfort, coughing, and aspiration.
A technique first reported by Myamoto restores tissue den­
sity in maxillary defect air spaces with saline38. The device con­
sists of a palatal stent, rubber bladder, and hose connector. Nor­
mal saline is used to fill a flexible bladder placed in the tissue
space. This method optimizes the dosimetry by restoring tissue
density throughout the defect, particularly at the margins, and
ensures uniform delivery of radiation to complex, irregularly
shaped contours. It also protects friable healing tissues, particu­
larly skin grafts, in the healing surgical wound. The device is
easy to insert and comfortable for the patient to wear.
Three and one half inch diameter, pure gum latex rubber
bladders are used. Dimensionally compatible bladder or hose
connectors are fabricated in polyurethane. A tissue surface po-

Fig. 4-16. a: Bladder secured to a two-part connector. As­
sembly imbedded within a palatal stent, b and c:
Assembly positioned within defect and the blad­
der filled with saline, d: CT scan of bladder filled
with radiopaque material.
Fig. 4-17. Surface bolus, a: Squamous cell carcinoma of tip o f nose, b: Cerrobend
nasal stent, c: Nasal stent in position, d: Surface bolus of acrylic resin and
cerrobend nasal stent in position.
Radiation Therapy o f Head and Neck Tumors 61
sitioning stent is fabricated with autopolymerizing acrylic resin,
to which the connector assembly is attached. Aplastic or rubber
hose is attached to the connector assembly and the bladder. The
bladder is attached to the plug shaped component of the 2-part
connector assembly. The central portion of the connector, with
the bladder attached, is then pressed into the second portion of
the connector, which is attached to the acrylic resin positioner
(Figure 4-16). Adhesive felt is placed at the border of the stent
to minimize the possibility of tissue irritation. The bladder is
then inserted and positioned in the defect and stabilized by the
opposing occlusion with an occlusal index. Once the palatal
stent is positioned, the bladder is filled with saline using a 50 cc
syringe. A finger-operated threaded clamp or hemostat constricts
the tubing beyond the radiation field, and prevents fluid escape
until completion of the treatment session. After the session is
completed, the hose is placed below the level of the defect, the
clamp is opened, and fluid is drained from the bladder (Figure
4-16).
Radiation delivery to extraoral structures that display ir­
regular tissue contours is also challenging. This can be simpli­
fied by filling voids and/or overlaying the irregular contours
with a bolus. Examples of such anatomic locations might be the
nose, ear or orbit. A facial moulage is made and poured in den­
tal stone. The radiation oncologist is consulted as to the treatment
field and the energy of the radiation to be delivered. From this in­
formation, a bolus is developed that extends beyond the edges
of the treatment field, is of known thickness, fills voids, and
smooths the tissue contours. These devices greatly simplify the
dosimetry calculations for the radiation oncologist (Figure 4-17).
62 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Radiation Effects
Oral Mucous Membranes
In oral mucosa, radiation effects appear early in the course
of therapy. Initially, an erythema appears that eventually leads
to extensive ulceration and desquamation, sometimes resulting
in a severe radiation mucositis (Figure 4-18). Pain and dysph­
agia, with resultant weight loss, are common. The mucositis
begins to appear 2 to 3 weeks after the start of therapy, reaches
a peak toward the end of treatment, and is most severe at the
tumor site. Similar changes are seen in skin. Initially, erythema
develops, leading to moist desquamation. Dry desquamation
results if the therapy is temporarily halted. Dry desquamation is
characterized by scaling and increased pigmentation (Figure 4-
18, dande).
c e
The mucosa of the oral cavity does not react in the same
manner in all locations. Severity of mucositis depends upon the
radiation fields, fractionation pattern and dose, and varies con­
siderably from patient to patient. Mucositis is most severe in
the soft palate, followed by, in descending order, the mucosa of
the hypopharynx, floor of the mouth, buccal mucosa, base of
the tongue, and the dorsum of the tongue. During this period,
acute candidiasis may occur (Figure 4-19). Patients with com­
promised oral mucous membranes secondary to alcoholism or
insulin-dependent diabetes exhibit the most severe mucosal
changes. Mucosal reactions are frequently intensified when
adjunctive chemotherapy is used to potentiate the effects of ra­
diation. After therapy, healing is rapid and usually complete in
2 to 3 weeks.
Fig. 4-18.
Acute radiation changes, a: Patient
is in fifth week of external beam ra­
diation therapy. Note large ulcerative
lesion on buccal mucosa. These ra­
diation induced ulcerations will re-epi-
thelize 3 to 6 weeks following comple­
tion of therapy, b: Radiation mucosi­
tis is particularly well localized. This
results when a metallic crown rests
against oral mucous membranes and
is in path of radiation beam. “Back-
scatter” raises radiation exposure lo­
cally, resulting in more aggressive
mucosal reaction. Prevention is eas­
ily accomplished by displacing buc­
cal mucosa or tongue away from the
crown with a stent, c: Radiation mu­
cositis: Note depapiliation of tongue,
d and e: Acute skin reactions. Note
skin scaling and increased pigmen­
tation.

Fig. 4-19. Candida albicans infection: Patient was in 5th
week of external radiation therapy for treatment
of squamous carcinoma of tonsillar area. He had
severe pain, and malaise. Examination revealed
numerous white colonies on hard and soft pal­
ate. Culture for Candida albicans was positive.
Infection resolved after treatment with nystatin oral
lozenges.
Changes in oral flora are thought by some investigators to
intensify radiation mucositis. Colonization by gram-negative
bacilli, in particular, appears to induce more severe mucosal
reactions during the later stages of radiation therapy. In a series
of experiments, Spijkervet attempted to minimize or prevent
mucositis during radiation by suppressing elements of the oral
flora such as fungi and gram negative bacilli39. Patients enrolled
in these studies received at least 5000 cGy with conventional
fractionation of 200 cGy per fraction or 1000 cGy per week.
First, he tested the effectiveness of chlorhexidine rinses on the
oropharyngeal ecology in 30 patients irradiated for oropharyn­
geal cancer. Half received a chlorhexidine spray-rinse while the
other half received a placebo spray-rinse solution. Carriage of a
particular microorganism was defined as “the condition in which
a study patient showed a minimum of 2 consecutive oral
washings positive for that microorganism”. A mucositis scor­
ing system was developed to measure the severity of the radia­
tion induced oral mucositis. The colonization index for strepto­
coccus viridens was reduced by a 5-week course of
chlorhexidine, but the colonization patterns of fungi and gram-
negative bacilli were not affected. There were no differences
between the study and experimental groups in the development
or severity of radiation mucositis. Twelve patients developed
pseudomembranes in each group after a mean of 18.8 days.
Spijkervet went on to demonstrate that the chlorhexidine bacte­
ricidal activity was reduced in saliva and was of limited value
in decontaminating the oral cavity of gram-negative bacilli39.
Radiation Therapy o f Head and Neck Tumors 63
Next, Spijkervet attempted to selectively suppress gram-
negative bacilli in the oropharynx in irradiated patients with an
oral lozenge consisting of 2mg polymyxin (Colistin), 1.8 mg of
tobramycin and 10 mg of amphotericin B39. The lozenges were
used 4 times per day in 15 patients being irradiated for oropha­
ryngeal cancers. In all patients enrolled in this study, the gram-
negative bacilli and fungi were eliminated from the orophar­
ynx. In addition, the severity of radiation mucositis was dra­
matically reduced. Mucosal reactions were limited to erythema
in all 15 patients. None progressed to pseudomembrane forma­
tion (as did 80% of the controls). Fungi carriage was within
normal values during radiation and was not a factor in the oc­
currence or severity of mucositis.
These studies have had significant impact on our view of
the etiology of severe cases of radiation mucositis and its sub­
sequent treatment. Until now, treatment during therapy has been
supportive and symptomatic (i.e., saline and soda rinses, vis­
cous xylocaine, systemic analgesics, and so forth). Occasion­
ally, nystatin oral suppositories, used as a lozenge, were em­
ployed to treat an oral fungal infection whose diagnosis was
made upon the basis of “clinical suspicion”. Spijkervet’s re­
sults, if verified by multicenter clinical trials, will undoubtedly
have great impact on our future treatment of radiation mucosi­
tis.
After therapy, there are significant changes in the field of
radiation which predispose to tissue breakdown and delayed
healing. The overlying epithelium becomes thinned and exhib­
its less keratinization, whereas the submucosa becomes less vas­
cular and more fibrotic. These late effects may be exacerbated
by hyperfractionated external radiation therapy40. These tissue
changes can make fabrication and tolerance of prosthetic resto­
rations more difficult and may induce an unknown factor of
risk (Figure 4-20). The clinical appearance of irradiated mu­
cous membranes is often a good indicator of individual toler­
ance and response. Transparent, pale-looking mucosa with
prominent telangiectasis are indicators of severe mucosal
changes. In such patients, minimal trauma in the field can result
in ulcerations, often requiring months for healing, and occa­
sionally leading to exposure of bone. Soft tissue ulcerations
occurring at the tumor site are difficult to differentiate from
recurrent disease (Figure 4-21). The so-called soft tissue radia­
tion necroses are non-indurated and quite painful, and these clini­
cal symptoms may be a valuable aid in differentiating them from
tumor recurrence. Exfoliative oral cytology can be a useful
supplement to clinical judgment in the evaluation of these le­
sions. Biopsy may be necessary to establish the diagnosis. Simi­
lar changes are also observed in skin. Chronic skin changes are
characterized by atrophy, telangiectasia and loss of skin append­
ages (Figure 4-20c).
64 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 4-20. Chronic soft tissue changes, a: Patient was treated with full course external radiation therapy for a squamous
carcinoma of anterior floor of mouth. Note scarring locally. Overextension of a denture flange in this area could
result in mucosal perforation, b: Patient received external radiation for carcinoma of floor of mouth. Note telangiectasia
within attached mucosa. Patient is poor candidate for mandibular denture, c: Late skin changes. Note loss of hair
within field (alopecia).

a
Fig. 4-21. Soft tissue necrosis, a: Patient presented with squamous cell carci­
noma of lateral border of tongue. He received 5500 cGy via Co60 fol­
lowed by 2500 cGy delivered by a radium implant. Nine months follow­
ing therapy he developed a 2 x 3 cm ulceration at tum or site. Cytology
and biopsy were negative, b: Lesion epithelized 7 months later.

Taste and Olfaction

Taste acuity is readily affected by cancericidal doses of
radiation41,42. Histologically, taste buds show signs of degenera­
tion and atrophy at 1,000 cGy43-44-45 and, at cancericidal levels
of radiation, the architecture of the buds is almost completely
obliterated. It is not known whether the changes observed in
taste cells and buds are due to direct radiation effects or indirect
effects resulting from impairment of innervation after therapy.
In experimental animals, when nerve fibers innervating the taste
buds are severed, the buds rapidly disappear. Most patients ex­
perience partial or complete loss of taste acuity during therapy.
Alterations in taste are discovered during the second week and
continue throughout the course of treatment. Perception of bit­
ter and acid flavors is more susceptible to impairment than salt
and sweet46. Taste gradually returns to near normal levels after
therapy is completed.
Some patients with severe xerostomia may never have nor­
mal taste acuity. The presence of saliva plays a significant role
in regaining normal taste acuity. Significant reduction of saliva
appears to decrease the number of taste buds and may alter the
form and function of the remaining buds47. Clinical trials with
zinc supplements have shown some promise45.
Olfactory loss in patients irradiated for head and neck can­
cer has not been well studied. However, since the olfactory epi­
thelium is high in the nasal passage and hence is not included
within the radiation field in treatment of most tumors, the sense
of smell is less affected. In a recent study, 12 patients were stud­
ied after irradiation of the olfactoiy mucosa48. In all 12, smell
thresholds for 2 test odorants increased dramatically after
completion of treatment. Six months after radiation treatment,
none of the 12 patients had achieved complete recovery.

Edema and Trismus
Edema of the tongue, buccal mucosa, and submental or
submandibular areas is occasionally clinically significant (Fig­
ure 4-22). Edema is most prominent in the submental areas fol­
lowing irradiation of lateral tongue or floor of mouth carcinoma,
and may make detection of recurrent local or regional disease
difficult Edema becomes apparent during the early postradiation
period when scarring and fibrosis begin to appear. Occasion­
ally, edema reaches proportions which compromise tongue
nobility, impair salivary control, and make denture utilization
a id speech articulation more difficult Recurrent tongue and
cheek biting is a common complaint and may require occlusal
alterations, removal of dentures, or placement of stents. A stent
can easily be fashioned to displace the tongue and/or buccal
mucosa and help alleviate this problem. This stent overlays the
teeth and can be fashioned of mouthguard material* on a dental
stone cast In some situations, the patients’ fluoride carrier can
serve the same purpose. The stent also prevents large metal res­
torations from directly contacting oral mucosa, and therefore
prevents localized severe radiation mucositis secondary to back-
scatter. When severe edema occurs in the floor of the mouth,
lingual denture extensions will be limited, impairing the stabil­
ity of the prosthesis. The severity of edema varies from day to
day and with the time of day, being most severe in the early
morning hours and diminishing as the day progresses. The re­
duced edema probably is a result of motor activities and the
patient’s assumption of an upright position. Occasionally, mas­
sage and exercise of the affected area are useful. Surprisingly,
most evidence indicates that the lymph channels are relatively
radioresistant Although direct effects of radiation are frequently
implicated, it is more likely that radiation-induced fibrosis im­
pairs the patency of both lymphatic and venous channels, re­
sulting in lymphatic and venous obstruction49,50. A radical neck
dissection may potentiate the effects and increase the edema.
Fig. 4-22. Edema. This patient is 9 months postradiotherapy
for a squamous carcinoma of the base of the
tongue. The edema of the buccal mucosa will pre­
dispose to recurrent cheek biting.
Penwalt Corp., Philadelphia, PA.
Radiation Therapy o f Head and Neck Tumors 65
Trismus is a disconcerting and often significant manifesta­
tion of cancerocidal doses of radiation therapy. It is most no­
ticeable following treatment of nasopharyngeal, palatal, parotid,
and nasal sinus tumors in which the temporomandibular joint
and muscles of mastication are in the radiation field. Maximum
mandibular opening may be reduced to 10 to 15 mm, impairing
mastication and preventing convenient oral access for a bolus
of food. Trismus occurs with unpredictable frequency and se­
verity. If the vertical dimension of occlusion is recorded at the
preradiation level in denture patients, the lack of sufficient
interocclusal space may compromise insertion of the bolus. Tris­
mus is accentuated by some surgical resections. Following a
total maxillectomy in combination with radiotherapy, trismus
may be of such severity that it impairs construction of an obtu­
rator of proper dimension and form. Border molding may be
difficult and lead to an under-extended prosthesis that compro­
mises seal, stability, support, and retention.
Treatment consists of exercise and the use of dynamic bite
openers. Dynamic bite openers are most effective in dentulous
patients but may be useful in selected edentulous patients. Open­
ing may be increased by as much as 10 to 15 mm. In patients
with a high risk of postradiation trismus, early manipulation
and exercise of the mandible probably lessens the severity of
impairment. Tongue blades, held together with adhesive tape
and used as a lever, have proven to be an inexpensive and prac­
tical alternative to dynamic bite openers. The discomfort pre­
cipitated during the required manipulation may prevent the pa­
tient from making meaningful progress.
Diet
During radiation therapy, loss of taste acuity, reduced sali­
vary output, and pain upon swallowing predispose the patient
to loss of appetite, nausea, and malaise. Not uncommon is a 20
to 30 pound weight loss. Enriched dietary supplements are use­
ful during this period. Citrus juices and other acidic foods can
result in oral discomfort and should be replaced with blander
items. As oral reactions become more profound, coarse foods
should be eliminated and the diet changed to a soft or semisoft
consistency. While dietary supplements may be a useful source
of calories, they should not be relied upon for the entire diet.
Also, care should be taken to avoid foods which favor an in­
crease in the activity of cariogenic microflora. Consultation with
a dietitian prior to radiation therapy can be of great value51.
Salivary Glands
Changes in volume, viscosity, pH, inorganic and organic
constituents of saliva are manifest following irradiation of ma­
jor salivary glands. These changes predispose the patient to car­
ies (Figure 4-23) and periodontal disease that may lead to more
serious bony infections. Increased viscosity and reduced flow
66 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
of saliva also contribute to impairment of taste acuity and poor
tolerance of prosthetic restorations. Swallowing becomes diffi­
cult and appetite is affected.
d b
F ig . 4-23. a, b, c, and d: Radiation caries. Patient was
treated for nasopharyngeal carcinoma. Teeth were
out of field of radiation.
.In view of the slow turnover rates exhibited by the epithe­
lium of the salivary glands, they should be relatively radioresis­
tant. Actually, the opposite is true. This apparent inconsistency
is related to the effect of radiation on the fine vasculature of the
gland. Available information suggests that changes observed in
the parenchymal epithelium after radiation are largely second­
ary to compromise of the fine vasculature.
During the early treatment period there is an infiltration of
the interlobular connective tissue, predominately with lympho­
cytes and plasma cells. Vacuolization of serous acinar cells oc­
curs within the first week. Interstitial fibrosis begins with the
appearance of numerous active fibroblasts. As treatment con­
tinues, there is progressive degeneration of acinar epithelium
with a progressive increase in interlobular and intralobular fi­
brosis. Serous acinar cells appear more readily affected by ra­
diation than mucous acinar cells. This effect may be caused by
the mechanism of initial damage, the relatively more rapid turn­
over rate of serous cells, or their more profuse vasculature as
compared to mucous acinar cells. Although degenerative
changes are observed in the secretory duct system, it remains
laigely intact after the completion of radiation treatment (Fig­
ure 4-24)5i53-54-55-56-57.
F ig . 4-24. a: Normal salivary gland, b: Irradiated salivary
gland. Note fibrosis and lack of acini in irradiated
gland. (Courtesy Troy C. Daniels).
 Radiation Therapy o f Head and Neck Tumors 67

Fig. 4-25. a and b: Initial bilateral posterior superior radiation fields used for nasopharyngeal carcinoma, c and d: Initial radia­
tion fields used for base of tongue carcinoma. Postero-superior radiation fields severely compromise salivary output
predisposing to radiation caries. More anterior and inferior fields that encompass most or all of body of mandible
predispose to osteoradionecrosis.

During therapy and for a few months thereafter, there is
evidence of varying degrees of recovery among acinar cells, as
demonstrated by attempts at secretion or mitotic activity. How­
ever, these attempts are followed by the continued degenera­
tion of the fine vasculature and progressive fibrosis. Ultimately,
the glands become reduced in size and become adherent to sur­
rounding tissues. Interstitial and interlobular fibrosis become
advanced, with marked degeneration of acinar elements (Fig­
ure 4-24). In some cases, regeneration of functional acini oc­
curs and, occasionally, may be clinically significant. Post-therapy
regeneration appears to be related to fields of therapy, dosage,
and age of the patient. Generally, the younger the patient or the
lesser the dose (below 5000 cGy), the better the chance for re­
generation and recovery.
Saliva originates from 3 sets of paired glands: the parotid,
submandibular, and sublingual, which are serous, mixed serous
and mucous, and mucous respectively. Under stimulated con­
ditions, the major glands produce over 90% of salivary flow
while the minor salivary glands account for the remainder. How­
ever, the submaxillary, sublingual and minor salivary glands
are responsible for most salivary production during non-stimu-
lated periods. The parotid is the biggest producer under stimu­
lated conditions. At moderate flow rates, it accounts for half the
salivary output and, at high flow rates, can account for two-
thirds of secretory production58. When all the major salivary
glands are within the radiation beam, mean salivary output can
be reduced from 86% to 93%59,60,61.
Changes in salivary secretions are quickly apparent to the
patient. Often within the first 4 or 5 treatments, some patients
note reduced output with increased viscosity. In posterior supe­
rior lesions (retromolar trigone, tonsillar area, soft palate, and
nasopharynx), in which all the major salivary glands are in the
radiation field (Figure 4-25a), secretory output can be almost
immeasurable at the end of therapy. Return of salivary function
is not significant in these patients and, consequently, the risk of
caries is high and everlasting. Conversely, in lesions of the floor
of the mouth, lateral tongue, and base of the tongue, the fields
are quite low (if a positioning stent is employed), sparing much
parotid tissue and resulting in significantly higher post therapy
salivary output (Figure 4-25b). In the latter group, the clinician
will often note increased secretory output 1 to 2 years after ra­
diation.
68 MAXILLOFACIAL REHABILITATION: PROSTHODONTTC & SURGICAL CONSIDERATIONS
The exact dosage level of radiation required to effect irre­
versible damage to major salivary glands is unknown. How­
ever, in many younger patients irradiated for Hodgkin’s dis­
ease, where Waldeyer’s ring is at risk for tumor and therefore
included in the radiation field, secretions appear to return to
near normal 12 to 18 months following completion of therapy
(fields include both parotid glands). The return of secretions
occurs even though these patients suffer moderate to severe
xerostomia in the immediate post-therapy period. Whether this
clinical observation is secondary to the total dosage, which ap­
proaches 4000 to 4500 cGy, the volume of salivary gland within
the field, or the biologic capability of the younger patient is
unknown.
The viscous nature of secretions after radiation is under­
standable when the radiosensitivity of the major glands is con­
sidered. The variable radiosensitivity, the fact that the sublin­
gual gland is partially out of the field in posterior superior le­
sions, and the increased sensitivity of serous acini to destruc­
tion all contribute to the viscous mucoid nature of postradiation
salivary secretions.
The changing nature of salivary secretions following
cancericidal doses of radiation therapy, and its effect on the car­
ies process, is well established. There is no doubt that the re­
duced output alone results in an exceedingly high predisposi­
tion for dental caries, but recorded changes in organic and inor­
ganic constituents and in pH have important effects on the car­
ies process. Until now, quantitative salivary changes were as­
sumed to be more important than the qualitative changes. A
study by Brown demonstrated that concentrations of the
immunoproteins and lysozyme per unit volume were higher after
radiation therapy62. Nonetheless, the total daily output was re­
duced sufficiently to create oral flora changes and lead to a higher
risk of dental caries. Although concentration levels of lysozyme
and immunoglobulins are elevated in the whole saliva of irradi­
ated patients, the dramatically reduced flow rates more than
offset the increase, thereby resulting in significant
immunoprotein deficit. Immunologic mechanisms are a potent
means of host protection. Their compromise is important rela­
tive to changes in oral flora, incidence of caries, and perhaps
also the severity of oral mucositis, and the incidence and course
of bone and soft tissue necroses.
The changes affecting the secretory duct system lead to
significant compromise of the buffering capacity of saliva. Re­
duced bicarbonate levels leads to a significant decrease in buff­
ering capacity following radiation of the major salivary
glands56,63. Bicarbonate concentrations appear to decrease as flow
rates decline and the radiation dose increases.
Decreased output and increased viscosity have an impor­
tant bearing on the use of removable prostheses. Saliva is an
effective lubricant at the denture-mucosal interface. With lesser
amounts of saliva present, more friction is produced during func­
tion. Additionally, peripheral seal in maxillary complete den­
tures may be difficult to obtain, ftirther compromising retention
in patients with deficient foundation areas. Changes in saliva,
combined with irregular bearing surfaces, induces an unknown
risk factor in patients using removable prosthodontic restora­
tions.
Attempts to stimulate salivary activity after therapy have
not been uniformly successful. Pilocarpine has been partially
successful in stimulating additional secretions in patients with
residual salivary gland parenchyma64,65,66. It has not been par­
ticularly helpful in patients for whom all major salivary glands
have been irradiated to high dose levels. Pilocarpine can be dis­
pensed in liquid form and used as a mouth rinse (lmg/cc, 5cc
per dose, 4 times per day) or in tablet form (5mg, 3 times per
day). Stimulating secretory activity during radiation therapy has
had very little beneficial long-term effect?7. Dosage levels above
20 mg daily may precipitate toxic side effects.
Attempts have been made to formulate salivary substitutes.
Mouth rinses based on carboxymethylcellulose, glycerin, and
mucin have received some attention and have been tested by a
number of investigators68,69,70. Attempts are being made to re­
produce the constituents of saliva in a mouth rinse. However,
patient responses have been mixed. Those who have difficulty
sleeping and/or speaking because of their xerostomia have re­
ported the most benefit70. Ideally, saliva substitutes should pro­
vide a protective coating for oral mucosa, maintain normal oral
flora population patterns, be capable of remineralizing decalci­
fied enamel, and be long lasting. All current formulations fall
far short of achieving these objectives.
Reducing the amount of salivary gland parenchyma within
the radiation field remains the most potent means of ensuring
reasonable salivary flow after radiation. For example, this may
be accomplished with the aid of positioning stents (see section:
Use o f Prosthodontic Stents and Splints During Radiotherapy)
when a patient is treated for an anterior two-thirds of the tongue
or a floor of the mouth lesion. However, treatment of tumors of
the nasopharynx, oral pharynx, or soft palate is difficult because
the fields of radiation usually are large, bilateral, and most are
equally weighted. Most of the major salivary gland parenchyma
receive doses in excess of 6500 cGy in these patients.
Bone
Since bone is 1.8 times as dense as soft tissue, it absorbs a
larger proportion of radiation than does a comparable volume
of soft tissue. With higher energy radiations, this phenomenon
is not nearly as pronounced as with low-energy sources. Since
the advent of high-energy apparatus, the incidence of
postradiation bone complications has declined somewhat. The
mandible absorbs more radiation than the maxilla because of
its increased density, and this, plus the mandible’s reduced vas­
cularity compared to the maxilla, accounts for the higher inci­
dence of mandibular osteoradionecroses.

Following cancericidal doses of radiation therapy, signifi­
cant changes are seen in bone. It becomes virtually a nonvital
tissue. Gross changes in the matrix of bone after irradiation are
relatively slow to develop. Early during treatment, however,
significant aberrations occur associated with the fine vascula­
ture and lead to progressive occlusion and obliteration of smaller
vessels (sometimes referred to as obliterative enteritis). Within
bone, this results in a reduction of the number of cells, disorga­
nization of the remodeling apparatus, and progressive fibrosis.
The rate of these progressive changes depends upon the dose
and the degree of initial damage. The late effects observed after
radiation are similar to the natural changes occurring mote slowly
with aging. The marrow exhibits marked acellularity and avas-
cularity, with significant fibrosis and fatty degeneration (Figure
4-26). Occlusion of the inferior alveolar artery has been dem­
onstrated in animals71 and in humans72. Some lacunae may be­
come devoid of their osteocytes; the endosteum atrophies with
significant loss of active osteoblasts and osteoclasts. The peri­
osteum demonstrates significant fibrosis with a similar loss of
remodeling elements71'73,74. Such bone exhibits a poor response
to trauma and infection, so the high incidence of osteoradion­
ecrosis in irradiated patients is not surprising. The histopatho-
Fig. 4-27.
a and b: Patient re­
ceived external radia­
tio n the rapy (7050
cGy) for lateral floor of
mouth lesion. Note the
dram atic change in
trab e cu la r patterns
betw een pre- and
postoperative radio­
graphs. Patient was
asymptomatic.
Radiation Therapy o f Head and Neck Tumors 69
Fig. 4-26.
Radiation effects; bone. Patient
had received 7000 cGy for a ton­
sillar pillar squamous carcinoma,
a: Shown are dentin, cementum,
periodontal ligament, trabeculae,
and marrow spaces, b: Take par­
ticular note of avascular and
acellular nature of the marrow
and lack of organized endos­
teum. c: Haversian systems.
Central artery is often missing.
Note empty lacunae.
logic changes seen in bone after therapy are of little signifi­
cance if the bone does not become exposed and infected. Alter­
ations in radiographic appearance, however, may cause some
alarm (Figure 4-27).
These tissue changes profoundly affect the remodeling ca­
pability of bone. Adult bone is changing continuously by the
destruction of certain areas and the reconstruction of new areas.
Osteoblastic and osteoclastic activity is responsible for this phe­
nomenon. This well-balanced process of destruction and recon­
struction is disturbed by cancericidal doses of radiation therapy.
.Whether the change in osteoblastic and osteoclastic activity is
secondary to vascular damage or to direct cellular damage from
radiation is still not clear71. Both phenomena may be important.
Because of compromised remodeling, the surgeon must
smoothly contour the alveolar ridge at the time of preradiation’
dental extractions. If radical alveolectomies are not performed
on these patients, the resulting alveolar ridge will not readily
remodel and will be quite irregular (Figure 4-28). Construction
and wear of mandibular dentures on such an irregular bony base
is quite risky in an irradiated patient, for it may lead to exposed
bone and, subsequently, to osteoradionecrosis.
Fig. 4-28.
Inadequate alveolectomy has been performed on patient.
Even though alveolar ridge is covered with healthy mucosa,
its irregular morphology precludes the use of complete den­
tures at this time. (Source: Curtis TA, Griffith MR, Firtell DN:
J Prosthet Dent. 36:66;1970.)
70 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Periodontium
The periodontal ligament likewise exhibits changes which
predispose to infection. Its rather specific network of fibers be­
comes disoriented and the periodontal ligament thickens71'73
(Figure 4-29). It exhibits decreased cellularity and vascularity,
also. Clinical experience indicates that many osteoradionecro­
ses are preceded by periodontal infection associated with teeth
in the primary beam of radiation75. When evaluating teeth for
extraction prior to treatment, the periodontal status of the denti­
tion is the most important dental consideration, aside from pre­
existing acute infectious processes.
Cementum demonstrates changes similar to those seen in
bone. Its capacity for repair and regeneration is severely com­
promised. Therefore, periodontal procedures, such as flap sur­
gery, in the radiation field should be considered with caution—
especially in the mandible when doses above 5500 cGy are used.
At these doses and above, reattachment of the zonal epithelium
will be comprised after most aggressive procedures.
a b
Fig. 4-29. Periodontal ligament, a: Irradiated periodontal
ligament that received 7000 cGy. Note changes
in arrangement of periodontal ligament fibers in
irradiated specimen, b: Irradiated periodontal liga­
ment that received 5000 cGy. Note cellularity, or­
ganization of fibril groups and improved vascu­
larity compared to subject that received 7000 cGy.
Teeth
The evidence is unclear whether there is significant change
in the crystalline structure of enamel, dentin, or cementum fol­
lowing cancericidal doses of radiation therapy. Some investi­
gators have reported that irradiated teeth decalcify more readily
than non-irradiated teeth76, but others have noted no difference
in decalcification rates in vitro77. Weiner was unable to demon­
strate change in enamel solubility or chemical composition fol­
lowing radiation78. It is unknown whether changes occurring in
the oiganic matrix of enamel and dentin would predispose to
decalcification and dental caiies.
There appear to be significant changes in pulp tissue. Ani­
mal experiments indicate that, although odontoblasts may not
be altered morphologically by significant doses of radiation
therapy (4200 to 6900 cGy), their secretory metabolism may be
affected. Abnormal tooth deposits, with excessive formation of
osteodentin by odontoblasts, have been observed in several spe-
cies79,80,81 as well as in humans (Figure 4-30). Most investiga­
tors agree that the pulp shows a decrease in vascular elements,
with accompanying fibrosis and atrophy73,79. Clinically, pulpal
response to infection, trauma, and various dental procedures
appears compromised. Pulpal pain, however, is less severe, even
in the presence of advanced caries with obvious pulpal expo­
sure.
Root sensitivity following full course radiotherapy may be
severe in a very small number of patients. An explanation for
this phenomenon has not been found. Burnishing the exposed
surface with a 1% fluoride solution has been effective in reduc­
ing pain and sensitivity.
Levels of radiation exposure as low as 2500 cGy can have
a marked effect on tooth development82-83. If exposure occurs
before significant calcification is completed, the tooth bud may
be damaged or destroyed. Exposure at a later stage of develop­
ment may arrest growth and may result in irregularities in enamel
and dentin. The dentitions of those patients receiving moderate
to high levels of radiation, with a large volume of tissue in­
cluded in the radiation field, reflect a variety of defects that
indicate the several stages of development existing during the
course of radiotherapy (Figure 4-31). Affected teeth, with sur­
face irregularities, usually require full coverage restorations.
Fig. 4-30. Specimen of human dental pulp received in ex­
cess of 6000 cGy. Note osseodentin formation.

b looked (Figure 4-32). These infections, although common dur­
F ig . 4-31. a and b: Patient received 3000 cGy at age three
to the maxilla and mandible. Changes reflect a
variety of defects that indicate the several stages
of development existing during the course of ra­
diotherapy.
Composition of the Oral Flora
The evidence is quite clear that radiation fields that include
substantial portions of major salivary glands lead to significant
changes in the balance of components of the oral flora that pre­
dispose an individual to dental caries and other oral infections.
Numerous studies have documented pronounced population
shifts in microbial oral flora with cariogenic microorganisms
gaining at the expense of the noncariogenic microorganisms.
Among aerobic organisms, significant increases have been noted
in the relative number of Streptococcus mutans and Lactobacil­
lus at the expense of Streptococcus sanguis, Neiseria, and Fu-
sobacterium. Among anaerobic organisms, increases have been
noted mActinomyces populations. Changes in oral flora are long
lasting, and are felt to be secondary to the radiation-induced
xerostomia rather than from more direct effects of the radia­
tion. In patients who had a major portion of the oral cavity in
the field, but had substantial areas of salivary gland tissue spared,
little or no floral changes were noted. The amount of plaque per
unit area increased as xerostomia became more profound. Total
microorganisms per gram of plaque, however, remained con­
stant with changes noted only in bacterial composition84’85,86.
Radiation Therapy o f Head and Neck Tumors 71
Strong evidence indicates that Streptococcus mutans is the
predominant microorganism associated with dental caries. Con­
vincing worldwide epidemiologic evidence, numerous studies
using animal models, plus the unique physiologic capabilities
of the organism support this view. The striking increase in the
Streptococcus mutans component of the streptococcus popula­
tion in the plaque of patients with radiation induced xerostomia
(1.6% of the total prior to radiation and 43.8% after radiation86)
provides additional evidence supporting the assumptions made
regarding this organism and its relationship to the caries pro­
cess. Although Actinomyces probably plays a minimal role in
caries, its increase in relative numbers cannot be ignored. It
may be an important factor in lowering salivary pH.
Brown has reported up to 100-fold increases in fungal popu­
lations86. This increase in fungal populations, although of little
or no importance in the caries process, does have other clinical
implications. Severe oral infections of Candida albicans result
in discomfort and morbidity during and after radiation therapy.
Post-therapy chronic candidiasis of the comers of the mouth
and beneath prosthetic restorations is common and often over­
ing delivery of radiation therapy, occur with increased frequency
in the posttreatment period. The acute form appears as erythema
and a burning sensation of the oral mucous membranes. Nysta­
tin continues to be the most useful drug in treatment of the
chronic and acute forms of candidiasis, and oral lozenges re­
main the most effective means of delivery. Considering the high
sucrose content of these lozenges (435 mg per lozenge), ex­
tended use in the dentate patient should be accompanied by a
strict oral hygiene regimen and topical fluoride use. The dete­
rioration of silicones intraorally in the presence of Candida
albicans is of special importance because of the value this ma­
terial has in gaining access to undercuts in patients with large
maxillary defects. In irradiated patients, the silicones have ex­
hibited reduced life expectancy. The changes in oral flora fa­
voring these fungi is responsible for this phenomenon.
Fig . 4-32.
Chronic candidiasis is common in irradiated patients. Patient
received full course radiotherapy for tonsillar carcinoma. She
periodically develops angular cheilitis which when cultured
indicates presence of Candida albicans. Lesion is reversed
with use of antifungal cream.
72 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Daily applications of topical fluoride have failed to affect
dramatic changes in the quantitative or qualitative composition
of the oral flora in irradiated patients, but one study revealed a
temporary delay of microbial population shifts during radiation
therapy86. Although the rates of increase in acidogenic microf­
lora were found to be delayed, it is probably of little signifi­
cance relative to the long-term incidence of caries in these pa­
tients. The primary benefit of fluoride results from its incorpo­
ration into enamel and dentin and, when replenished daily to
maintain adequate levels, caries are dramatically reduced60.
tient. Experience indicates that the clinician should not rely on
specific rules for guidance when arriving at such decisions.
Obviously, before arriving at a final decision, consultation with
the radiation therapist is mandatory. The following issues should
be considered before making decisions regarding extraction or
retention of teeth87. For purposes of discussion, they are divided
into 2 categories: dental disease factors and radiation delivery
factors.
Dental Disease Factors

Dental Management-Dentuious Patients
Criteria for Preradiation Extraction
The majority of patients developing osteoradionecrosis are
those with teeth present prior to the beginning of radiation
therapy. Hence, many questions arise concerning dental evalu­
ations before initiation of radiation treatment: How does one
manage the dentulous patient prior to therapy? Which teeth
should be extracted? How should they be extracted? How long
should one wait to begin radiation therapy after tooth extrac­
tion? and How does one maintain the remaining dentition dur­
ing and after radiation therapy? These are difficult questions
and historical reviews of the literature indicate significant con­
troversy. Some clinicians have recommended full mouth ex­
traction prior to therapy, whereas others prefer to extract only
those teeth in the primary beam. Still others discourage
preradiation extraction of teeth insofar as dental pathology per­
mits. We think that a number of factors should be considered
before deciding upon dental extraction for any particular pa­
Condition o f the residual dentition The clinician’s pri­
mary goal should be to place the dentition in optimal condition
so that high risk dental procedures will not have to be performed
in the posttreatment period. All teeth with a questionable prog­
nosis should be extracted before radiation. Teeth with advanced
carious lesions (with pulpal exposure), periapical infection, and
significant periodontal bone loss are most suspect.
The patient’s periodontal status is most important in this
assessment. Dentitions with significant periodontal deficiencies
are difficult to maintain and are susceptible to caries and infec­
tion. An aggressive extraction philosophy is recommended in
the management of dentitions with periodontal involvement.
We believe significant furcation involvement o f mandibular
molar teeth in the radiation field is groundsfo r preradiation
extraction in most patients, particularly i f the dose to the
immediate area is above 5500 cGy (Figure 4-33 ). The pres­
ence of moderate caries is less important, since in most instances
it is restorable and can be controlled with appropriate oral hy­
giene measures and topical fluoride applications. Mandibular
teeth in the primary beam should receive the closest scrutiny.

a b c

Fig. 4-33. a: Preradiation dental radiograph. Note furcation involvement of teeth #18 and #19 and endo-perio lesion associ­
ated with tooth #31. There was an incipient furcation involvement of tooth #30. Therefore, all mandibular molars
were extracted prior to radiation, b and c: Periodontal infections of mandibular molars led to an osteoradionecrosis
in this patient.

Dental compliance o f the patient This factor is a highly
important consideration when evaluating a patient for dental
extractions prior to therapy. Hygiene becomes increasingly dif­
ficult after treatment that results in reduced salivary output. Tris­
mus, impaired motor functions, and surgical morbidities may
also compromise oral hygiene procedures. Patients must pos­
sess the motivation and the physical ability to maintain their
dentition properly. Without the patient’s help and cooperation,
the risk of complications is increased immeasurably. The less
motivated the patient, the more aggressive one should be in the
extraction of teeth prior to therapy. The awareness and motiva­
tion of the clinician is of no less importance. The patient’s oral
hygiene at the initial examination is often a reliable indicator of
future performance. If oral and dental health is to be maintained,
the patient must understand the implications of his or her radia­
tion therapy and be disposed to carry out the prescribed proce­
dures. These instructions must be reiterated constantly because
patients often foiget or fail to grasp the issues with a single
presentation.
Radiation Delivery Factors
Urgency o f treatment The status and behavior of the tu­
mor may preclude preradiation dental extractions, since delays
secondary to healing could significantly compromise control of
the disease. The dentist, radiation therapist, and patient must
accept the attendant risk of complications and must attempt to
maintain oral health at an optimum level. Control of the tumor
obviously is the most important consideration.
Mode o f therapy Radiation is delivered to the tumor ei­
ther by an external source or by implanting radioactive materi­
als. In external therapy, the radiation beam often must traverse
important structures before reaching the tumor and, conse­
quently, salivary gland, periodontium, and bony tissues may be
damaged. However, when external beam therapy is used in com­
bination with radioactive sources implanted in the area occu­
pied by tumor (brachytherapy), the dose to adjacent tissues is
reduced and the radiation is more confined. Rarely is salivary
gland function significantly compromised by combined exter­
nal-interstitial therapy. Consequently, radiation caries is not as
significant a problem in patients treated in this manner. In these
patients, extraction of teeth after radiation therapy does not in­
volve high risk (unless the teeth and bone are adjacent to the
implant), since the dosage delivered by the external beam por­
tion of therapy rarely exceeds 5500 cGy. Osteoradionecrosis is
more common when the implant is located in close proximity
to the bone. Pretreatment extractions should be considered when
teeth with pathology are located close to the implant site.
When external radiation is the sole means of radiation de­
livery, close scrutiny of the dentition is mandatory because sali­
vary glands and bone will be exposed to higher doses of radia­
Radiation Therapy o f Head and Neck Tumors 73
tion (6500 to 7200 cGy). Depending upon fields and dosage,
external radiation increases the risk of complications such as
caries and bone and soft tissue necroses. Hence, a more aggres­
sive philosophy is used in removing teeth prior to therapy.
The majority of patients are treated solely with external
beam therapy. However, when both external and interstitial
therapy are used, the external dosage used is generally limited
to 5000 to 5500 cGy. Therefore, in this instance, decisions re­
garding extraction of teeth are dictated by the location and dos­
age administered by the interstitial implant. For example, if a
patient is to receive combined therapy (a 5000 cGy external
beam plus a 3000 cGy interstitial implant) for a carcinoma in
the right floor of mouth, the lingual surface of the right man­
dible is likely to receive over 7500 cGy. The presence of teeth
in this region predispose to a high rate of bone necrosis. There­
fore, these teeth should probably be extracted unless they are in
excellent condition and the patient has a history of good dental
compliance. The opposite side of the mandible will receive less
than 5500 cGy, approximately 5000 cGy from the external beam
therapy, plus a small amount from the interstitial implant. Since
the dose to the mandible on the left side is below 5500 cGy, the
risk of necrosis is low and teeth in this area need not be ex­
tracted unless they demonstrate advanced periodontal bone loss
or periapical pathology. Postradiation extractions of mandibu­
lar teeth at this dosage level can be carried out with a minimal
degree of risk88.
Radiation fields The risk of caries or necrosis is depen­
dent upon the radiation fields. Consequently, the fields are im­
portant to consider when evaluating the dentition prior to therapy.
For instance, in lesions situated in the nasopharynx and poste­
rior soft palate, in which the field is directed superior-posteri-
orly and includes both parotid glands (Figure 4-25, a and b), the
risk of postradiation caries is high because of the profound xe­
rostomia that results. However, since little of the body of the
mandible is included in the radiation field, the incidence of bone
necrosis is low in this group75. We therefore advocate a conser­
vative philosophy when considering extraction of teeth in such
patients. In this group of patients, postradiation extractions in
both mandible and maxilla may be performed with less risk.
When external beam radiation is the sole means of therapy
for lesions of the lateral tongue and floor of the mouth, the fields
(Figure 4-25, c and d) will encompass the entire body of the
mandible but the superior one half of both parotid glands are
usually spared. Hence, salivary flow, although reduced, is not
as profoundly impaired as it is in the more posterior-superior
radiation fields. Radiation caries have not proven to be as preva­
lent in this group of patients. The incidence of osteoradionecro­
sis, however, is higher75. Since dental disease causes most os­
teoradionecroses, all questionable teeth should be extracted, par­
ticularly mandibular molars with furcation involvement. The
clinician must attempt to place the patient’s dentition in optimal
74 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
condition so that after therapy, extractions need not be performed
in the postradiotherapy period.
When treating tonsillar, soft palate, or retromolar trigone
carcinomas, the radiation field will include the major salivary
glands and a significant portion of the body of the mandible.
Clinical experience indicates that both the incidence of caries
and osteoradionecrosis is high in this group89. We believe a more
aggressive approach to preradiation extraction of teeth is justi­
fied in these patients, especially mandibular molars within the
radiation field.
Mandible versus maxilla Almost all osteoradionecroses
occur in the mandible75’90-91,92,93,94. Osteoradionecrosis in the max­
illa is rare and, therefore, a conservative approach regarding
preradiation extraction of teeth in the maxilla is justified. Ex­
traction of maxillary teeth in the radiation field can be performed
after radiation therapy with little risk of a bony infection. A far
different situation exists in the mandible, where exposure of
bone and infection after therapy may lead to the loss of large
mandibular segments, resulting in significant morbidity. Con­
sequently, a more aggressive management approach is advo­
cated when evaluating mandibular teeth for extraction prior to
therapy. Particular attention should be directed to the mandibu­
lar molars when they are in the radiation beam, since this area is
a common site of osteoradionecrosis75.
Prognosis fo r tumor control Tumor prognosis can be of
predominant importance in patients in whom palliation and re­
lief of symptoms is the primary goal of the radiation therapist.
Teeth that ordinarily would have been extracted in a patient
with a more favorable prognosis are not extracted in terminal
patients. If the clinician thinks that the remaining teeth will cause
the patient unnecessary pain and discomfort during his remain­
ing days, they probably should be extracted. However, if ex­
tractions could compromise the functional or emotional well
being of the patient, they probably should be deferred.
Dose to bone The higher the dose, the higher the inci­
dence of postradiation sequelae95. For tissues treated to the high­
est level of tolerance, a more aggressive program of extracting
teeth prior to therapy is indicated. Conversely, for tissues treated
more conservatively, a less aggressive approach is indicated.
For example, consider a patient with a TN0M0squamous carci­
noma of the right lateral tongue that is to receive 5000 cGy
external beam therapy, plus a boost of 3000 cGy to the primary
tumor with an iridium implant The left mandible will receive
slightly more than 5000 cGy and, therefore, a more conserva­
tive approach in extracting teeth from this region is justified
prior to therapy. If the teeth on the left side of the mandible
become diseased after radiation therapy, they can be extracted
with virtually no risk of osteoradionecrosis because the dosage
is below 5500 cGy.
The type of tumor will also dictate the radiation levels used
in treatment. Patients treated for Hodgkin’s disease receive dos­
age levels which reach4000 to4500 cGy, whereas patients with
squamous cell carcinoma of the oral cavity receive 6500 to 8500
cGy. Although osteoradionecroses have been reported at these
lower radiation levels, occurrence is rare. In addition, lympho­
mas and Hodgkin’s disease occur in a younger population of
patients whose capacity for repair is greater. Clinical experi­
ence indicates that post-therapy extractions involve less risk in
this particular patient population.
Preradiation Extractions
Current Philosophies and Literature Review
Prophylactic extraction of diseased teeth in the radiation
field has been considered by most clinicians as a means of re­
ducing the long-term incidence of bonenecrosis73,96,97,98,99. Some,
however, propose that preradiation extractions increase the risk
of bone infections91’92,100’101’102. However, specific data indicat­
ing the risks of osteoradionecrosis, and its relation to timing of
extractions, dosage levels, and radiation fields employed, may
never be available. We believe that a moderately aggressive
policy o f preradiation extraction will minimize the risk of os­
teoradionecrosis. Opinions are, however, mixed.
The dilemma is that, as one becomes more aggressive in
removing mandibular teeth in the radiation field prophylacti-
cally prior to radiation therapy, the rate of bone necrosis in­
creases as a consequence of these extractions. If the clinician is
relatively conservative regarding the removal of mandibular
teeth within the field prior to therapy, the rate of post-therapy
spontaneous bone necroses increases due to dental infections
associated with the remaining teeth. We feel the overall rate of
necrosis is minimized when the clinician employs a philosophy
of preradiation tooth removal somewhere between these ex­
tremes.
Wildermuth and Cantril reported 6 out of 14 patients re­
quiring dental extractions prior to therapy developed bone ne­
crosis101. The time interval between extraction and commence­
ment of therapy was 9.5 days in the osteoradionecrosis group
and 15.3 days in the non-osteoradionecrosis group. Orthovoltage
was used, and dosage levels ranged from 4100 to 6300 cGy in
those requiring dental extractions. Six patients requiring
postradiation dental extractions did not develop osteoradion­
ecrosis. Based on these data, Wildermuth and Cantril suggested
that extractions prior to radiation were not prudent.
Daly and Drane reported that 22 of 74 bone necroses oc­
curred in patients at the site of preradiation dental extractions91.
Average healing time before radiation commenced was 11.1
days. Thirteen of these patients had 10 or more days of healing
and 5 patients had 2 weeks or more. They suggested that only
completely unsalvageable teeth should be removed prior to ra­

diation. They thought that if extractions were difficult or rapid
tumor growth required immediate commencement of radiation,
teeth should not be consideredfor elective removal.
Starcke and Shannon reported that bone necrosis did not
occur in any of the 62 patients requiring preradiation extrac­
tions103. The average time interval between extractions and ra­
diation was 25.3 days, with a range of 5 to 72 days. Only 15 out
of 62 patients enjoyed healing periods of less than 15 days.
Dosage levels were somewhat low, as 36 of the 62 patients re­
ceived less than 6000 cGy. No patient received in excess of
7000 cGy. Starke and Shannon concluded that dental extrac­
tions by themselves are not associated with an increased inci­
dence of bone necrosis. He suggested that the time interval be­
tween dental extraction and radiation therapy is not critical. We
feel that, while the average 25-day healing time may reduce or
possibly eliminate the risk of necrosis, it may compromise the
opportunity for cure for some patients.
Two studies at the same institution (M.D. Anderson Hos­
pital and Tumor Institute), both reviewing essentially the same
data, serve to illustrate the paradox regarding preradiation ex­
tractions expressed in the literature. Bedwinek believed that elec­
tive dental extractions prior to therapy increased the risk of bone
necrosis92. During a period of elective dental extraction, 24 of
203 patients developed bone necrosis from preradiation extrac­
tions. During a subsequent period of dental conservation, 4 of
203 patients developed bone necroses from preradiation extrac­
tions. Unfortunately, the delineation between elective dental
extraction and dental conservation was not well defined. Also,
data was not provided for either group regarding the number of
patients who required preradiation extractions or who subse­
quently developed bone necroses from post-therapy, tooth-re­
lated dental infections.
Murray came to different conclusions regarding the effi­
cacy of a conservative policy of extraction of teeth93,94. The
records of 236 dental patients who received dental evaluations
prior to therapy were reviewed. Two hundred and eleven dentu-
lous patients were selected for study based upon the complete­
ness of follow-up records. Pre-therapy dental extractions were
performed for only 25 of these patients. They observed that the
rate of spontaneous bone necrosis increased to 25.1% among
these patients during this conservative period of preradiation
extraction.
Murray also compared the incidence of necrosis occurring
at extraction sites between the conservative and the more ag­
gressive extraction periods93,94. Osteoradionecrosis occurred in
24 of 132 patients (18.1%) in the non-extraction group. Murray
and his coworkers proposed that, although a conservative policy
of tooth removal before therapy may reduce the incidence of
bone necrosis secondary to preradiation dental extraction, this
policy predisposes patients to a significant increase in the post­
therapy incidence of spontaneous necroses; many of which can
be attributable to dental disease.
Radiation Therapy o f Head and Neck Tumors 75
Beumer reported the results using a moderately aggressive
philosophy of preradiation extraction99. Mandibular teeth in the
radiation field were carefully scrutinized, and mandibular mo­
lars with roentgenographic evidence of furcation involvement
were invariably extracted. Caries did not mandate extraction
unless there was clinical or roentgenographic evidence of pul-
pal exposure and/or significant pain. All teeth within die field
demonstrating periapical pathology were extracted. Maxillary
teeth were seldom removed, even when they were in the radia­
tion field, except where dental pathology was severe or the teeth
involved were symptomatic. When mandibular teeth were ex­
tracted, mucoperiosteal flaps were reflected, and radical alveo-
lectomies were performed to permit primary closure without
tension. Maxillary teeth were extracted using conventional sur­
gical techniques, but alveolectomies were less aggressive and
primary closure was seldom achieved. Patients received antibi­
otics during the immediate post-extraction period.
In this study, 120 patients submitted to preradiation extrac­
tion of teeth in the radiation treatment volume99. Of the 106
patients undergoing extraction of mandibular teeth within the
treatment volume, 17 (16%) eventually developed bone necro­
sis at extraction sites. Twelve occurred spontaneously, 2 devel­
oped in association with tumor regression when teeth were ex­
tracted in the tumor bed, and 3 were caused by irritation from
new mandibular complete dentures inserted after completion
of therapy (Table 4-1). Of the 44 patients undergoing extraction
of maxillary teeth in the radiation treatment volume, only 1 de­
veloped a bone necrosis, and this occurred with regression of
the primary tumor.
Ninety-one of the 106 patients submitting to mandibular
extractions in the radiation treatment volume received only ex­
ternal radiation therapy. Twelve of these 91 patients (13 inci­
dents) developed bone necrosis at preradiation extraction sites:
8 spontaneously, 3 associated with the use of mandibular com­
plete dentures inserted after therapy, and 1 associated with tu­
mor regression (Table 4-2). Seven of the 8 bone necroses were
noted at the termination of or soon after completion of radiation
therapy. There were no statistically significant differences in
tumor dosage or healing time prior to extraction between the
necrosis and non-necrosis groups (Table 4-3).
Thirteen of the 106 patients requiring extraction of man­
dibular teeth in the radiation field were treated with external
radiation therapy combined with an interstitial implant, or a re­
lated treatment modality therapy. Five of these 13 patients de­
veloped bone exposure at preradiation extraction sites. Two other
patients eventually developed bone exposures of the mandible
in locations distant from preradiation extraction sites. In all 7
cases, however, a review of radiation records revealed the im­
plant source had been placed adjacent to the site of subsequent
bone necrosis. A comparison of tumor doses and healing times
for extraction wounds revealed no statistically significant dif­
ferences between the osteoradionecrosis group and the non-os­
 Radiation Therapy o f Head and Neck Tumors 77

Table 4-3. Patients treated with external radiation alone submitting to extraction of mandibular teeth in the
radiation field.*

Osteonecrosis Nonosfeonecrosis
group group

Patients 12 79
| Tumor dosage (cGy)
Range 6,000-7,278 5,200-7,400
Average 6,568 - 6,469
Healing time
Range -6 to 15 days -28 to 33 days
Average 9.8 9.76
(-) Implies that teeth were removedafterradiation therapy hadbegun.

^ H a w is o t^ R , Slanders B, Kurrascj5 _M. Preradiation dental extraction

and thejncide/ieaof:'osteor,adionecrosis. Head and Neck Surg. 5:514; 1983.

teoradionecrosis group. O f the bone necroses occurring at
preradiation extraction sites, complete epithelialization of ex­
traction wounds had been noted in 4 of them after completion
o f therapy, and bone exposures subsequently became apparent
4 to 6 months later.
Thirty-nine patients received external beam radiation
therapy delivered by means of equally opposed bilateral man­
dibular fields encompassing 75% or more of the body of the
mandible (Table 4-2). Eleven patients (28%) developed bone
necrosis at the site of a preradiation dental extraction. Eight
presented spontaneously, 2 occurred in association with tumor
regression, and 1 resulted from denture irritation. When the ra­
diation fields included from 25% to 75% of the mandibular body,
necrosis occurred at preradiation extraction sites in 5 of 54 pa­
tients (9.3%) (3 spontaneous and 2 from denture irritation). One
additional necrosis occurred at an extraction site in a patient
treated with a unilateral posterior mandibular field (Table 4-2).
Of the 12 patients (13 incidents) who developed bone ne­
croses spontaneously at an extraction site, 4 healed with con­
servative therapy with sequestration of particles of nonvital bone,
7 were stable or improving at the last follow-up examination,
and 2 required mandibular resection for resolution of the bone
necrosis. The 3 bone exposures occurring secondary to denture
irritation at extraction sites all healed with conservative mea­
sures. Of the 2 patients whose bone necroses were associated
with tumor regression, 1 died of persistent tumor 8 months af­
ter completion of radiation therapy, with the exposure stable
and improving, and the other patient expired 24 months after
the onset of the bone exposure of a second primary tumor, with
the exposure worsening, resulting in pathologic fracture and an
orocutaneous fistula. Seventeen of the 18 incidents of bone ne­
crosis occurred in the mandibular molar area.
The data and clinical experience indicates that most pa­
tients who develop bony necroses are those with teeth present
prior to radiation therapy. The major dental initiators are: (1)
Preexisting dental disease not identified prior to therapy, lead­
ing to dental infections after therapy. These infections are pri­
marily periodontal in nature. (2) Poor dental compliance of the
dentulous patients allowed to retain teeth in the radiation treat­
ment volume, leading to dental disease and infection after
therapy. (3) Breakdown of preradiation extraction wounds, due
to either surgical trauma during extraction, inadequate healing
time after extraction (and before radiation therapy), or a combi­
nation of these 2 factors. (4) Breakdown of postradiation ex­
traction sites, due to the impaired vasculature of mucosa, peri­
osteum, and bone in the radiation field.
78 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Our data and other reports in the literature appear to indi­ Extraction of Third Molars
cate that selected tooth removal prior to radiation therapy does
reduce the risk of necrosis93,94,95. This is especially true in denti­ Extraction of impacted mandibular third molars prior to
tions presenting at the time of radiation therapy with advanced radiation is not advocated for most patients (Figure 4-34). Such
periodontal disease, particularly mandibular molars demonstrat­ extractions often necessitate removal of considerable bone, thus
ing furcation involvement. However, wholesale extraction of creating large defects requiring prolonged periods for healing.
the remaining mandibular dentition, particularly dentitions free Patients with partially erupted mandibular third molars repre­
of significant periodontal bone loss, is certainly not indicated, sent a particularly difficult and perplexing problem because of
and may increase the risk of bone necrosis91. the risk of pericoronitis. Fortunately, the majority of these pa­
Our data indicated that, when a moderately aggressive tients are below age 40 and most have Hodgkin’s disease and
policy of preradiation extraction was followed, the rate of bony other types of lymphomas. The dosage and small volume of
necrosis varied from 8% to 10% in both the extraction and non­ mandible included in the radiation field results in less compro­
extraction groups99. Of 303 dentulous patients screened by the mise of the vasculature of the mandible and salivary glands.
authors with teeth present in the proposed radiation treatment Our clinical experience indicates that the incidence of osteora­
volume, 18 of the 120 who underwent extractions eventually dionecrosis in patients receiving less than 5000 cGy has been
developed a bone necrosis. Of the 113 patients who had teeth negligible. Operculectomy is useful in selected cases.
retained in the treatment volume, 16 developed a bone necro­
sis. The best indication of the risk of necrosis from preradiation
extractions may come from the data from patients receiving
external therapy only. In this group, the risk of spontaneous
necrosis was 8.7% (8 out of 91 patients). As previously noted,
Murray reported that, with a conservative policy towards ex­
tractions, the rate of bone necrosis in the non-extraction group
of 236 patients was 25.1%93,94. Hence, we believe that a more
aggressive preradiation policy of extraction is justified.
Dental extractions and/or dental disease, per se, are prob­
ably of less importance as causative factors of necrosis in pa­
tients treated, with combined radiation therapy. Tissue break­
down is thought to be secondary to the dosage from the implant
combined with the external beam dosage, exceeding maximum
level of tissue tolerance locally.
We feel that, when external radiation is delivered in mod­
erately high dosages (above 6500 cGy), the volume of the body
of the mandible included within the radiation field is an impor­
tant contributing factor in the development of necrosis. As ra­
diation fields move anteriorly to encompass more of the body
of the mandible (as in therapy for floor-of-mouth lesions), the
risk of necroses rises significantly. In these patients, healing
times for extractions should be extended to at least 10 to 14
days, particularly when molar teeth are removed. Less time for
healing is necessary following the extraction of bicuspids, cus­
pids, and incisors.
How long should the interval be between tooth extraction
and the commencement of radiation therapy? Healing time is
variable and will depend upon host response, degree of surgical
trauma inflicted during tooth removal, extraction location, and c
the pathology and potential aggressiveness of the tumor. Hence, Fig. 4-34.
clinical impressions and experience may be the most valuable a: Patient presents prior to radiation with diseased second
tool in making judgments as to when radiotherapy can begin. molar next to an impacted 3rd molar, b: Root canal therapy
performed on second molar, thereby avoiding extraction of
3rd molar, c: Crown amputated and recontoured to facilitate
oral hygiene.

Surgical Procedures
When extractions are performed in the preradiation period,
clinical experience and the literature indicate that the following
factors should be observed for best results. (1) Radical alveo-
lectomy should be performed, edges of the tissue flaps everted,
and primary closure obtained. Meticulous care should be exer­
cised in the care of the tissue flaps. Good surgical technique
will pay great dividends in reducing the incidence of complica­
tions. (2) Teeth should be removed in segments in the field of
radiation. It is far easier to perform an appropriate alveolec-
tomy and attain adequate closure by extracting teeth in seg­
ments. When individual teeth are extracted, closure is difficult
to obtain without excessive tension on tissue flaps. (3) Some
clinicians advocate administering antibiotics during the heal­
ing period. It is difficult to assess the benefit that prophylactic
antibiotics provide in these situations. They probably are effec­
tive when extractions result in excessive trauma. (4) In most
patients, 7 to 10 days are adequate for healing before therapy is
begun. This period may be extended or shortened depending on
the progress made by the patient, ease or difficulty of the sur­
gery, proposed dosage and radiation fields, and the histologic
aggressiveness of the tumor.
Preradiation extractions should be accomplished with mini­
mal trauma to flaps, and closure should be accomplished with­
out excessive tension. The lingual flap in the mandible is sus­
ceptible to mishandling during the surgical procedure, and per­
foration or thinning may lead to a bony exposure after radiation
therapy. It should be reemphasized that, in the field, the perios­
teum will be the predominant source o f vascularity and all ef­
forts should be made to avoid mishandling it during the surgi­
cal procedure.
Post-Radiation Dental Disease
Extraction Of Teeth
Current philosophies and literature review The risk of
bone necrosis secondary to dental extractions in the postradia­
tion period has been debated by many clinicians. Following a
definitive course of radiation therapy for head and neck tumors,
vascular changes in bone and oral mucosa impair blood supply
and predispose to tissue breakdown and secondary infections
of the bone and soft tissue. In recent years, with the use of topi­
cal fluoride, regular dental care, and close follow-up, more pa­
tients have been allowed to retain teeth in the radiation treat­
ment volume. However, it is difficult to predict the future den­
tal compliance of a patient based upon the initial dental exami­
nation and consultation prior to radiation therapy. Consequently,
some patients may develop serious dental disease in the radia­
tion treatment volume after the completion of therapy. Some
clinicians have proposed that diseased teeth in the radiation field
Radiation Therapy o f Head and Neck Tumors 79
can be removed with little risk of bone necrosis, while others
suggest that postradiation extraction of these teeth create a sig­
nificant risk.
Many questions about postradiation dental extractions re­
main undecided. They include the incidence of bone necrosis
secondary to extraction of teeth in the field after therapy, the
influence of such aspects of radiation delivery as the radiation
fields, dosages, fractionation, the radiation modality employed,
and the value of hyperbaric oxygen and root canal therapy as
preventive measures. Interpretation of these studies is difficult
because of imprecise definitions of bone necrosis and poor docu­
mentation of radiation dosages and fields.
In a report by Carl, 101 mandibular teeth and 86 maxillary
teeth were removed in 47 previously irradiated patients102. Tu­
mor dosage ranged from 3600 to 12900 cGy. Healing was un­
eventful in most patients, but “delayed” in a few. The method
of tooth removal was described as atraumatic. The authors rec­
ommended that no more than 2 or 3 teeth be removed at one
time to avoid overtaxing the local blood supply. The authors
proposed that preradiation dental extractions represented a
greater risk of bone necrosis than postradiation extractions.
Solomon, in a report originating from the same institution, de­
scribed their experience with 48 patients requiring tooth removal
after radiation therapy104. Bone necroses did not occur. This re­
port also stressed the importance of atraumatic tooth removal
in postradiation patients.
Maxymiw reported on 196 teeth removed in the radiation
fields in a study involving 72 patients105. One hundred and
twenty-three of these teeth were in the mandible. Tumor doses
ranged from 2500 to 8400 cGy (mean 5000 cGy). Extractions
were performed atraumatically, avoiding periosteal elevation,
using a non-lidocaine (prilocaine) local anesthetic with a low
concentration of epinephrine. Oral penicillin was begun just
before surgery and continued for 1 week. When multiple ex­
tractions in the same quadrant were required, only 1 or 2 teeth
were removed per appointment. Additional extractions were
staged by alternating quadrants at subsequent sessions. None of
the 72 patients developed an osteoradionecrosis.
In contrast, Daly and Drane91, Murray93,94, and Monish95
discouraged tooth removal in the field after radiation therapy
because of the high risk of osteoradionecrosis. Murray found
that 7 of 8 patients undergoing postradiation extractions devel­
oped bone necrosis93,94. Three eventually required resection of
the involved portion of the mandible. Monish reported that 11
of 18 patients undergoing postradiation extractions developed
bone necrosis95. Dosage to the mandible ranged from 6700 to
8100 cGy (mean 7300 cGy), and the average time of onset of
necrosis was 20 months after completion of radiation therapy.
The methods of tooth removal were not described in these reports.
Hoffmeister recognized the risk inherent in attempting to
remove teeth in the field after completion of radiation therapy,
but he maintained that occasionally it was necessary106. He at­
80 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

tempted to determine if the elapsed time following radiation
had any impact on the risk of complications following dental
extractions. He exposed the skin of mice to 6000 cGy fraction­
ated in a conventional way using a 250 kV machine. Hoffrneister
calculated the circulatory efficiency of tissue in the field of ra­
diation at specific time intervals. He reported that circulatory
efficiency is gradually reduced to 50% of normal 4 months af­
ter the start of therapy. At this point, he reported evidence of
recovery and, at 12months, circulatory efficiency had rebounded
to 75% of normal. He also investigated the incidence of major
wound complications in a series of patients undergoing
postradiation extraction during the first 12 months after the com­
mencement of radiation therapy. Hoffrneister reported that the
complication rate (prolonged bone exposure and infection) was
highest between the third and ninth month. During this interval,
all 13 extractions resulted in major complications. When ex­
tractions were performed 12 months or more after therapy, the
major complication rate was reduced to 50%. He concluded
that there was evidence of some revascularization within the
radiation field and recommended that extractions be performed
before vascular compromise became marked, or after the initial
stages of the recovery. He further suggested that, since the rate
of wound complications was high in extractions performed in
the post-therapy period, tooth extraction should be performed
prior to radiation.
In the UCLA study, bone exposures of 3 months or longer
were evident in 16 of the 72 postradiation extractions, includ­
ing 13 of 45 in the mandible and 3 of 27 in the maxilla88. Of the
13 bone exposures occurring in the mandible, 8 eventually healed
in 3 to 12 months (averaging 5.8 months) with conservative
measures (local saline irrigations with occasional use of oral
antibiotics). The remaining 5 necroses eventually required radi­
cal resection of the mandible. There was no relationship be­
tween the incidence of prolonged bone exposures in either the
mandible or the maxilla and the elapsed time between the end
of radiotherapy and dental extraction. The 3 bone exposures in
the maxilla healed with conservative measures in 13,18, and
19 months.
In patients treated with external radiation therapy only, 11
bone exposures were noted following 40 postradiation extrac­
tions of mandibular teeth in the radiation field. Six of these bone
exposures proceeded to re-epithelialize with conservative mea­
sures, while the remaining 5 progressively worsened and even­
tually required resection of the affected portion of the mandibu­
lar body to control the infection. The mean dose in patients re­
quiring mandibular resection was 6884 cGy (range 6600 to 7150
cGy). When prolonged bone exposures healed with conserva­
tive measures following extraction, the mean dose was 6000
cGy (range 5100 to 7100 cGy). When healing occurred without
complications, the mean dose was 6058 cGy (range 3925 to
7000 cGy). The distribution of extractions, prolonged bone ex­
posures, and the course of these bone exposures is presented in
Table 4-4. The 5 remaining patients undergoing postradiation
extraction ofteeth in the radiation treatment Volume were treated
with external therapy followed by placement of an interstitial
implant. In 4 of these 5, the primary tumor was located in the
floor of the mouth. Two prolonged bone exposures resulted from
5 extractions, but both healed with conservative measures in 4
and 7 months.
Of the bony exposures in the mandible, 5 occurred at mo­
lar extraction sites (2 resections), 6 developed at bicuspid sites
(3 resections), and the remaining 2 developed at anterior sites

Table 4-4. Postradiation extractions— external radiation dose and mandibular bone exposures.*

^ f:f3o'ne exposures: •C- Radical: ; :

^ExtraGtion- . jn.jexGes.si6f 'Jr healecTvyith-, * . -resectionof
(Centigray) ^0 ^^^g Im a n d ib )e ) ;^;rnootb's (mandible) conservative'm^e^ilires-' mandible

r ’ <4,999 3 ' ;%0 (0%) ■

i§ 5,000-5,499 4 1(25.0%) 1 —
i 5,500-5,999
S .6,000-6,499
6 ?.
10-
2(33.3%), ,
2 (20.0%) "
Kfl
2 .
; # a 500-7,000) fe 4(32.5%) ' — 4
||*7,0000 4 2(50.0%) • 1

H* Total' 40 , m 1 (27.5%) .. 6 ; • 5

SisSource Beumer^J, Wai;nson R^S.andersB, Kurrascb M. Preradiation dental extraction

and?thejneidepcXol osteoradionecrosis. Head and Neck Surg. 6:581 ;1983.
 Radiation Therapy o f Head and Neck Tumors 81

Table 4-5. Postradiation extractions— multiple versus single tooth extraction.*

Extraction :Bong exposures"-/ Bone'exposu resf '

Character of .I:-/ episodes p p te fc e s s of - healed with Radical
extraction sites ^ (quadrants) 3 months conservative measures resection

•: Multiple 33 ^,6'(18.1%) I I2 4
Mandible
Single 25. 7 (28.0%) 6

Multiple 12 3(25.0%) 3 1
. Maxilla
H Single 18

^ Total 88 l i f j 6 (18.1%) 'J ii' I 5 f!-;

. Source: Beurrier J, Harrison R, Sanders B, Kurrasch Mivgostradiation dental extractfbns. A review of the
lite r a tu r e and ^ re p o rt of 72 episodes. Head and Neck Surg' 6:581 ;1983.» ;

(no resections). In the mandible, bone exposures in excess of 3
months were about equally divided between sites where single
teeth were removed and sites where multiple extractions were
performed. However, 6 of the 7 bone exposures occurring at
single tooth sites healed with conservative measures, whereas 4
of the 6 exposures developing at multiple tooth extraction sites
progressively worsened and subsequently required wide resec­
tion of the body of the mandible (Table 4-5). In 4 extraction
episodes, when multiple mandibular teeth in the field were to
be removed in a quadrant, hyperbaric oxygen was employed
during and after the extraction procedures. The dose to man­
dibular bone was above 6500 cGy in all 4 cases, but all healed
without complication.
In patients treated with external therapy alone, the volume
of the mandibular body in the radiation fields appeared to have
a significant impact on the risk of prolonged bone exposures
following postradiation extractions (Table 4-6). When 75% or
more of the mandibular body was in the radiation field, the risk
of osteoradionecrosis was 38% (8 of 21). The risk decreased
significantly as the field involved less of the mandibular body.
Marx recognized the high rate of necrosis secondary to
postradiation extraction of mandibular teeth, and designed a
study to test the influence of hyperbaric oxygen on healing107.
His 2 study groups consisted of 37 patients each. All patients
underwent extraction of mandibular teeth in the radiation treat­
ment volume. All patients received a minimum of 6000 cGy.
The non-hyperbaric groups received 1,000,000 units of aque­
ous penicillin G intravenously just prior to extraction, and 500
mg of phenoxymethyl penicillin 4 times daily for 10 days after
surgery. Osteoradionecrosis was defined as exposure of bone at
the extraction site for 6 months or longer. Bone necrosis oc­
curred at 31 of 135 extraction sites (22.9%) in 11 patients
(29.9%). The hyperbaric group (37 patients, 135 extraction sites)
received 20 hyperbaric treatments before surgery and 10 treat­
ments after surgery, but no antibiotics. Bone necrosis occurred
at 4 of 136 sites (2.6%) in 3 patients (3/37 - 5.4%). Marx and
his colleagues concluded that, when postradiation extraction of
mandibular teeth in the radiation treatment volume was unavoid­
able, the risk of necrosis could be dramatically reduced with
hyperbaric oxygen treatments.
Therapeutic recommendations Based on the literature and
our clinical experience, we believe the best indicator of poten­
tial risk is the radiation dose to the bone in the area of the den­
tition being considered for removal. Accelerated fractionation,
unilateral fields, or fields favoring one side versus another in
patients treated with opposed fields, the dosimetry and location
of the interstitial implant, if used, as well as individual patient
82 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Table 4-6. Fields of radiation and bone exposures in patients who underwent external therapy only.*

'Amount of ' Bone exposures Bone exposures' • < Ra(|c^l:

mandibular body Exfraction ;; iji ex^ss of ' healed with I resection | | j
in the field ■ 'episodes' 3/m6Mhs|:-:' conservative measures mandible

>75% i2 1 1 8 (38°/o)f 3
25 -75% 13 | 2 (15;3%) 2
>25%, 6 ^ 1 (26.6.0%) 0

Total ' 40 11 (27;5%):>

81® m si mm
H HI
\ Source: Beumer J,Harrison R; Sanders B. Kurrasch M. Preradjation dental extractjqn anct;

responses must also be taken into consideration. For purposes
of discussion, let us consider these categories: high dose pa­
tients (dose to affected bone above 6500 cGy), intermediate
dose patients (dose to affected bone between 5500 and 6500
cGy), and low dose patients (dose to the affected bone of 5500
cGy or less). A dose to bone in excess of 6500 cGy implies
significant risk, particularly when multiple teeth in a mandibu­
lar quadrant are considered for removal. In this situation, we
believe a planned combined course of hyperbaric oxygen therapy
will minimize the risk.
In most high dose patients, root canal therapy for the af­
fected teeth is the treatment of choice because it avoids the risk
of extractions and the expense of hyperbaric oxygen. Root ca­
nal therapy allows the clinician to safely amputate the crowns
of teethjust above the epithelial attachment, reducing periodontal
pocket depths, and exposing furcation areas for oral hygiene
procedures. Most importantly, mucosal integrity is maintained.
Any perforation of the mucosa, whether it be from trauma or a
surgical procedure, predisposes the high dose radiation therapy
patient to a great risk of bone necrosis.
In the low dose patient (below 5500 cGy), there appears to
be little risk of necrosis secondary to postradiation extractions.
Teeth should be removed atraumatically with minimal reflec­
tion of the periosteum. Based on the UCLA data88and the Prin­
cess Margaret data105, there appears to be significantly less mor­
bidity associated with extraction of single mandibular teeth in
the radiation field as compared with multiple-tooth extractions.
During single-tooth extractions, the periosteum and overlying
attached mucosa may suffer less damage (as compared to mul­
tiple-tooth extractions) and thus the limited available vascular­
ity is maintained.
In the intermediate dose category (5500 to 6500 cGy), in­
dividual patient factors become important, such as an acceler­
ated fractionation schedules, the amount of the body of the man­
dible in the field of radiation, history of a radical neck dissec­
tion on the side of the proposed extraction(s), clinical signs (scar­
ring and telangiectasia) of radiation induced mucosal atrophy
(Figure 4-20), altered radiographic appearance of the mandible
(Figure 4-27), signs of acute infection, and so forth. Endodon­
tic therapy should be the first option considered; however, if
root canal therapy is not applicable and extractions are unavoid­
able, the question becomes whether to use hyperbaric oxygen
as an adjunct. The factors mentioned above all increase the risk
of bone necrosis in association with postradiation extractions,
and may convince the clinician to employ hyperbaric oxygen.
There is no clinical evidence of any significant
revascularization of mandibular bone within the treatment field
as implied by Hoffmeister106. At doses above 6500 cGy, the risk
of bone exposure from postradiation extractions does not ap­
pear to be dependent on the time elapsed since the termination
of radiation therapy88. Other factors affecting the local vascula­
ture may also be important, such as a radical neck dissection on
the side of the proposed postradiation extractions. During a clas­
sic radical neck dissection, the external maxillary artery and its
 Radiation Therapy o f Head and Neck Tumors 83

cervical and facial branches are often resected. These vessels, strates their efficiency60. Three groups of patients were studied
particularly the cervical branches, provide blood supply to the for caries control. One group received intensive oral hygiene
mucosa and periosteum of the mandible. instruction and was placed on an unrestricted diet A second
There seems to be little risk of prolonged bone exposure, group used daily applications of a 1% solution of topical fluo­
following extraction of maxillary teeth in the field, after radia­ ride applied with custom-made earners, and was also unrestricted
tion therapy due to the more diverse blood supply to the maxil­
lae. Even when a prolonged exposure of bone occurs, rarely
does significant morbidity ensue. Extractions in the maxilla and
bony recontouring of extraction sites should be directed toward
prosthodontic considerations rather than the need for primary
closure and healing.

Dental Maintenance

The objective is to bring the patient’s remaining dentition

to optimal levels prior to therapy in order to minimize the need
for dental treatment during and immediately following therapy.
Osteoradionecroses and soft tissue necroses occur most fre­
quently during the first year after therapy is completed, but the
risk of radiation caries remains high indefinitely. It follows that
regular and close follow-ups should extend indefinitely. In re­
cent years, strict oral hygiene procedures, in combination with
regular application of topical fluoride, have been quite effec­
tive in maintaining the health of the dentitions of irradiated pa­
tients.
Prior to therapy, the patient is given oral hygiene instruc­
tion, and a thorough and aggressive oral prophylaxis is per­
formed. The patient is followed at weekly intervals during ra­
diation therapy, and oral hygiene instruction is reinforced dur­
ing these appointments. The use of disclosing tablets or solu­
tions is helpful for both the dentist and the patient to monitor
the effectiveness of oral hygiene. After therapy is completed,
the patients are placed on a regular recall schedule that usually
requires visits every 3 months during the first year. Strict adher­
ence to oral hygiene procedures must be demanded. If hygiene
falters, patients should be reenrolled into the plaque control pro­
gram.

Fluoride Topical fluoride applications are begun immedi­

ately. A variety of fluoride solutions have been advocated, in­
cluding mouthwashes and gels. Although a gel, in combination
with custom-made carriers, is popular among clinicians, com­
pliance and the frequency of application is probably more im­
portant than the manner in which the application is made. The
gel is confined to the dentition by these custom-made carriers
and is held in position for 5 minutes once a day (Figure 4-35).
Fluoride treatments are continued for the lifetime of the patient, c
but may be reduced if there is evidence of improved salivary
function and continued good oral hygiene. Fig. 4-35. a, b, and c: Fluoride carriers. This method of topi­
Since topical fluorides have been used in patients with ra- cal fluoride application is favored by many clini­
diation-induced xerostomia, a dramatic decrease in the incidence cians and has been found to be clinically effec­
of radiation caries has been noted. A study by Dreizen demon­ tive.
84 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
in dietary intake. A third group received daily topical fluoride,
and sucrose intake was restricted. Patients using oral hygiene
alone for caries control had a mean incremental caries rate of
1.24 DMFT and 2.51 DMFS per postradiation month. When
this group began daily topical fluoride applications, mean in­
cremental caries rate dropped to 0.05 DMFT and 0.15 DMFS
per month. These latter rates closely approximated the caries
rates for the 2 groups that were using topical fluoride from the
beginning. These applications, besides dramatically reducing
caries incidence, were also successful in arresting existing le­
sions. This study confirms the importance of fluoride in con­
trolling and preventing caries in patients irradiated for head and
neck neoplasms.
The mechanism of caries prevention by fluoride in this
patient population is probably identical to normal populations
and oral environments. In existing carious lesions, the presence
of fluoride is highly effective in accelerating surface
remineralization, and this phenomenon is clinically well dem­
onstrated in the effectiveness of caries arrest in patients with
extensive radiation caries. Although caries arrest in vitro ap­
pears most effective in early enamel caries, clinical reports im­
ply that remineralization does occur even in patients with ad­
vanced radiation caries60. Supplementing topical fluoride ap­
plications with twice-daily use of a supersaturated solution of
calcium phosphate as a mouth rinse has been shown to effec­
tively remineralize carious dentin in irradiated patients108,109.
Fluoride uptake following topical application is primarily
a surface phenomenon and is confined to the outer 30 to 50 (X.
Uptake and effectiveness is affected by a number of factors of
which the patient and clinician must be cognizant First, pen­
etration into enamel is compromised in the presence of plaque
or salivary residues on the tooth surface and, consequently, ap­
plication is most effective following thorough and effective oral
hygiene procedures. The presence of debris prior to application
dramatically impairs penetration and therefore caries preven­
tive effectiveness"0. Second, the acidulated phosphate fluoride
solutions have gained some popularity because increased acid­
ity facilitates fluoride uptake. However, the low pH of these
solutions in some patients results in significant mucosal dis­
comfort, appearing as burning pain with occasional erythema
and ulceration. In addition, the acidulated fluoride solutions will
etch glazed porcelain and, therefore, its use should be avoided
in these patients111. Consequently, the form of topical fluoride
used may be dictated by these factors, as well as patient toler­
ance and acceptance. Third, although fluoride diffuses into
enamel when applied topically, it fails to rapidly form com­
pounds that are stable in the oral environment and much is lost
within 24 hours112. Therefore, to ensure maximum benefits, topi­
cal applications should be instituted on a daily basis. Increasing
application time and avoidance of rinsing the oral cavity for an
extended period after application (30 to 60 minutes) likewise
enhance fluoride uptake.
It is still unclear what effect fluoride has on the composi­
tion of the oral flora in the irradiated patient. The ascendance of
cariogenic organisms in patients with radiation-induced xeros­
tomia is profound. Although clinical data are somewhat contro­
versial, some investigations indicate that fluoride may inhibit
plaque formation113’114and may also reduce the relative num­
bers of Streptococcus mutans in plaque115. It is not known
whether this phenomenon is of clinical significance in caries
inhibition for patients with radiation-induced xerostomia in view
of their altered floral compositions. As previously mentioned,
Brown and others have demonstrated that the use of topical
fluoride results in delayed onset of the ascendancy of cariogenic
organisms in irradiated patients86. Dietary exclusion of sucrose
during radiotherapy has also been shown to inhibit the progres­
sive increase in cariogenic organisms. In the long term, how­
ever, diet and topical fluoride appear to have little effect on
floral composition in irradiated patients.
Numerous methods of fluoride application have been pro­
posed, including highly concentrated fluoride toothpaste, gels
carried to position by custom applicators, and mouth rinses.
Repeated application of the usual levels employed has not re­
sulted in a single reported case of systemic toxicity. We prefer
fluoride gels held in position with custom applicators. The ritu­
alistic nature of this process promotes more consistent use by
the patient.
A recent report by Boctor suggests that fluoride uptake is
enhanced with the use of a fluoride gel applied with custom
trays116. She studied fluoride uptake in enamel of 25 patients
who were scheduled to receive cancericidal doses of radiation
for treatment of oropharyngeal tumors. All patients were sched­
uled to receive a minimum of 6000 cGyover a 6-week period.
None of the patients had received fluoride treatments prior to
this study, and all were free of any physical handicap that might
prevent them from applying the fluoride gel. Following exami­
nation and the presentation of a 30-minute audiovisual training
tape, an enamel biopsy was performed. Custom fluoride trays
were made, and a 0.4% Stannous Fluoride gel was prescribed.
Enamel biopsies were again obtained 7 to 10 days, 3 months,
and 6 months later. As indicated in Table 4-7, fluoride levels in
enamel had increased from 605 ppm to 1932 ppm at the end of
6 months.
Follow-up and restorative care The importance of close
follow-up can not be overemphasized. If stringent oral hygiene
measures are not maintained, caries can destroy the entire den­
tition within 6 months. The risk of an aggressive caries attack
remains indefinitely. Patients tend to forget the implications of
their treatments and constantly need to be reminded of the ne­
cessity for proper oral hygiene procedures. Restorative dental
care is provided as necessary. In the early post treatment period,
amalgam and composite restorations are favored. Full cover­

age gold restorations are inappropriate until the patient has dem­
onstrated that he or she can maintain his or her oral hygiene at
an acceptable level.
When follow-up and oral hygiene are compromised, the
patient inevitably will develop rampant dental caries. Most le­
sions occur in the gingival third of the teeth and in areas with
extensive abrasion in which dentin is exposed, such as the in­
cisal or occlusal surfaces. Cervical lesions may involve the en­
tire circumference of the teeth, eventually leading to amputa­
tion of the crown. Incisal lesions can progress rapidly and soon
involve the entire crown and result in a heavy brownish-black
discoloration. TTiehistopathology of these lesions has been found
to be identical to caries in non-irradiated patients52. Carious le­
sions in radiated patients, as in normal patients, exhibit high
concentrations of Streptococcus mutans. A past history of car­
ies immunity is of little significance. All radiation induced xe­
rostomia patients are susceptible to caries.
When preventive measures are not employed and the pa­
tient has radiation caries, the clinician has few options, particu­
larly if the lesions are advanced. Dental extraction of mandibu­
lar teeth in the field of radiation should be contemplated only if
conservative measures fail to control the infection. In high risk
patients, multiple extractions should be accompanied by hyper­
baric oxygen treatments.
Table 4-7. Fluoride level and biopsy depth.*
Fluoride ( 3pm)
Visit Mean
Baseline 605 :
7-10/jjayi *992
3 months later. *1569
6 months later *1932
NS = Not Significant
** Source: Boctor RAL. The topical use of stannous fluoride as a preventative meagre f° r heacl and Reck-cancer
patients. Master T h e sis^986. UCLA.
Radiation Therapy o f Head and Neck Tumors 85
The following therapeutic measures are suggested. Attempt
to remove all caries and restore the affected teeth with tempo­
rary restorations. If the lesion is limited, it may not require place­
ment of atemporary restoration. Once caries has been controlled,
the temporary restorative material is replaced with amalgam or
composite restorations. Amalgam is preferred since these res­
torations can be extended if recurrent decay develops. Also,
amalgam restorations are less sensitive to moisture contamina­
tion. When esthetics are a concern, composite resin is the mate­
rial of choice. Recent clinical experience indicates that the small
particle composites are more color stable and durable in the
xerostomic patient than conventional composites. However, all
composite restorations are fraught with problems in the radia­
tion induced xerostomic patient First, during cavity prepara­
tion, margins frequently terminate in dentin or cementum and,
as a result, the risk of subsequent microleakage and recurrent
decay is high. Second, moisture control is frequently less than
optimal due to difficulty in controlling gingival hemorrhage.
Surprisingly, most patients are relatively asymptomatic and
voice few complaints, even with evidence of carious pulpal ex­
posure. Often, these initial restorative procedures can be per­
formed without local anesthesia. The length of fluoride appli­
cations in these patients is increased from 5 minutes to 10 or 15
minutes per day. There is clinical evidence that some reminerali-
; j j Biopsy Depth (microns)
Standard - Standard
Delation' - Mean. ^ Deviation
' fg S j 9.437 3.600"
413 :/ ^9.98 3.000
542 ^10.39 3.067
554 10.28 ' 2.57
86 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
zation and caries arrest occurs when exposure time is increased60.
Mouth rinses of a supersaturated solution of calcium phosphate
have also been reported to promote some remineralization of
carious dentin in irradiated patients108109. The patient is reen­
rolled in a plaque control, oral hygiene instruction program and
followed closely. Definitive restorative procedures are begun
as hygiene improves and caries is controlled.
When the caries process proceeds to amputation of the
crown, the clinician, in most instances, needs only to smooth
the jagged edges resulting from the fracture (Figure 4-36). These
teeth continue to be asymptomatic and a periapical roentgeno­
gram of the area will usually be within normal limits. If there is
evidence of active infection, however, endodontic therapy may
be employed for control. Endodontic procedures have often been
b
Fig. 4-36. Patient had been successfully treated with exter­
nal radiation therapy for a squamous carcinoma
of soft palate, a: Four years later she presented
with severe radiation caries. She was asymp­
tomatic. Remaining maxillary teeth were extracted
without complication. Mandibular teeth were am­
putated at gingival margins, b: Some residual
roots exfoliated, whereas others eventually were
covered with oral mucosa.
successful and have spared patients the risk of bone exposure
from unnecessary extraction of teeth117.
Extensive cervical caries is best restored with silver amal­
gam restorations. These lesions commonly involve the entire
gingival area, although the buccal and labial surfaces are most
often affected. If caries extends interproximally as well as buc-
cally and lingually in posterior teeth, a conventional MOD res­
toration is placed initially, taking care to extend the restoration
subgingivally. At a subsequent appointment, the buccal and/or
lingual amalgam restorations are placed. Sequential restoration
of circumferential lesions is advisable in anterior teeth. With
large Class V restorations, a method that has worked well for us
is to restore approximately one-half of the gingival area at the
first appointment and restore the remaining gingival portion
subsequently. If the caries extends into interproximal areas, plac­
ing a small section of matrix band with a suitable interproximal
wedge will simplify and improve the condensation of the amal­
gam.
Full coverage restorations may be considered for patients
with good oral hygiene and caries control, for key teeth that
serve as partial denture abutments. Prosthodontically, there are
many advantages to restoring abutment teeth with full cover­
age restorations. Such teeth can be contoured for optimal place­
ment of retainers, guiding planes and occlusal rests. However,
the judgment to provide extensive restorative procedures must
be tempered by the prognosis for tumor control, general health,
oral hygiene, the extent of radiation caries, and the patient’s
motivation. As a general rule, in the patient with severe radia­
tion-induced xerostomia, if crown restorations are necessary,
complete coverage is indicated and, in contrast with patients
with normal salivary flow, the margins are placed subgingivally.
Evidence of radiation caries precludes placement of three-fourths
crowns or pin ledge restorations because of the risk of caries
due to the more extensive marginal area. If there are extensive
cervical caries, consideration should be given to performing
prophylactic endodontic procedures followed by amputation of
the tooth at the gingiva.
Although no substantiating evidence is available, some cli­
nicians suggest that, if multiple crowns are being prepared, the
patient should be given prophylactic antibiotics. Exposure of
margins should be carefully effected with retraction cord. Al­
though no sound evidence is available at this time, we believe
the use of electrosurgery for gingival retraction should be
avoided. Temporary restorations should be well contoured to
minimize gingival irritation.
Pulpal procedures aimed at eliciting secondary dentin for­
mation are generally not successful. The compromised vascu­
larity of the pulp and the impaired capabilities of odontoblasts
predispose to failure with direct or indirect pulp capping tech­
niques. If carious or mechanical exposures are encountered
during tooth preparation, endodontic therapy is suggested.
 Radiation Therapy o f Head and Neck Tumors 87

Endodontic Therapy as an Alternative to Postradiation
Extraction
As discussed previously, postradiation dental extraction of
diseased teeth within the radiation field in high risk patients
leads to a high rate of osteoradionecrosis. Given the expense of
hyperbaric oxygen treatments, it would follow that other means
of controlling dental disease should be pursued, particularly for
the dentate mandible.
Montgomery described the difficulty of performing endo­
dontic therapy in irradiated patients, and reported the success­
ful treatment of 6 teeth118. Various techniques for endodontic
therapy were discussed, but the indications for endodontic
therapy and the criteria for success were not defined. Maikitziu
and Heling reported that, after 18 months of follow-up, endo­
dontic treatment was successful in only 2 of 11 teeth in patients
irradiated for oral neoplasms119. Both of the successfully treated
teeth were not in the radiation fields. The authors theorized that
the failures were due to the reduced healing potential of irradi­
ated tissue and the presence of nonvital pulps prior to endodon­
tic treatment. Unfortunately, the criteria for success or failure
were not well described.
Seto reported the results from patients who received
cancericidal doses of radiation therapy to the head and neck
and subsequently underwent root canal therapy117. A classifica­
tion of endodontic treatmenUengiivjas developed aad defined
with appropriate radiographs. A fill was considered normal when
the endodontic filling material was from 0 to 2 mm short of the
radiographic apex. A short fill was recorded when the fill was
more than 2 mm short of the radiographic apex. A long fill was
considered when filling material extended beyond the radio-
graphic apex. Post-endodontic complications were documented,
such as percussion sensitivity, pain, swelling, and osteoradion­
ecrosis. The periodontal status of the treated teeth was assessed,
including pocket depth, mobility, and inflammation. The post-
endodontic restorative requirements were also documented.
Success of endodontic therapy was based upon the absence of
symptoms, purulence, and on a stable or improving periapical
condition. The complete resolution of bony changes was not
considered a criterion for success due to the compromised heal­
ing capacity of irradiated bone.
Sixteen postradiation patients who underwent endodontic
therapy were followed. All teeth studied were in the radiation
field. Sixty-three percent (10/16) received a tumor dose greater
than 6500 cGy and 37% (6/16) received between 4500 and 6500
cGy. Eleven preradiation endodontically treated teeth (23 ca­
nals) and 35 postradiation endodontically treated teeth (54 ca­
nals) were evaluated. Follow-up, defined as the time between
completion of endodontic therapy and the most recent recall
visit, ranged from 6 months to 54 months (median: 21.6 months)
for tiie postradiation group. The indications for postradiation
root canal treatment were caries (80%), periodontal disease
(17%), and periapical abscess (3%) (Table 4-8). Pretreatment
periapical changes were evi&entm'iV?©, and pain‘m 29%.

Table 4-8. Indications for endodontic treatment— postradiation root-canals-field and arch versus changes.*

Periodontal Periapical
. . Caries - disease changes Swelling ; Pain :

_ .Arch Radiation
^ f ie ld 5/: - ^ , Ves No sum Kum Yes No Yes. No Yes No

Maxilla 'In jagg jp 1 1 .. I - : ;;1' j 1 ' 1.~

- .Out M 3 6 1 8 5 4
9 BiilS 9

Mandible J ^ ln '''' 11 6 11 4 13 1 17' 3 14

'jO u t , ' IjjP 8 3 5 - 8 2 6

28 7 6 29 11 24 . 34 10 25
- (80%) . ,(17.1%) (31.4%) (2.9%) (28.6%)

Source: Beumer J, Kagawa T, Klovkkevold P, Wolinsky L. Analysis of endodontic therapy in patients irradi­
ated for head and neck cancer.^Qrai-Surg, Oral Med, Oral Path. 60:540;i 986
88 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Evaluation of the length of endodontic fills showed 22 nor­
mal, 25 short, and 7 long fills in the postradiation root canals,
according to the previously defined criteria. In the preradiation
group, there were 3 normal, 7 short, and 3 long fills. When
multiple-rooted teeth were present, each canal was evaluated
separately when possible. In 22 teeth (3 preradiation and 19
postradiation root canals), coronal tooth structure was ampu­
tated at or below the level of the gingiva. Eighteen teeth were
provided with fiill-coverage crown restorations. Five of these
crowns were eventually amputated at or below the gingiva.
Eight postradiation endodontically treated roots and 3
preradiation endodontically treated roots exfoliated spontane­
ously or were extracted. A relationship was not found when the
length of endodontic fills and post-endodontic restorative treat­
ment was compared to subsequent tooth loss. In the immediate
post treatment period (within 1 week), 31 % of the postradiation
endodontically treated teeth (11 of 35) had postoperative pain
and 42.9% (15 of 35) had local edema (Table 4-9).
On follow-up (ranging 6 months to 54 months), 12 teeth
and 2 roots of 35 postradiation (40%) and 3 of 11 (27%)
preradiation endodontically treated teeth did not have periapi­
cal changes, purulence, or pain. Fifty-nine percent (27 of 46) of
the teeth demonstrated periapical changes (5 of 11 of the
preradiation and 22 of 35 of the postradiation root canals). Seven
percent (3 of 46) of the teeth had pain to percussion or palpation
(1 of 11 of the preradiation and 2 of 35 of the postradiation root
canals).
Relationships between endodontic length and post-endo­
dontic changes in teeth treated after radiation therapy (outlined
in Table 4-10) showed no relationship between the length of the
endodontic fill and subsequent periodontal disease, pain, or
extractions. However, a significant relationship existed between
periapical changes and the length of the endodontic fill. The
short endodontic fills resulted in significantly fewer periapical
changes than either the long or normal fills The overall reten­
tion of postradiation endodontically treated roots was 85% (46
of 54 roots).
Endodontic therapy of periodontally compromised teeth
allows for coronal amputation and greater access to periodontal
pockets (Figure 4-37). However, when multiple-rooted teeth
are amputated, care must be exercised to avoid exposure of the
interradicular bone. The furcation should be opened short of
the gingival attachment and incrementally fluted as the soft tis­
sues recede. Thus, extraction of teeth that demonstrate moder­
ate to severe periodontal disease can be avoided, and these teeth
can be maintained with hope of exfoliation maintaining mu­
cosal coverage.
Fig. 4-37.
C oronal am puta­
tio n , endodontic
treatment and root
contouring can re­
duce the depth of
periodontal pockets
and expose furca­
tion area for proper
hygiene.

Table 4-9. Postendodontic complications within 1 week of treatment.*

Periapical
changes Swelling Pain
Radiation
Arch field Yes No Yes No Yes No

Maxilla In Bp 1 |S | 1 jjjjj 1
Out 3 6 fill 8 2 7

Mandible In 6 11 1 6 11 ;
Out 6 2 jjKsaMBa 3
Rill 20 2 33 11 24
(42.9%) (5.7%) (31 4%)

Source: Beumer J, Kagawa T, Klovkkevold P, Wolinsky L. Analysis of endodontic therapy in patients irradi­
ated for head and neck cancer. Oral Surg, Oral Med, Oral Path. 60:540; 1986
 Radiation Therapy o f Head and Neck Tumors 89

Table 4-10. Postradiation root canal length versus complications.*

Caries. Periodontal Periapical ^ P a jn ^

Extraction ;
Length Arcjx , gg§J No No Yes -No

Maxilla In 1 PlP^s|lP 1 1 :v 1
1 jjl 3 2 1 " - i- V " ' 3
H 9
Normal "
Mandible ln s ' 3 11 5 9 8' ■ 6 4 10
Out 3 1 2 - , 2 / 4 l l l j g l liilliiM 4 3

Maxilla In'' I _ _ wk 1 H H 111

■ Out 2 1 _— S IR ? 1 2 — •v '3
Short
Mandible " 1- • 16 4 4 13 6 1 11 1
' Out 1 4 — S B ■ 3 4 1 ;- '" 2 " j

Maxilla ln .; __ . _- _ _ 1 | _ I§
O u t^ illllii 3 * — ,| 2 1 j ||w k B I B
Long - - ?•
Mandible In '2 llft lf ll § l|if§ fl 1 2 1
. Out ' ■ B p s iS i M ! _ L _ x ;\ _1
16' J 22 32 25 29 16 38 8
(29.6%) (40.7%)' (41.3%) ' ' -(29.6%) - ■

Sourcfe^Beunier J, KagawalX KIovklcevold P, Wofinsky L. Analysis of endodontic therapy in patients irradiated for
head and neck cancer. Ora! Surg, Oral Med, Oral Path. 60:540;1986 :
■ ■ ■ ■ ■ Wmmlm.

The criteria for endodontic success must be reconsidered
for the irradiated patient. We define success as prevention of
osteoradionecrosis. If the criteria for success is defined as non­
progressive periapical changes with a lack of pain, a low suc­
cess rate (40%) was seen in the Seto study. However, a high
percentage of roots (85%) were retained despite minor periapi­
cal changes and minimal pain. Osteoradionecrosis was not seen
in association with endodontic therapy. The success rate in treat­
ment of severely diseased teeth in irradiated patients, based on
avoidance of extraction and prevention of osteoradionecrosis,
was 100% in the Seto report. This is in contrast to the high
incidence of osteoradionecrosis encountered when severely dis­
eased teeth were extracted after radiation therapy. Therefore,
endodontic therapy is a reasonably predictable alternative to
extraction for patients who have been irradiated for oral tumors.
Shorter endodontic fill lengths have the fewest post-endo­
dontic periapical changes117. It is probable that fills close to the
radiographic apex are overextended, thus precipitating the same
pathologic responses as seen in long fills. Therefore, shorter fill
lengths would appear to be more desirable than overextended
fills in the radiation patient; however, further study with a larger
sample population is needed for confirmation.
Endodontic treatment for postradiation patients is difficult
technically. Rubber-dam isolation is complicated by minimal
coronal tooth structure and the risk of tissue trauma and result­
ant bone exposure. Oropharyngeal reflexes may be compro­
mised by surgery and/or radiation therapy; that translates into a
greater risk for aspiration of files. A throat screen, consisting of
an open 2 x 2 inch piece of gauze, should be used whenever a
rubber dam cannot be employed. All files should have floss or
thread attached for easy retrieval if inadvertently dropped be­
yond normal reach. Trismus and small pulp canals make access
for instrumentation and filling difficult When access is limited
by trismus, the files can be bent along the non-cutting portion
of the shank to increase working space between the maxillary
and mandibular dentitions. Hemostats can be used above the
non-cutting portion of the file to instrument the canals. Coronal
amputation or facial access can be helpful in the location and
instrumentation of root canals in the presence of canal sclerosis
and trismus. Canal obturation is effective with gutta-percha,
condensed with finger spreaders and directed towards lateral
condensation. Techniques that aid in the access, preparation,
and completion of endodontic therapy can be used as long as
the patient is protected from aspiration and soft tissue trauma.
90 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Summary— Osteoradionecrosis
Treatment of Severe Post-Radiation Dental Disease
Osteoradionecrosis is a dreaded complication of radio­
Our current approach to the management of dental disease therapy since it may progress to intractable pain and pathologic
in the mandibular radiation field is dependent upon 3 factors: fracture of the mandible, often accompanied by orocutaneous
(1) the dose to bone at the affected area, (2) the radiation mo­ fistula and requiring resection of major portions of the man­
dality used, and (3) the nature and severity of the dental infec­ dible (Figure 4-38). In the past, these sequelae usually required
tion. If the dose to bone locally is below 5500 cGy and the tooth resection of the involved mandibular segment to viable, bleed­
or teeth in question are restorable, a number of conventional ing bone, resulting in a discontinuity defect. Recent advances
therapies can be employed, including root planing and curet­ in radiotherapy and improved treatment methods, particularly
tage, crown lengthening, and root canal therapy. Periodontal the use of hyperbaric oxygen, have reduced the impact of os­
flap surgery, however, is not recommended. If the tooth is non- teoradionecrosis for many patients.
restorable, a simple extraction with appropriate antibiotic cov­ Osteoradionecrosis is not primarily an infectious process.
erage is justified. We prefer the following definition: exposure of bone within the
When the tumor dose exceeds 6500 cGy, options are de­ radiation treatment volume of 3 months or longer in duration.
pendent upon the radiation treatment modality used. If a patient Most bone necroses occur in the mandible of patients who
is treated with a combination of external beam and radiation are dentulous at the time of tumor diagnosis. Unfortunately, the
implant, the therapeutic options are dependent on the site of the incidence of postradiation bone necrosis has not declined93,94,95—
dental infection in relation to the site of the implant. The man­ not even with increased dental awareness of radiotherapists, the
dibular dose at any particular location will be dependent upon
the dosimetry of the implant plus the external beam dose. If the
patient presents with a serious dental infection associated with
a molar on the side opposite of the implant, the dose to bone in
this region most likely will be below 5500 cGy, and the options
previously discussed could be employed. However, if the den­
tal infection involved the molar region adjacent to the implant
in the absence of exposed bone, dental extractions are employed
only as a last resort. Endodontic therapy is recommended in
order to maintain mucosal integrity. If the infection is periodon­
tal and/or into the bifurcation region following root canal therapy,
the crown can be amputated, thereby providing access for oral
hygiene to this area. If the infection results in exposure of bone
adjacent to the molar on the lingual aspect of the mandible, a
conservative therapy is justified in almost all patients. If the
infection persists and dental extraction is deemed unavoidable,
the decision to use hyperbaric oxygen is dependent on the dose
distribution patterns of the implant. If the buccal plate, inferior
border, and buccal slopes of the alveolus were not affected by
the implant, dental extractions and removal of nonvital bone is
appropriate. If the implant increases the dose in these regions
above 5500 cGy, hyperbaric oxygen may be considered.
If the patient is treated with external beam alone, and the
dose to the bone sites in question are above 6500 cGy, root
canal therapy is again our first choice. If root canal treatment is
not successful in eliminating the infection, and dental extrac­ b
tions are unavoidable, the use of hyperbaric oxygen will im­
prove the prognosis for healing. If the dose to bone falls be­ F ig . 4-38. a and b: Both patients developed osteoradio­
tween 5500 and 6500 cGy, decisions for therapy should be based necroses following external beam radiotherapy for
on individual patient factors such as history of a radical neck squamous cell carcinoma of floor of mouth. Op­
dissection, mucosal or radiographic changes, and so forth. posed mandibular fields, which included whole
body of mandible, were used. Note bone expo­
sure of left tori in b.
 Radiation Therapy o f Head and Neck Tumors 91

more consistent practice of dental consultation prior to therapy, Predisposing Factors

and dental prevention programs during and after therapy. Many
issues concerning this disease remain confusing and at times
controversial. Opinions vary as to the factors which predispose
a patient to the development of osteoradionecrosis. Additional
questions associated with a bone exposure in the field are: (1)
What is the expected clinical course of this disease? (2) Are
there any reliable predictors regarding the numerous therapeu­
tic approaches that have been recommended? and (3) Which
treatment strategies have the best chance of resolving the infec­
tion, in the most cost-effective manner, and before significant
segments of the mandible require resection for infection con­
trol? The most comprehensive studies dealing with these issues
were conducted at UCLA75 and M.D. Anderson, Hospital and
TVimor Institute93-94.
It seems apparent from studies75,93,94that diseased teeth in
the radiation treatment volume are the prime initiator of osteo­
radionecrosis (Table 4-11). Even though there is risk of bone
necrosis at preradiation extraction sites, few of these bone ex­
posures proceeded to eventually require resection of the man­
dible. In contrast, bone necroses that occurred as a result of
dental disease, either spontaneously or in association with
postradiation extractions, more often required radical resection
for control of infection (36.8% and 45.4%, respectively)75. The
data from these studies documented that the conservative policy
of tooth extraction, as proposed by Daly and Drane91, is not
justified. The suggestions of Hayward98, regarding tooth removal
prior to therapy, seem more timely than ever.

Table 4-11. Predisposing factors for necrosis and treatment in 70 patients."

Therapeutic measures

Without hyperbaric'o'xygenJ ' With hyp6rt)OTCoxygen

Mandibular resection deemed necessary

- : Mandibular resection deemed necessary

i .Conservative.* Surgical Conservative- • '"'Surgical, '
measures sequestrectomy measures sequestrectomy

B• Cto
.. o> - HH1iSHHHra
c.
Or H I if-W<r£i£>'~', •;'
-1 , 2
BaaE Q. ' Q-: o. '■■■:—:
c G E 'M " §g H
_ o Ha B b BB k
£A :
<B -
•o 3 -g S H s .
o 2 i's" 8 a s 2 js s . o.
-E Mgm&w 1> § x v> ■5 '- CE

Pr§- -
rediation 17 5 8 4 1 2
extraction'•

fiS H ►:: - i l l
'radiation I : 22 ftBaa -1 13 3 5 3 - 5 5 45.0
extraction „

.Spontar
neous 19 4 2 13 1 . b 2 4 1 1 2
''dentition

Denture'’'
irritation R 1 8- n i p

Resection
for disease '5 "'~3 i ' ^ B Q 1

p m o i^ lP
progression _ 3 1
330
Totals 83 : 31 15 37 4 6 1 6 l 1 i 2

Source: Beumer J? RamsonlR, Sanders B, Kurrasch M: Osteoradionecrosis

prediSpCfeing factorsarfa outcomes of therapy. Head arid Neck Surg. 6:819;1984.
92 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
In addition, the data of Beumer99 and the reports by
Murray93,94indicate that the risk of bone necrosis is less in pa­
tients who have undergone preradiation extractions than in those
patients who have been allowed to retain all remaining teeth in
the radiation field. During the period when a conservative ap­
proach to preradiation extraction was advocated by Daly and
Drane91, Murray reported that 53 of 211 dentulous patients (25%)
who did not undergo preradiation extractions subsequently de­
veloped bone necrosis93,94. The rate of necrosis during this same
period in those who underwent preradiation extractions was 16%
(4 out of 25). In the UCLA review, of 120 patients who under­
went preradiation dental extractions, the incidence of break­
down of preradiation extraction sites was from 8% to 10%, de­
pending upon the variables one wished to consider99.
Therefore, we believe that an aggressive policy of removal
of diseased teeth in the radiation treatment volume, particularly
in the mandible, will minimize the incidence of necrosis. All
teeth with a questionable prognosis should be extracted. Teeth
with advanced caries involving the dental pulp and/or evidence
of periapical infection, as well as teeth with significant peri­
odontal discrepancies, should be considered for removal. The
patient’s periodontal status is a highly important consideration.
Dentitions with significant periodontal deficiencies are diffi­
cult to maintain after radiation therapy, and are quite suscep­
tible to caries and periodontal infections. In our judgment, in­
volvement of the furcation area of mandibular molar teeth within
the radiation treatment volume, whether or not in association
with pockets of 3 mm or more in depth, is grounds for extrac­
tion. This examination is best confirmed using a periodontal
probe combined with appropriate dental radiographs. Whole­
sale extraction of all remaining teeth in the radiation treatment
volume, however, is not indicated and probably increases the
risk of bone necrosis91, particularly in those patients with healthy
dentitions and a history of good dental compliance.
Post-therapy extraction of diseased teeth within the radia­
tion treatment volume, when the dose in the area exceeded 6500
cGy and was not accompanied by a course of hyperbaric oxy-
gen107, seems inappropriate88. The rate of necrosis is unaccept-
ably high and, in one study, bone exposures caused by
postradiation extractions lead to a high rate of mandibular re­
section for infection control (45.4%)88. A more viable option to
die treatment of dental disease in the field after radiation treat­
ment is.root canal therapy. After endodontic therapy, teeth can
be amputated at the gingival margins, and the remaining tooth
structure can be recontoured to improve access for cleansing.
Osteoradionecrosis, precipitated by the use of partial or
complete dentures, does not appear to be as significant, particu­
larly if a patient has been edentulous for more than 6 months
prior to radiotherapy120. Beumer reported that only 1 of the 8
bone exposures, that resulted from a removable prosthesis, led
to resection of the mandible; all others healed with conserva­
tive measures75. It should be noted, however, that 7 of the 8
bone exposures occurred at either preradiation or postradiation
extraction sites. Caution should be considered before placing
dentures in these circumstances, for the remodeling apparatus
of bone is severely disrupted by tumoricidal doses of radiation
therapy. In addition, it should not be forgotten that, as radiation-
induced xerostomia increases, the risk of bone exposure from
complete dentures also increases. With mandibular complete
dentures, saliva is an important lubricant, and decreased amounts
may lead to increased friction at the denture-mucosal interface
as the denture slides over the mucosa during function.
When the primary tumor is adjacent to or is overlying bone,
the risk of bone necrosis is increased. Rapid shrinkage of a tu­
mor, particularly in large lesions, can result in a bone exposure.
If the mucosa does resurface the affected area, it is often thin
and atrophic, and thus more susceptible to perforation. More
importantly, more of the body of the mandible is irradiated in
these lesions.
Beumer reported that, in 46 of the 82 incidents of necrosis,
75% or more of the body of the mandible was in the radiation
treatment field75. As more of the body of the mandible is irradi­
ated, and as the dose increases, conservative therapy becomes
less effective, regardless of the location of the bone exposure.
The reason for this phenomenon is not clear. There may be less
vascular recovery, or perhaps the fibrosis and vascular impair­
ment of the mandible is more profound with these radiation
fields. Rohrer71, in an animal study, and Merkesteyn72, in a hu­
man study, provided convincing evidence that, in such fields,
obliteration of the inferior alveolar artery may occur.
Obviously, as the dose is increased, tissue changes become
more profound and irreversible, leading to increased rates of
bone necrosis. Beumer reported that 14 of the 15 patients, who
were treated with external radiation alone, received less than
6500 cGy (tumor dose), and developed necrosis, were controlled
with conservative measures75. The one patient requiring radical
resection of the mandible to control the infection was treated
with a unilateral field and, although the dose to the tumor was
less than 6500 cGy, the dose to bone of the mandible in the field
was in excess of 6700 cGy. Among the patients receiving more
than 6500 cGy of external therapy, mandibular resection was
required in 40% (18/45) of the cases.
The dose to bone is probably the best predictor of risk.
Cheng and Wang, using the nominal single dose (NSD) index,
reported that most bone necroses occurred in patients who re­
ceived in excess of 2,100 rets to the mandible121. No bone ne­
croses occurred in patients who were exposed to less than 2,000
rets. They suggested that other factors may be important, since
a significant number of patients receiving more than 2,100 rets
did not develop necrosis. In a study by Morrish, in which dose
to bone was calculated on all patients, mandibular bone necro­
sis developed in 85% of the dentulous patients who received
7,500 cGy or more to bone95. None of the patients who received
less than 6,500 cGy to mandibular bone developed necrosis.
 Radiation Therapy o f Head and Neck Tumors 93

The most important dental disease factor, predisposing pa­ ful, the local area of bone exposure must be kept meticulously
tients to the development of bone necrosis, was the presence of clean by the patient. The reasons for the refusal of many pa­
periodontal deficiencies associated with dentitions retained tients to comply are complicated and in need of further study.
within the treatment field75. Even carious exposure of the den­
tal pulp seemed to be less of a predisposing factor. We propose Treatment Options
the following explanation for this phenomenon. When bone
necrosis occurs spontaneously in association with teeth, the Osteoradionecrosis Associated with External Beam
exposure soon spreads beyond the mucogingival junction and
to the center of the mandible via the periodontal ligament. In Many bone exposures, following external radiation treat­
our experience, few bone exposures advancing beyond the ment, can be controlled with local irrigation and packings of
mucogingival junction have been responsive to conservative iodoform gauze, impregnated with tincture of benzoin, when
therapy when the dose to bone is above 6500 cGy. the dose to bone in the local area is less than 6500 cGy and the
When external radiation is combined with an applicator or exposure is localized (Figure 4-39). When the dose to bone is
implant to increase the tumor dose locally, dental disease seems above 6500 cGy, and the exposure extends beyond the
to be less important as a causative factor of bone necrosis. Tis­ mucogingival junction, or if the bone exposure occurs in asso­
sue breakdown is probably secondary to the local dosage to the ciation with teeth (Figure 4-40), hyperbaric oxygen combined
mandible, and its overlying mucosa, exceeding tissue tolerance. with a surgical sequestrectomy should be considered122,123.
Beumer disclosed that, in 18 of 22 incidents of necrosis in this If conservative measures are to be successful, stringent oral
group, the local dosage exceeded 8000 cGy75. At this dosage hygiene measures must be employed by the patient and close
level, the position of the radioactive source, used to boost the follow-up by the clinician is mandatory. These patients are moni­
tumor dose locally, in relation to the mandible is critical. When­ tored from twice per week to once per month, depending upon
ever possible, consideration should be given to displacing and the extent and severity of the exposure. Sharp, bony projections
positioning the tissues to be implanted with a radiation stent to can traumatize adjacent soft tissues or contribute to plaque ac-
minimize radiation exposure to the mandible. The rate of resec­
tion necessary to control infection in bone necrosis occurring in
these patients is low. The lower rate is undoubtedly due to the
rapid drop in dosage as the distance from the radioactive source
increases. These bone necroses, particularly when the external
radiation dosage was less than 5500 cGy, are more self-limiting
and, thus, are more responsive to conservative therapeutic mea­
sures.
Although many bone necroses occur within the first year, a
substantial number occur after extended periods following
completion of radiation therapy. Most bone exposures occur­
ring within the first year are secondary to preradiation extrac­
tions or tumor regression, whereas most bone exposures pre­
cipitated by dental disease occurred after 2 years had elapsed.
There appears to be no relationship between the time of onset
and the clinical course of bone necrosis. The revascularization
of bone within the radiation field, as speculated by Hoffmeister,
based on an animal model, either does not occur or is not clini­
cally significant at higher dosage levels106.
The hygiene compliance of the patient is possibly of greater
importance as a predictor of clinical outcome. Beumer reported
that of the 23 patients requiring mandibular resection, only a
few were notably different with regard to such factors as radia­
tion treatment or dosage99'887. However, most resection patients
shared one characteristic, namely, poor dental compliance. Prior Fig. 4-39. a: Bone necrosis occurred at preradiation extrac­
to development of necrosis, many of these patients had poor tion site beneath a complete denture 6 months following
hygiene and irregular dental care. More important, after the onset completion of external radiation therapy for squamous carci­
of necrosis, they continued with their pattern of poor oral hy­ noma of right tonsil and soft palate, b: Bone exposure healed
giene compliance. If conservative measures are to be success­ with conservative measures 8 months later.
94 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
d osteoradionecrosis, adjacent to an interstitial implant, is deter­
F ig . 4-40. a: Bone necrosis discovered 18 months following
external radiation therapy for squamous carcinoma of lateral
floor of mouth. Dose to bone in region exceeded 7100 cGy.
b: Status after hyperbaric oxygen using protocol described
by Marx, et al., 1983. c: Surgical resection of nonvital bone
and primary closure, d: Wound healed 2 months later.
cumulation, and should be smoothed with an air rotor. As the
edges of the necrotic bone are undermined by oral mucosa, these
bony edges are carefully removed, taking care to avoid injury
to underlying epithelium or granulation tissue. If the necrosis
remains limited to the local area, and if pain and swelling of the
adjacent soft tissues is not evident, conservative methods can
be continued. If the exposure expands beyond the local area
and beyond the mucogingival junction, hyperbaric oxygen, com­
bined with surgical sequestrectomy, should be considered. Re­
current soft tissue infection and evidence of detachment of the
periosteum are negative signs which indicate the need to em­
ploy the more aggressive therapeutic measures. Poor oral hy­
giene compliance, continued alcohol and tobacco abuse, and
poor dietary intake are factors which could indicate the need
for more aggressive measures.
Patience on the part of the clinician is of prime importance
when conservative measures are used. Bone exposures in irra­
diated tissues require extended periods for healing. Healing is
accomplished by natural sequestration and resorption of this
nonvital bone, which may take many months—or even years—
because of the relatively avascular nature of the affected bone.
Antibiotics are necessary only to control local acute infectious
episodes involving the adjacent soft tissues. Routine adminis­
tration of antibiotics to patients with osteoradionecrosis for ex­
tended periods is not advised. Doing so provides little benefit
because of the compromised vasculature of the local area, and
may lead to the development of resistant organisms.
Osteoradionecrosis Associated with External Beam and
Interstitial Implants
The clinical course of bone necrosis associated with the
use of external beam and interstitial implants is much more pre­
dictable. The outcome is almost always dependent upon the
magnitude of the external beam dosage. In most patients, exter­
nal beam dosage to the mandible is limited to 5000 to 5500
cGy. The interstitial implant boosts the dose to the tumor region
by approximately 3000 cGy. The risk of bone necrosis, how­
ever, is dependent upon the number and distribution of the in­
terstitial radiation sources. When the sources are in close prox­
imity to the mandible (Figure 4-41), the risk of necrosis is high.
However, almost all will heal with conservative measures and
will not require aggressive suigery or hyperbaric oxygen (Fig­
ure 4-42).
In summary, we believe the outcome of treatment of an
mined by the external beam dose. If the external beam dose to
the bone is below 5500 cGy, the prospects for conservative
therapy are excellent, and surgical sequestration in combina­
tion with hyperbaric oxygen is rarely needed.
 Radiation Therapy o f Head and Neck Tumors 95

Fig. 4-41. a and b: CT scan of a patient treated with an

iridium implant. Sources are represented by
white dots. Note dosimetry. Lingual plate of
mandible has been exposed to high dose. Buc­
cal plate of mandible has been exposed to low
dose.

Fig. 4-42. Bone exposures associated with iridium implants, a, b, and c: Patient treated for carcinoma of left lateral tongue and
floor of mouth (all mirror projections). Tumor site received 5000 cGy via external beam and 3000 cGy with iridium implant.
Osteoradionecrosis developed 8 months after therapy which resolved with conservative measures, d, e, and f: Patient pre­
sented with carcinoma of left floor mouth and advanced periodontal bone loss associated with remaining teeth. He refused
preradiation extraction. Patient received 5000 cGy with external beam and 2500 via an iridium implant. Presented 18 months
later with osteoradionecrosis. Nonvital bone was removed with cotton pliers revealing epithelial coverage, g, h, and i: Patient
received 5500 cG y external beam and 2500 cG y via iridium im plant. Tw enty-four months later he presented with
osteoradionecrosis. Nonvital exposed bone was removed with an air rotor under copius irrigation. After several episodes
epithelial coverage was attained.
96 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Hyperbaric Oxygen
A major advance in the treatment of osteoradionecrosis has
been the use of hyperbaric oxygen. Hyperbaric oxygen stimu­
lates neovascular proliferation in marginally necrotic tis-
sues123,124-125, enhances fibroblastic proliferation126, enhances the
bactericidal activity of white blood cells127, and increases the
production of bone matrix128. The early work in hyperbaric oxy­
gen for irradiated patients was performed by Hart and
Mainous122, and continued by Marx107,123,125’129’130. Hart &
Mainous reported on patients with osteoradionecrosis of the
mandible treated in a hyperbaric chamber122. Patients with bone
necrosis were exposed to 2 atmospheres of oxygen in a hyper­
baric chamber for 2 hours per session. Each course of therapy
extended for 120 hours. Nine-amino acridine was used to irri­
gate the local area daily, and the patients were placed on sys­
temic tetracycline once oral suppuration had been controlled.
Neomycin packings were used in purulent oral wounds. Surgi­
cal procedures, such as extraction and surgical sequestrectomy,
were performed between the twentieth and fortieth treatments.
Alpha-tocopherol (100 mg daily) was administered during the
treatment. All patients presented with advanced bone necrosis
and would normally have been considered for mandibular re­
section according to a formula previously developed by Rankow
and Weisman131. After the first series of hyperbaric treatments,
37 of 46 patients were free of symptoms, including elimination
of all bony exposure intraorally. Nine patients had teeth extracted
with radical alveolectomy, and all sites healed without compli­
cation. Five of these patients had immediate dentures inserted
using a temporary denture liner. These prosthetic restorations
were employed without complication. Mandibular bone grafts
were placed in 4 patients to restore a discontinuity defect. All 4
were successful. It should be noted that this series of osteoradi­
onecroses consisted of those patients with the most serious and
extensive bone exposures. For instance, 19 patients had patho­
logic fractures of the mandible and 15 had oral cutaneous fistu-
lae prior to hyperbaric therapy.
Marx107,123,125provides additional evidence that hyperbaric
oxygen is a valuable therapeutic modality not only in treatment
of osteoradionecrosis but, also, in preventing osteoradionecro­
sis. Its use increases the vasculature of the local soft tissues and,
if a bone grafting procedure is necessary to reconstruct the man­
dible, the prognosis is significantly enhanced.
The Marx protocol for treatment of osteoradionecrosis is
well known by those in this field. It is worthy of discussion and
so we repeat it here. Osteoradionecrosis is defined by Marx as
the “presence of exposed bone in the region of radiation therapy
for 6 months with or without pain.”
Stage I These patients have osteoradionecrosis but with­
out pathologic fracture, orocutaneous fistula, or radiographic
evidence of bone resorption to the inferior border of the man­
dible. Marx recommends that patients in this group be given 30
hyperbaric treatments (2.4 atmospheres, 100% oxygen for 90
minutes). If, at the end of the 30 treatments, there is clinical
evidence of improvement, another 20 treatments are added. If
no clinical improvement is noted, the patient is considered a
non-responder and advanced to Stage n.
Stage II After 30 hyperbaric treatments, non-responders
are taken to surgery. A surgical sequestrectomy of the local area
is performed, and the wound is closed primarily in 3 layers over
a base of bleeding bone. An additional 10 hyperbaric treatments
are given. If the wound dehisces, the patient is identified as a
non-responder and advanced to Stage QI.
Stage III Non-responders from Stage II therapy, and pa­
tients presenting with orocutaneous fistula, pathologic fracture
or radiographic evidence of bone resorption to the inferior bor­
der of the mandible, are considered Stage HI patients. Follow­
ing the initial 30 hyperbaric treatments, bony segments of
nonvital mandibular bone are resected transorally with the aid
of tetracycline fluorescence under ultraviolet light. External fixa­
tion of the mandibular segments is achieved, orocutaneous fis-
tulae are closed, and soft tissue deficits restored with local or
distant flaps. Another 10 hyperbaric treatments are given and
the patient is advanced to Stage IIIR.
Stage III/? Ten weeks after resection, the mandible is re­
constructed with a bone graft, using a transcutaneous exposure.
Oral contamination of the surgical wound is to be avoided. Man­
dibular fixation is achieved and maintained for 8 weeks. Ten
hyperbaric treatments are given postoperatively.
Contraindications to hyperbaric oxygen treatment include
persistent tumor, optic neuritis, active viral disease states, and
untreated pneumothorax. Complications include barotrauma of
the ear, temporary myopia, and, in rare instances, pulmonary
fibrosis. The pre-hyperbaric oxygen workup includes a history
and physical examination, chest film, ophthalmologic exam,
hearing test, and a complete blood count
The work of Marx and others123,125is an important contri­
bution to our understanding of osteoradionecrosis, and we be­
lieve their recommendations for treatment are appropriate when
the osteoradionecrosis is advanced, the radiation dose to the
involved bone is above 6500 cGy, and the radiation is delivered
by external beam only. However, as discussed previously, we
believe that almost all patients who are treated with a combina­
tion of an external beam and an interstitial implant, and then
develop bone necrosis, can be treated successfully with conser­
vative measures and do not require hyperbaric oxygen. An in­
terstitial implant limits die dose to a confined area (because of

the inverse square law) and, although the total combined dose
may be sufficiently high to predispose to a high rate of osteora­
dionecrosis locally, most of these “implant related” bone ne­
croses are resolvable with conservative measures.
Management of Osteoradionecrosis with Myocutaneous
Flaps or Free Flaps
Some clinicians believe that myocutaneous flaps can be
used to manage severe cases of osteoradionecrosis132. The irra­
diated nonvital bone is removed surgically down to viable bone.
Administration of tetracycline prior to surgery, and use of an
ultraviolet light source during surgery, aids in identification of
bone that retains its viability. The exposed bone is then covered
with a myocutaneous flap (Figure 4-43). These flaps bring their
blood supply along with them and thus facilitate healing. This
technique has been employed successfully in selected cases132.
If a mandibular continuity defect is anticipated, a free flap may
be preferred because both bone and soft tissue can be generated
to reconstruct the defect.
F ig . 4-43. This bone necrosis was debrided, nonvital bone
was rem oved and the area covered w ith a
myocutaneous flap. Small area of exposed bone
remains. This area epithelialized within 3 months.
Tab le 4-12. Soft tissue necrosis.*
Onset (months)
Sitef Number Range Average
Tongue 13+ 1.5-17
Mouth floor 3 6-17
Tonsillar 2 8-9
pillar
t Site of necrosis same as tumor site.
$ Seven had radium needle implants.
Source: Beumer J, Silverman S, Benak S. Hard and soft tissue necrosis following radia­
tion therapy for oral cancer. JProsth Dent. 27:640;1972.
Radiation Therapy o f Head and Neck Tumors 97
Soft Tissue Necrosis
Soft tissue necrosis is defined as a nonneoplastic mucosal
ulceration occurring in the postradiation field and which does
not expose bone. These lesions occur most often following treat­
ment with interstitial implants and peroral cone modalities; tech­
niques which are used following a prescribed course of exter­
nal beam therapy, allowing the radiation therapist to bring the
local dose to higher levels without compromising surrounding
structures. Most of these necroses occur within 1 year after
completion of radiation therapy. In one study, in which a per­
oral cone was used, 20 of 36 patients developed soft tissue ne­
crosis133. In another study, 18 soft tissue necroses were observed
in 278 patients examined (6.5%), and 11 were treated with ei­
ther interstitial or peroral cone therapy as all or part of their
radiation treatments (Table 4-12)90. Fifteen healed without in­
tervention, other than local irrigations, within 10 months of ini­
tial presentation. Three required surgical excision and primary
closure of the soft tissue wound. Intense local discomfort is a
clinical symptom that is sometimes useful in differentiating this
lesion from persistent disease. A tumor recurrence usually pre­
sents with irregular, indurated margins, whereas soft tissue ne­
croses present with regular, non-indurated margins. Exfoliative
cytology and incisional biopsy may be necessary to rule out
persistent tumor.
Clinical experience indicates that an appreciable number
of soft tissue necroses are precipitated by cheek and tongue bit­
ing. In many patients, a misshaped oral cavity and compromised
sensory and motor innervation of the tongue, lips and buccal
mucosa, combined with aberrant mandibular movements, pre­
dispose to tongue and cheek trauma. Often, occlusal adjustments
in the dentulous patient, or removal of the mandibular denture
in the edentulous patient, will alleviate the difficulty and reduce
the chances of recurrent trauma. Treatment consists of estab­
lishing the diagnosis and close follow-up. In severe cases, heal­
ing can be accelerated by means of hyperbaric oxygen.
Healing time
Radiation (months)
(centigrade)
Range Average
8 5,000-7,200 1.5-10 3
10 6,000-6,900 1.5-6' 3
9 7,000-8,000 2-5 4
98 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Prosthetic Management—Edentulous Patients dered edentulous by pre- or postradiation extractions120. Two

Risk of Bone Necrosis
In view of the histopathologic changes associated with oral
mucous membranes and bone, and reduction of output and com­
promise of the physical properties and biologic effectiveness of
saliva, some radiotherapists have been reluctant to permit their
patients to wear dentures. Some dentists have been reluctant to
fabricate restorations for edentulous patients after radiotherapy.
However, studies by Beumer and others reveal that the risk of
developing osteoradionecrosis is minimal if the patient was
edentulous prior to radiotherapy120. Of 92 edentulous patients
receiving complete maxillary and mandibular dentures, in which
a portion of the denture-bearing surface was in the radiation
field, none developed bone exposures. The reader should note
that this study is a retrospective analysis of a carefully screened
population of edentulous patients. In 87 of these patients, the
denture bearing surface of the mandibular denture was within
the radiation field (Table 4-13).
The risk of osteoradionecrosis is always greater in patients
requiring removal of teeth either prior to or after completion of
radiation therapy. Wildermuth and Cantril reported 6 cases of
osteoradionecrosis in 104 patients observed101. All occurred in
patients who were edentulous and who had submitted to full
mouth extractions prior to radiation therapy. An association
between denture use and these bony infections was not implied.
In 72 patients who were edentulous prior to therapy, none de­
veloped osteoradionecrosis. How many of these patients used
dentures after radiation therapy was not reported. In a study
completed at the University of California, 3 cases of bone ne­
croses were attributed to dentures in a group of 36 patients ren­
occurred in a group of 23 patients with preradiation extractions
and 1 occurred in 16 patients requiring postradiation extrac­
tions. All 3 bone necroses developed at an extraction site. From
a prosthodontic perspective, this finding appears to underscore
the importance of performing adequate alveolectomies when
extracting teeth in the field of radiation prior to radiation. The
well-balanced process of bone remodeling is seriously disturbed
by cancericidal doses of radiation therapy and, if radical alveo­
lectomies are not performed, the resulting alveolar ridge will be
irregular, possibly increasing the risk of bony exposure in a pa­
tient wearing complete dentures (Figure 4-28).
Soft Liners
Silicone liners have been suggested as a means of mini­
mizing mucosal trauma in mandibular dentures134135. Clinical
experience, however, has confirmed silicone to be less benefi­
cial than polymethylmethacrylate. The silicones exhibit reduced
wettability, and this phenomenon contributes to an increased
drag that does not allow the denture to slide as easily over the
dry mucosal surface during function. In patients with radiation-
induced xerostomia, this phenomenon assumes added clinical
significance. In one study, in which dentures with soft silicone
liners were used in 25 patients, 8 developed soft tissue necrosis
and 1 developed osteoradionecrosis91.. The high risk of tissue
abrasion plus the poor adjustability of silicone have influenced
clinicians to abandon its use in irradiated patients. In addition,
because of the significant increase in fungi populations in pa­
tients with radiation induced xerostomia, more rapid deteriora­
tion of silicone liners is observed.

Table 4-13. Patients edentulous prior to therapy.*

Numberofpatients
[ Full
Igg0ijjjljf PFullupperdenturesinfield 72 ^ '
reviousexperiencewithremovableprosthesis
m m m 84 mm
Timeinterval,therapytodelivery(months) llfgllgi %i
\|p|| Average ■■■^5.4
IK m Range Mil
gm ^ y Fj3fow-uplaf#Fdeliver^(months) 1
ij§§i jjBBg >20J9 0
' ^^
W StM
Z—' " -Range illMS 6- 114 ^
®§® Osteoradionecrosissecondarytodenture^
0 c
-m (111
m * Beujner„XGtftirsT,MorptehLR.RadratlQn-conipifcatrorfs'irreden-
xtufousnaiiertf&iJ/ProsthVerft 36:183:1976. ' 1 1
H
 Radiation Therapy o f Head and Neck Tumors 99

Placement of Dentures—Timing mucosal perforation from complete dentures. Severe mucosal

reactions to radiation are rarely seen, and only then in those
Some controversy exists regarding when dentures should patients with long standing mucosal atrophy prior to radiation,
be constructed for irradiated patients. Krajicek suggested that either secondary to diabetes mellitus or chronic alcoholism com­
patients could wear dentures after therapy, if 12 to 14 months bined with severe dietary deficiencies (Figure 4-44). In these
had elapsed for mucosal healing136. He maintained that, if the patients, if telangiectasia is noted in the zone of the attached
mucosa appeared atrophic or ischemic, dentures would not be tissue of the mandible, use of mandibular dentures is not rec­
tolerated. He also suggested that removable partial dentures ommended.
should generally not be considered for postradiation patients, Experienced complete denture wearers usually have de­
but he provided no data to support this view. Rahn felt that at veloped the necessary neuromuscular coordination necessary
least 12 to 18 months should elapse after radiation therapy be­ for successful function with dentures, and are less likely to ex­
fore considering dentures for a patient135. They suggested that hibit tongue or cheek biting. Edentulous patients with a history
some patients must wait 2 to 3 years before the mucosa has of multiple complaints and difficulties, associated with their
recovered sufficiently for dentures to be tolerated. Daly and dentures prior to radiation treatment, may indicate an added
Drane proposed that the clinician should wait at least 1 year risk factor for complications with postradiation dentures. This
before considering fabrication of removable prosthetic restora­ possibility must be discussed frankly with the patient and a fam­
tions for the irradiated patient91. One survey indicated that only ily member prior to prosthetic treatment, and the patient must
a few radiotherapists and prosthodontists adhered to the doc­ be well informed of the risks associated with dentures. Since
trine that therapeutic doses of radiation for oral malignancies most complaints are associated with mandibular complete den­
preclude the possibility of edentulous patients ever wearing tures, rarely will these patients be pleased with their new man­
complete dentures137. Most prosthodontists, however, advised dibular denture.
that construction of dentures be deferred for at least 1 year after
radiation therapy had been completed.
A study by Beumer provides some insight into this clinical
dilemma120. In 92 patients who were edentulous prior to the
onset of disease (87 having reported previous experience with
complete dentures), prostheses were inserted on an average of
15.4 months following completion of radiation therapy. Elimi­
nating 9 patients who waited longer than 50 months from radia­
tion therapy to delivery, the average time from completion of
radiation therapy to delivery of dentures was reduced to 8.9
months. In 45 patients, or approximately one-half the total num­
ber in the study, dentures were delivered within 6 months after
completion of radiotherapy. None in the group of 92 developed
osteoradionecrosis associated with the use of their dentures.
From this data and our clinical experience, we believe dentures
can be fabricated or reinserted soon after completion of radia­
tion therapy in most of these patients. For example, if the radia­
tion fields cover little of the mandibular denture-bearing sur­
faces, such as in treatment of a nasopharyngeal carcinoma, den­
tures can be inserted as soon as the mucositis resolves. In oth­
ers, with greater amounts of denture-bearing area in the fields, a
slightly longer period of recovery is recommended.
There are several reasons for this. Most patients who have
been edentulous for extended periods (more than 1 year) prior
to therapy present with nicely remodeled denture-bearing sur­
faces. The bony irregularities associated with past dental ex­ b
tractions have long since resolved. In addition, when an exter­
nal beam is employed with conventional fractionation and dos­ Fig. 4-44. a and b: Patients had severe radiation-induced
age, rarely does one see the kind of mucosal compromise (ex­ mucosal atrophy. Note prominent telangiectasis.
tensive telangiectasia, thinning, and atrophy of epithelium) of Patients are poor candidates for mandibular den­
the mandibular denture bearing surfaces that predisposes to tures.
 100 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

In patients who submitted to extraction of teeth in con­
junction with radical alveolectomies immediately prior to
therapy, a more conservative approach appears to be in order.
In a University of California study involving 23 patients, den­
tures were placed on the average of 22.2 months following
completion of therapy120. Two cases of bone necrosis devel­
oped in this group. In 13 patients (57%), dentures were deliv­
ered within 1 year of completion of radiation therapy (Table 4-
14). The status o f the residual ridge is an important clinical fac­
tor to be carefully appraised. An irregular mandibular ridge, in
which the entire body of the mandible is in the field, may prompt
the clinician to defer placement of dentures indefinitely. On the
other hand, a smooth, well-contoured mandibular denture-bear­
ing surface may enable the clinician to insert dentures quite
soon after therapy. Sixteen patients had complete dentures placed
after postradiotherapy extractions were effected in the radiation
field. Extractions were performed on an average of 26.1 months
alter therapy and the dentures inserted on the average of 11.8
months later. One patient developed an osteoradionecrosis as­
sociated with his denture at a recent extraction site (Table 4-
14). Based on these data, it is difficult to recommend how the
clinician should proceed in the patient who has undergone mul­
tiple extractions in the field after completion of radiotherapy.
The numbers are too few to generalize from, yet it is notewor­
thy that only 1 of these 16 patients developed osteoradionecro­
sis.

Table 4-14. Denture use in patients dentulous prior to therapy requiring extractions in
the radiation field.*

Number o f patients | , — •; 36
Full lower dentures ^ 31
pull upper dentures I B Z' 30
S oft tissue necroses H |9 - 11 •
Previous experience with removable prosthesis
(patients) ' - :' 18

Pretreatment

Patients . 23 |
Osteoradionecrosis secondary to dentures
(patients) 2
Time interval, therapy to delivery (months)
Average 22.2
Range 3-98
F ollow-up after delivery (months)
Average 19.1
Range 6-72

Posttreatment

Patients \ 16
Osteoradionecrosis secondary to dentures
Inpatients) IH > -
Time interval, therapy to delivery (months)
Average ^ 26.1
Range 1 ' 3-92
Time interval, extraction to delivery (months)
Average , . 11.8
Range 2-45

* Source: Beumer J, Curtis T, Morrish LR. Radiation complications in eden­

tulous patients. J Prosth Dent. 36:183;1976.

The question remains as to when dentures should be in­
serted for the irradiated patient. It seems logical to differentiate
between those patients who are edentulous and have used den­
tures prior to therapy and those who have had extraction of teeth
in the field of radiation prior to therapy and have not subse­
quently used complete dentures. Edentulous patients have little
risk of developing significant complications from wearing den­
tures, so, in most instances, it seems justified to place dentures
in these patients 3 to 12 months after radiation therapy. Defer­
ring denture use in this group for the 12 to 18 months, as is
often advocated in the literature, does not seem necessary. Those
in the dentulous group have the greater risk of developing com­
plications from their dentures, and deferment of dentures for
extended periods may be in order for selected patients.
Dentures and Preexisting Bone Necrosis
The possibility exists for selected patients to use mandibu­
lar or maxillary dentures over areas of exposed bone within the
radiation field. Ideally, the bone exposures should be well lo­
calized, with significant amounts of circumscribing attached mu­
cosa. The use of dentures over bone exposures in irradiated pa­
tients has been reported to be successful. Employment of im­
mediate dentures following post radiation extraction is described
by Hart and Mainous122. However, all the patients in their study
had received hyperbaric oxygen therapy.
Beumer observed 3 patients with osteoradionecrosis of the
edentulous mandible in the field of radiation and prior to pros­
thetic treatment120. All 3 necroses developed at the sites of ex­
tractions performed prior to radiation therapy. All 3 bony ne­
croses were confined to the attached mucosa of the alveolus,
and each measured less than 1.5 cm in diameter. Dentures were
inserted over these bony exposures with the denture generously
relieved over the region of the exposure. All 3 patients tolerated
their restorations successfully without enlargement. One expo­
sure proceeded to completely epithelize following sequestra­
tion of small amounts of bone. Utmost caution should be used
when inserting dentures over bone necroses. Proper relief must
be provided in the denture, and the patient should understand
the risks of denture use and be available for close follow-up.
When considering a patient for dentures, it must be remem­
beredthat osteoradionecrosis is a phenomenon confined almost
exclusively to the mandible. It would follow that extreme care
should be taken in construction of the mandibular denture base
ao insure distribution of pressure as widely and as equally as
possible over the mandibular denture-bearing surface during
famction. Likewise, the intent of any occlusal scheme should be
to minimize lateral movement of the mandibular denture base.
Radiation Therapy o fHead and Neck Tumors 101
Soft Tissue Necrosis and Dentures
The risk of developing a soft tissue necrosis when wearing
complete dentures, following therapeutic doses of radiation, ap­
pears to be relatively small and die resultant morbidity insig­
nificant Rahn reported observations on 50 patients for whom
complete dentures had been constructed following irradiation135.
Two developed soft tissue necrosis. Upon removal of the den­
tures, both lesions healed without further complications. In an­
other study, 6 out of 128 patients developed soft tissue necroses
attributed to dentures120. Five of the 6 were attributable to man­
dibular dentures. Three of the 6 had been treated with a combi­
nation of high-energy external radiation therapy followed by a
radioactive implant After removal of the dentures, 5 healed
within 6 months without incident. The sixth patient died of a
cardiovascular accident before resolution of the lesion.
In this study, as well as in other reports, the risk of soft
tissue necrosis was most often associated with implantation and
peroral cone techniques. Because of the risk of necrosis, pre­
cautions should be taken to avoid local trauma and infection.
This is especially important at the tumor site, for scarring and
fibrosis is most severe at this location. Extreme care should be
taken in developing the peripheral extensions of the denture
base in these areas.
Morbidity
Recent literature reveals few cases of bone necrosis, asso­
ciated with dentures, which lead to resection of the mandible.
In 1972, Daly and Drane reported 5 cases of osteoradionecrosis
in a group of 82 patients receiving intraoral prostheses after
therapeutic radiotherapy to the head and neck region91. Sixty-
four patients received complete dentures, and 18 received re­
movable partial dentures. Four healed under conservative treat­
ment, and 1still was presenting at the time ofpublication. Twelve
years later, Beumer reported 8 osteoradionecroses attributed to
complete dentures or removable partial dentures75. All but 1
occurred at either a preradiation or postradiation extraction site.
Seven healed with conservative measures accompanied by se­
questration of small amounts of nonvital bone (Figure 4-38).
The eighth progressively expanded and eventually required a
partial mandibular resection. None of the patients received hy­
perbaric oxygen.
Prosthodontic Procedures: Complete Dentures
Examination
Prior to the construction of dentures, the clinician must
contact the radiation therapist who treated the patient to inform
the therapist of his or her intentions. Information collected from
the therapist should include the type and site of the tumor, mode
102 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
of therapy employed (external, interstitial or combination), to­
tal dose, dates of treatment, radiation fields, tumor response,
and the prognosis for disease control. When interviewing the
patient, a histoiy of successful use of complete dentures prior to
therapy is an accurate indicator of future success. The patient’s
attitude towards self and the disease is of prime importance.
Many are emotionally distraught over the uncertainty regard­
ing cure and the morbidity inflicted by their radiation treatment.
These attitudes should be anticipated, and psychosocial coun­
seling provided when appropriate (see Chapters 1 and 2). An
uncooperative, poorly motivated patient is obviously a poor
candidate for postradiation denture service. The clinician must
remember the objectives of rehabilitation—ultimately, the re­
turn of the patient to society. Without a prosthesis, this objec­
tive may not be realized.
Upon initial oral examination, important clinical manifes­
tations of the radiation treatment include appearance of oral
mucous membranes, scarring and fibrosis at the tumor site, de­
gree of trismus, presence and nature of lymphedema, and status
of salivary function. The appearance of oral mucous membranes
is an important and valuable indicator of radiation response.
Translucent, boggy mucosa with prominent telangiectasia im­
plies poor tolerance to prosthodontic restorations; with an in­
creased risk of compromising mucosal integrity. Where severe
mucosal changes are present, use of dentures may be delayed
or forbidden.
Scarring at the tumor site may be quite prominent, espe­
cially if interstitial therapy was employed. Particular note should
be taken of floor of mouth lesions because some limitation in
extension of the lingual flange of the mandibular denture may
be prudent. Scar tissue is most unyielding and the slightest over­
extension may result in a mucosal perforation.
Excessive trismus is often observed in patients having pos­
teriorly and superiorly situated oral and pharyngeal lesions that
require radiation fields that include the temporomandibularjoint
and the muscles of mastication. In these patients, an exercise
program should be initiated as soon as possible after therapy.
Dynamic bite openers are not as effective in edentulous patients
as in dentulous patients, but may be useful occasionally (see
Chapter 12).
As has been noted previously, the amount and viscosity of
saliva is an important determinant of prosthodontic success.
Compromised salivary function leads to more friction at the
denture mucosal interface and, obviously, more mucosal irrita­
tion. The less saliva, the more difficulty the patient will have
tolerating dentures. In addition, the retention of the maxillary
complete denture may be compromised due to the film thick­
ness of a scanty and more mucinous saliva. No specific tech­
nique is advantageous over any other in the construction of den­
tures for these patients. The clinician should employ those meth­
ods with which he or she is most familiar, following sound,
prosthodontic principles.
The clinician should also examine the denture foundation
area thoroughly for undercuts, tori, high tissue attachments,
enlarged maxillary tuberosities, flabby and redundant tissue, lack
of attached gingiva, and abnormal jaw relationships. Any con­
dition which compromises the prosthetic prognosis in non-irra-
diated patients assumes added significance in irradiated patients.
For example, mandibular ridges with severe bilateral undercuts
or excessive ridge resorption with little attached mucosa are
poor candidates for complete denture service following radia­
tion therapy.
Impressions
Conventional border molding, using a custom tray and
modeling plastic, is advocated for making impressions. Although
use of modeling plastic is thought to be contraindicated by some
clinicians135, there has yet to be a reported case of bone or soft
tissue necrosis attributable to the use of this material. Border
molding should be performed with care, with the clinician guard­
ing against overextension. If xerostomia is particularly profound,
a thin coating of petrolatum may be applied over the soft mod­
eling plastic to prevent its sticking to the dry mucosa. Particular
attention should be paid to the lingual extension of the man­
dibular denture because overextension could result in a mu­
cosal perforation. Displacement of the tissues of the floor of
mouth, in an attempt to obtain peripheral seal, is not advocated.
Peripheral seal is virtually impossible to obtain in these patients
because of the curtailment of the patient’s salivary flow. Efforts
to develop the lingual flange should be directed toward gaining
stability and support rather than retention. Edema of the tongue
and floor of mouth, which is particularly prominent if the pa­
tient has undergone a radical neck dissection, will occasionally
be sufficiendy large to compromise tongue space, compromise
floor of mouth posture, and limit the extent of the lingual flange.
Cutting away the denture base in regions in the fields of irradia­
tion has been advocated for some patients135; however, our ex­
perience indicates that this procedure is neither useful nor nec­
essary.
Any of the traditional impression materials may be used
with success. There is no evidence that zinc oxide wash materi­
als contribute to increased morbidity, although they may pre­
cipitate some discomfort. However, if the impression must be
repeated, a substitute impression material should be utilized.
The clinician should use the material with which he or she feels
most comfortable. The primary objective is to obtain an im­
pression which displaces tissue as little as possible. The mylo­
hyoid area is a critical spot on which to avoid excessive pres­
sure. How the clinician accomplishes this depends on what works
best in his or her hands. Removal of residual viscous secretions
with gauze or a mouth rinse immediately prior to obtaining the
final impression will improve surface detail.

Vertical Dimension
The completed impressions are boxed and poured in den­
tal stone. Record bases are prepared in the usual way and used
to determine the vertical dimension of occlusion. The traditional
methods of determining vertical dimension are applicable, such
as phonetics, closest speaking distance, swallowing, neuromus­
cular perception, and recording vertical dimension of rest, hi
some patients, the clinician should consider reducing the verti­
cal dimension of occlusion. This consideration is based on 2
lines of reasoning: First, reducing the vertical dimension may
limit the extent of the forces applied to the supporting mucosa
and bone during a forceful closure. Second, in patients with
clinically significant trismus, entrance of the bolus is more eas­
ily accomplished by increasing the interocclusal space.
Centric relation records are obtained in the usual manner.
Wax, plaster, zinc oxide paste, and silicone are suitable media
for obtaining the final registrations. Graphic recording devices
can similarly be successfully employed. There is no evidence
indicating that a therapeutic course of radiation therapy results
in changes of mandibular lateral border or intraborder move­
ments during mastication.
Occlusal Forms
It is not possible, with the information at hand, to make
assumptions relative to the efficacy of any particular occlusal
scheme available in the construction of complete dentures for
irradiated patients. In our review of 128 patients, both anatomic
teeth with full balance and nonanatomic forms were employed.
On a theoretical basis, however, the authors have come to favor
lingualized or monoplane occlusal schemes with balance facili­
tated by posteriorly situated balancing ramps. The literature
seems to indicate that less horizontal force is generated with a
nonanatomic occlusal scheme138,139-140’141; this assumption, if true,
would mean an obvious advantage to irradiated patients.
la arranging posterior teeth, careful attention should be di­
rected toward attaining a proper buccal horizontal overlap. Some
clinicians use only 3 posterior teeth, 1 bicuspid, and 2 molars in
order to avoid trauma to the posterior buccal mucosa. In some
patients, edema of the tongue and buccal mucosa is prominent,
and tongue and cheek biting is not uncommon. Occlusal trauma
n a y lead to a soft tissue necrosis, particularly in patients whose
longue lesions were treated with interstitial radiation therapy.
I i dentures constructed with anatomic posterior teeth, bilateral
balance is mandatory.
Delivery and Post-Insertion Care
Occlusal discrepancies caused by processing errors should
he eliminated prior to removing the dentures from the cast. Af-
t r removal, any rough projections on the tissue surface should
Radiation Therapy o f Head and Neck Tumors 103
be smoothed. Pressure indicator paste is used to identify areas
of excessive pressure, and disclosing wax is useful in delineat­
ing overextension of denture flanges. Remounting the dentures
on a suitable articulator with new maxillomandibular records
made at the time of delivery is mandatory. Lightly polishing the
bearing surface of the mandibular denture is advisable.
The patient is given an instruction sheet, detailing possible
problems and precautions. Instructions concerning removal of
the dentures if soreness develops, the necessity for periodic re­
turn visits, and the initial limited use of the prosthesis for mas­
tication are provided. Such restorations should never be worn
while sleeping. The care after delivery of dentures is critical
and requires an understanding patient to avoid untoward com­
plications. During the first week, 24-hour and 48-hour recall
appointments are recommended regardless of how well the pa­
tient is tolerating the dentures. At the end of the adjustment
period, the patient is required to return 4 times during the first
year. If the patient continues to present without complications,
the interval between visits may be lengthened during succeed­
ing years.
The risk of serious postradiation sequelae in denture wear­
ers is small. However, individual reactions to therapeutic doses
of radiation may vary greatly, and good judgment and sound
technique are factors which can never be ignored in placement
of prostheses in postradiation patients. Cooperation of the pa­
tient is a necessity because, without it, the best intentions of the
dentist may only result in bone or soft tissue necrosis. The pa­
tient must understand the tissue changes resulting from radia­
tion treatments, and must be available for close follow-up.
Implants in Irradiated Tissues
Irradiation of head and neck tumors predispose to changes
in bone, skin, and mucosa, which affect the predictability of
osseointegrated implants. Long term function of osseointegrated
implants is dependent on the presence of viable bone that is
capable of remodeling and turnover as the implant is subjected
to stresses associated with supporting, retaining, and stabilizing
prosthetic restorations. The viability of irradiated bone may not
be sufficient to ensure a predictable result, particularly in ana­
tomical sites such as the supraorbital rim and the body of the
mandible. Even in the maxilla, remodeling and turnover of bone,
subjected to high dose radiotherapy (above 5000 cGy), may be
adversely affected to the point where an implant, subjected to
functional stresses, cannot be sustained.
When implants are considered for the irradiated patient,
several issues require careful consideration such as the risk of
osteoradionecrosis, the potential benefit provided by implants,
the potential morbidity associated with implant failure or com­
plications (such as osteoradionecrosis), and the potential use­
fulness of hyperbaric oxygen.
104 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Predictability of Implants In Irradiated Bone
Preliminary reports and our own experience indicate that
the success-failure rate of osseointegrated implants in irradi­
ated bone appears to be dependent upon the anatomical site
selected, the dose to the site, and the use of hyperbaric oxygen.
Animal experiments have shown that the quantity of the bone
at the bone-implant interface (the bone implant appositional
index) is reduced142143. Hum and Larsen studied the interface
using the New Zealand adult rabbit142. IMZ* implants were
placed in the proximal tibia and 2 weeks later received 4050
cGy (450 cGy per fraction, 9 fractions delivered during a 19-
day period equivalent to 1728 Rets).
R o fc _ D (tota l D o s e )
n e ia — m o .24T o.11
N = num ber o f fra c tio n s
T ss tim e o f th e rap y (in days)
The specimens were recovered 2 months after implant place­
ment. The bone implant appositional index was calculated by
examining non-decalcified histologic sections using a grid tech­
nique. The appositional bone index for non-irradiated speci­
mens was 94.8% and, for the irradiated specimens, 76.2%.
Weinlander and others tested 3 different types of implants us­
ing a dog model143. Three implants, Br&nemark**, IMZ*, and
HA coated***, were placed on one side of the mandible in 7
dogs. After 3 months of healing, 21 implants in the 7 dogs were
recovered with block section and served as controls. After a
suitable period of healing, these 3 selected implants were posi­
tioned into the contralateral mandible of each of the 7 dogs.
Radiation commenced 3 weeks later. A dose equivalent to 5000
cGy was delivered to these sites. The specimens were recov­
ered 3 months later and studies conducted included a
histomorphometric analysis of the bone implant interface. For
the Branemark implant, the appositional bone index was 34%
for the non-irradiated control specimens versus 24% for the ir­
radiated specimens; for the IMZ implants, 50% non-irradiated
controls versus 45% irradiated specimens; and, for the HA coated
implant, 69% non-irradiated controls versus 72% irradiated
specimens.
Nishimura has shown that the quality of bone in the im­
plant appositional zone is compromised, particularly at high
radiation dose levels144. Forty-four adult New Zealand rabbits
were assigned at random to 6 test groups. The animals received
radiation to either the proximal or diaphyseal segments of both
tibias. Equivalent doses ranged from 4000 to 7000 cGy. Three
months following completion of radiation treatment, 5 mm screw
type implants were placed into each half of the left tibia of the
* Interpore International, Irvine, CA.
** Nobelpharma USA, Chicago, IL.
*** Calcitek, San Diego, CA.
surviving 38 rabbits. Polyfluorochrome labeling was performed
3 months after implant placement and 2 days prior to sacrifice.
Ground non-decalcified sections were prepared and evaluated.
Results revealed a steady decrease in the label, especially when
the equivalent dosage exceeded 5800 cGy, indicating reduced
cellular activity. When viewed under polarized light, the qual­
ity of bone in the appositional zone was shown to be affected
by radiation. The specimens receiving the highest levels showed
a preponderance of woven bone, as compared to the dense lamel­
lar bone seen in the controls and at the lowest dosages (Figure
4-45).
The early trends seen in recent clinical reports145146appear
to substantiate the concerns raised in the animal studies; namely,
a high percentage of implants in irradiated tissues demonstrate
advanced bone loss at an early stage146,147. Implants in irradiated
tissues appear to have significantly lower success rates than
a b
Fig. 4-45. a: Specimen received the equivalent of 4900 cGy.
Normal lamellar bone is seen in the appositional
zone, b: Specimen received equivalent to 6600
cGy. Note the woven bone in the appositional
zone.
implants in non-irradiated tissues145,146,147. The UCLA data is
particularly interesting. From 1987 to 1989, 92 craniofacial
type** implants were placed in 30 patients to retain facial pros­
theses. Sixty-nine were placed in non-irradiated tissues and 23
were placed in irradiated tissues. After 1 year of follow-up, the
success rates were about the same for both the irradiated and
non-irradiated groups. By the end of 3 years, however, only
68.4% of the implants in irradiated sites remained in place as
compared to 84.0% of the implants in non-irradiated sites. Doses
delivered to all irradiated sites exceeded 5000 cGy146.
 Radiation Therapy o f Head and Neck Tumors 105

In the maxilla, the implant failure rate in irradiated patients plants can be placed with a high degree of predictability in this
has been slightly higher than in normal patients. Roumanas re­ region (Figure 4-47).
ported on the results of 33 implants placed in the irradiated In the maxilla, the risk of bone necrosis is probably negli­
maxillae of 13 patients147. All patients received at least 5000 gible. The use of hyperbaric oxygen can be justified only on the
cGy to the implant sites. Eleven of the 33 failed and were re­ basis of improving success rates.
moved, and 2 others were buried beneath the mucosa, for a
success rate of 60.6%. Many of the remaining implants demon­ Irradiation of Existing Implants
strated moderate to severe bone loss around the remaining im­
plants (bone loss extending to at least the level of the fourth Irradiation of titanium implants already in place results in
thread). backscatter and, therefore, the tissues on the radiation source
Because of these results, some clinicians148149150 have at­ side of the implants receive a higher dose than the other tissues
tempted to improve the viability of bone with hyperbaric oxy­ in the field. The dose is increased about 15% at 1 mm from the
gen treatments prior to implant placement Granstron treated implant (Figure 4-48). Because of backscatter155,156and the in­
13 patients with hyperbaric oxygen who had previously been creased numbers of elderly patients receiving implants, clini­
irradiated150. Each patient received 20 treatments, and implant cians ask if osseointegrated implants should be removed in pa­
surgery was performed, followed by 10 more hyperbaric treat­ tients about to be irradiated for head Mid neck tumors (Figure 4-
ments. Only 1 implant fixture was lost (2.0% of the total). Marx
reported similar results in a large series of patients who had
implants placed in irradiated mandibles148.
In summary, it is clear from the current data that osseo-
integration is impaired in bone that has received doses in ex­
cess of 5000 cGy. Success rates, based on short-term clinical
reports, are reduced, as compared to non-irradiated sites, par­
ticularly the orbit151’152,153and the mandible154. The success rates
are lower than in normal individuals, even in the maxilla, with
its excellent blood supply147. In addition, preliminary animal
studies referred to previously appear to indicate that the bone-
implant interface may be significantly compromised, making
the implant less able to tolerate functional loads. Hyperbaric
oxygen appears to help revitalize the bone, leading to improved
success rates, but long-term clinical follow-up data is still lack­
ing. In addition, its high cost precludes its use in most patients.

Risk of Osteoradionecrosis

Risk of osteoradionecrosis in the mandible is probably best

determined by an analysis of the bone necrosis rate seen in
postradiation extractions. Based on this data, it should be rela­
tively safe to place implants in irradiated mandibular sites if the
dose is less than 5500 cGy. Conversely, the risk would be quite
high for doses above 6500 cGy (Figure 4-46). In the latter case,
if implants are desirable, we recommend a course of hyperbaric
oxygen as described by Granstron149. In patients with doses to
b
bone sites between 5500 and 6500 cGy, individual patient fac­
tors, such as the dose per fraction, a previous radical neck dis­ Fig. 4-46. a: Patient received 6600 cGy for left base of
section, and so forth, may be important cofactors to consider tongue carcinoma. Five implants were placed and
when assessing the risk. In these patients, if implants are con­ a fixed hybrid prosthesis fabricated, b: Patient de­
sidered elective, they should be deferred. If implants are deemed veloped osteoradionecrosis associated with the
essential, we recommend they be placed in conjunction with left posterior implant 30 months following place­
hyperbaric oxygen149. It should be noted that most patients do ment of implants and 60 months postradiotherapy.
not receive radiation to the symphyseal region; therefore, im­ Mandible was resected and reconstructed with
fibula free flap.
106 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

b c
F ig . 4-47.
Patient irradiated fo r lateral tongue lesion. He received 6500 cGy. Disease was still present
at completion of radiotherapy and he underwent a right composite resection, a: Note ab­
sence of facial hair in region of mandibular body and pres­
ence o f facial hair in symphyseal region, indicating that
this area was not irradiated, b and c: Implants in position,
a d: Master cast with retention bar. e: Mandibular prosthe­
sis. f: Facial view following insertion of prostheses. Most
patients do not receive radiation therapy to symphyseal region and osseointegrated implants
placed in the mandible are predictable when placed anterior to field of radiation.

%i
1S0-
140 - Tissue Mandibular Tray Implant

130 -

1 Vitallium (136% maximum)

2 Stainless Steel (135% maximum)
3 Titanium (129% maximum)
4 Dacron/Polyetherurethane (101% maximum)

F ig. 4-48. Results of radiation measurements. Doses are

expressed as percentage of dose measured at
th a t point in absence o f in te rfa ce . (Source:
Schwartz HC, Wollin M, Leake D, Kagan R: Inter­
face radiation dosimetry in mandibular reconstruc­
tion. Arch Otolaryngol. 105:293;1979.).
F ig . 4-49. Two years following implant placement, patient
was irradiated fo r recurrent carcinom a. Note
erythema. Eventually these implants failed.

49). Granstom addressed this question in his report of 11 pa­
tients, with 33 existing titanium implants, who were scheduled
to be irradiated157. Dosages ranged from 5000 to 6600 cGy. Based
on the findings, Granstom recommended that all abutments and
superstructures be removed prior to radiation and that skin and/
or mucosa should be closed over the implant fixtures. When
healing is complete, radiation therapy can begin. Following
completion of radiation, abutments and the superstructure are
reattached and the prosthesis remade or readapted.
References
1 Elkind MM, Sutton H: X-ray damage and recovery in
mammalian cells in culture. Nature. 184:1293; 1959.
2 Kallman RF: The phenomenon of reoxygenation and its
implication for fractionated radiotherapy. Radiology.
105:135;1972.
3 W ithers HR: Cell cycle redistribution as a factor in
multifractionation irradiation. Radiology. 114:199; 1975.
4 Hermens AF, Barendsen GW: Changes of cell proliferation
characteristics in a rat rhabdomyosarcoma before and after
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141 Swoope CC, Kydd WC: The effect of cusp form'and occlusal 156 Wang R, Pilli K: In vitro backscattering from implant materials
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142 Hum S, Larsen P: The effect of radiation at the titanium/bone 157 Granstrom G, Tjellstrom A, Albrektsson T: Post-implantation
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152 Nishimura R, Roumanas E, Sugai T, Moy P, Lewis S: Nasal
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153 Nishimura R, Roumanas E, Sugai T, Moy P, Lewis S: Orbital
defects and osseointegrated implants. UCLA experience. J
Prosthet Dent, (submitted); 1994.
154 Visch L, Lavendag P, Denissen H: Implants in irradiated tissue;
5 year results of227 HA coated implants (Abstract #121). 1st
International Congress on Maxillofacial Prosthetics. 1994.
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105:293,1979.
Chapter 5
Acquired Defects of the Mandible
Etiology, Treatment, and Rehabilitation
John Beumer III, Mark T. Marunick, Thomas A. Curtis, and
Eleni Roumanas
Etiology, Treatment, and Disability
The management of malignant tumors associated with the
tongue, floor of the mouth, mandible, and adjacent structures
represents a difficult challenge for the surgeon, radiation on­
cologist, and prosthodontist relative to both control of the pri­
mary disease and rehabilitation following treatment. The most
common intraoral sites for squamous cell carcinoma are die
lateral margin of the tongue and the floor of the mouth. Both
locations predispose the mandible to tumor invasion, often ne­
cessitating its resection in conjunction with large portions of
the tongue, the floor of the mouth, and the regional lymphat­
ics.
Disabilities resulting from such resections may include
impaired speech articulation, difficulty in swallowing, problems
with mastication, deviation of the mandible during functional
movements, compromised control of salivary secretions, and
severe cosmetic disfigurement. In the past 10 years, the intro­
duction of myocutaneous flaps, free tissue transfers and dental
implants have resulted in considerable improvement in the form
and function of these patients. The impact of free tissue trans­
fers in reconstruction of the tongue has been particularly no­
table. In the previous edition, we noted the differences between
patients with tongue, jaw, and neck defects and those with max­
illary defects, particularly in regard to effectiveness of rehabili­
tation and subsequent quality of life. Using these new surgical
and prosthodontic methods, many more patients with tongue-
mandible defects can be restored in appearance and function to
levels which approach their presurgical condition. These reha­
bilitative efforts are more complex and require the efforts of a
sophisticated, well-trained, multidisciplinary team of oncologic
surgeons, maxillofacial prosthodontists, reconstructive surgeons,
speech therapists, social workers, and others.
Section on epidemiology of oral cancer contributed by Sol Silverman, Jr.
The reader must remember that the treatment modalities
for malignant neoplasms that invade or approximate the man­
dible or contiguous soft tissues impact on the jaw that can least
afford to be compromised1. Many vital and life sustaining func­
tions evolve around the moveable mandible, tongue and adja­
cent structures. The prognosis for a normal, nonsurgical patient
requiring a maxillary complete denture to function with a par­
tially edentulous mandible and a removable partial denture is
usually within acceptable limits, while the prognosis for the
reverse scenario is poor. In addition, a partially resected tongue
compounds the problem since it may not function like a normal
tongue. Radiation therapy has a more significant impact on
mandibular structures. Therefore, following mandibular resec­
tions, it is not uncommon for the remaining bony mandible and
teeth to function with essentially normal maxillary structures.
The functional movements and occlusal proprioception of a
mandible that has lost bony continuity is entirely different from
normal mandibular movements and occlusion. Thus, cancer
treatment may compromise the jaw that can least afford to be
compromised.
It is unrealistic to discuss functional impairment without
reference to the psychic and social factors affecting patients
with mandibular resections. Distortions in self-image, inability
to communicate, and altered family and vocational roles require
the reconstruction of psychic systems to handle these new de­
mands. Those involved in rehabilitation of these patients must
be sensitive to the emotional trauma precipitated by cancer and
its treatment.
The Epidemiology of Oral Cancer*
The ideal approach to oral cancer control is prevention.
This implies recognition and adequate treatment of precancer-
114 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
ous lesions as well as modification of the associated risks of
tobacco and alcohol use. Additionally, in a certain sense, pre­
vention can be practiced by reducing morbidity and mortality
through the early detection of oral malignancies. Careful as­
sessment of occurrence and demographics, along with an un­
derstanding of causative factors, assist measures in prevention
through education, research, and patient care.
Incidence
Oral cancer is the sixth most common tumor worldwide
and the fourth most common cancer among men. In some na­
tions, it represents 25% to 30% of all cancer cases. More than 1
million new cancers of all sites (excluding skin) are diagnosed
in the United States each year. Cancers of the lips, tongue, floor
of the mouth, palate, gingiva, buccal mucosa, and oropharynx
will account for about 3% of these cases23. If the nasopharynx,
hypopharynx, larynx, sinuses, and major salivary glands are
included with the oral sites, then cancers of these sites, combined,
will account for more than 5% of all cancers in the United States.
Histologic types
Carcinomas account for about 96% of all oral cancers, and
sarcomas for about 4%. Since the most common type of oral
cancer is squamous cell carcinoma, which accounts for approxi­
mately 9 out of 10 oral malignancies, the oral cancer problem
primarily concerns the diagnosis, biology, and management of
squamous cell carcinoma.
Age and sex
Of all the factors that may contribute to the development
of cancer, age is the factor that incurs the highest risk. Oral
cancer, like most cancers, is a disease of older age. About 95%
of all oral cancer occurs in persons over 40 years of age, and the
average age at the time of onset is about 60. The importance of
this factor in cancer prevalence is augmented by the fact that
the over-65 population in the United States now exceeds 13%
of the total population and is expected to exceed 20% beyond
the year 2000. The older age of oral cancer patients suggests
that a time factor may be operating that involves predetermined
changes in the biochemical-biophysical processes of aging cells-
changes that may be influenced by chemicals, viruses, hormones,
nutrients, or physical irritants.
Oral cancer occurs more frequently in males, but the male-
female ratio, which in 1950 was about 6:1, is now about 2:1.
One explanation for this reduced ratio is thought to be the great
increase in smoking among women. In addition, considering
cancer as an age-related disease, it should be noted that, in the
over-65 age group in the general population, the number of
women exceeds the number of men by 45%.
Sites
The tongue is the most common site for oral cancer for
both men and women. Data from the National Cancer Institute’s
SEER Program (Surveillance Epidemiology End Results)
showed that 85% of all oral cancers diagnosed between 1973
and 1985 occurred in the tongue, oropharynx, mouth floor, and
lips. Oral cancer incidence has remained stable relative to the
occurrence of all newly diagnosed cancers, with the absolute
numbers increasing each year. The only site contrary to this
trend was lip, where a 5% reduction occurred. This trend may
reflect public education regarding the dangers of ultraviolet
exposure and the use of sunscreens. The greatest increase in
cancer of the 4 most frequent cancer sites was in the tongue.
Oral tongue malignancies (located in the anterior two-thirds)
accounted for 53% of tongue cancers. Since 47% occurred in
the base of the tongue, the problems regarding recognition of
signs and symptoms for early diagnosis are apparent.
In the United States, the increased male prevalence of oral
cancer appears to be due to the higher number of lip cancers
that occur in men, approximating a ratio of 10:1 over women.
This preponderance of cases in men relative to women may
also be partly accounted for by out-of-doors occupations and
recreational activities, and histories of heavier daily tobacco and
alcohol consumption by male patients.
Stage at Diagnosis
In comparing various tumor registry data, there was uni­
form agreement that about 95% of all oral cancers were squa­
mous cell carcinomas. Based on 12,425 recorded in the SEER
Program, for which there was adequate information, advanced
lesions (staged as spread) outnumbered localized lesions by more
than 2 to 1 (Table 5-1). The lip was the only site where local­
ized cancers were more frequently found than those that were
advanced. If the 3 leading cancer sites of tongue, oropharynx,
and floor of the mouth were considered, the number of local­
ized tumors at diagnosis would be reduced to about 25% for the
1973 through 1984 study. It becomes obvious at the present
time that an earlier diagnosis is a key factor in oral cancer con­
trol.
Race and Genetics
Ethnic background is known to influence many types of
cancer. For example, cancer in American blacks is increasing at
a faster rate than in American whites. Blacks have higher rates
of oropharyngeal cancer than do other racial groups. This find­
ing suggests a genetic factor, although habits or living differ­
ences have also been implicated4. As another example, cancer
of the nasopharynx is 20 to 30 times as prevalent in Chinese as
in whites. The rate of nasopharyngeal carcinoma is highest in
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 115

Table 5-1. Oral Cancer: Stage at Diagmosis.*

1973-1978 1979-1984
|S M K
Percentage Percentage
C ancer N um ber o f
S ite Cases Localized Spread Localized Spread

Tongue 3715 29 71 32 68
O ropharynx 3612 . 21 79 21 79
M outh Floor 2017 11 89 20 80
Lip 1822 75 "";25'Z 87 13
G ingiva 657 10 90 14 86
B uccal 320 12 88 24 76
Hard Palate 282 35 65 34 66 |

12,425 29 % 71 % 34% 66 j j j

* Source: Data from National Cancer Institute: Surveillance, Epidemiology, and End Results Program, 1973-1984.

Chinese who have remained in Asia, for example, those in South­
east Asia, where it is one of the most common cancers in both
men and women. Studies of human cancer of certain specific
sites (breast, prostate, lung, colon, stomach, liver, and skin) have
shown that these neoplasms tend to occur in families, implying
a genetic influence5. No such evidence of familial grouping has
been presented for oral cancer.
Multiple Cancers
The data unequivocally show that persons with oral cancer
are at an increased risk for developing subsequent additional
malignancies. A study of smoking habits of oral cancer patients
at the University of California San Francisco found that, of 160
patients observed for more than 1 year after treatment, 18%
developed second primary oral cancers6. The risk was greater
for those whose tobacco habits remained unchanged (30%) than
for those who quit (13%).
In a study of 153 patients with carcinoma of the mouth
floor, who were treated and observed at the University of Cali­
fornia San Francisco between 1957 and 1973, it was found that
36% had at least 1 second primary cancer7. Twenty-three pa­
tients (15%) had a second primary oral cancer. In a similar fol­
low-up study involving 204 patients with carcinoma of the
tongue who were observed between 1940 and 1971,19% had
second primary cancers; 61% of these were second oral pri­
mary malignancies (12% of the total group)8.
In a 1969 review of 1,250 patients with cancers of the
mouth, pharynx, or larynx, it was found that 104 (8.3%) devel­
oped second primary cancers within the same anatomic areas9.
In a 1970 study of 9,415 patients with squamous carcinomas of
the upper respiratory or upper digestive tract, second primary
cancers occurred at a rate that was twice the expected incidence10.
The observed-to-expected ratio for oral cancer patients was 1.9:1.
The increased risk for additional new oral cancers in pa­
tients also has been confirmed in 3 other studies'1-12’13. One study
of 377 patients treated for cancer in the floor of the mouth re­
ported that 18% developed new cancers of the respiratory and
upper digestive tracts and 9% had second primary cancers oc­
curring in the mouth13. Another of these studies suggested an
increased risk of subsequent oropharyngeal carcinoma in women
with already diagnosed carcinomas of the breast or uterus12.
The increased risk for multiple head and neck carcinomas is
further accentuated in alcohol and tobacco users14,13.
Mortality
Worldwide, cancers of various forms account for more than
2 million deaths each year. In the United States, cancer is a
leading killer, second only to cardiovascular disease. It is re­
sponsible for more than 1 out of every 5 American deaths—
about 500,000 deaths each year, or more than 1,300 each day.
Someone in the United States dies of cancer almost every minute.
The cancer death rate has risen almost without interruption
in the United States (over200per 100,000population currently).
Oral cancer accounts for about 10,000 yearly deaths. The rela­
tive survival for black patients is lower than that for white pa­
tients and, in recent years, there does not appear to be any im­
provement in these figures. This may be due to socioeconomic
disadvantages in the health care system as well as to the known
greater prevalence of smoking and alcohol consumption in that
population group. Most discouraging of all is that about half of
all oral cancer patients die from their disease.
116 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Etiology and Predisposing Factors*
The exact cause of oral cancer is unknown. Because time
is needed for the cellular events involved in neoplasia to accu­
mulate, the most prominent factor determining susceptibility to
cancer is age. Variations in incidence rates among different
groups or populations can be explained by differences in expo­
sure to carcinogenic initiators or promoters. For example, the
use of tobacco or alcohol significantly increases the risk of can­
cer, indicating an etiologic role. The role of growth and sup­
pressor factors in promoting human cancer remains unclear. Cell
transforming genes (oncogenes) certainly play a role. The known
fact is that, at a certain time, a cell or group of cells may un­
dergo uncontrolled growth. This capacity for disorderly divi­
sion continues in daughter cells, producing a malignancy through
subsequent spread and destruction of other tissues and organs,
whose integrity and functions are necessary for life. The role of
various chemicals produced by cells regulating the capability
of attachment, invasion, and disruption is under intensive in­
vestigation. Because survival and generation times of cells com­
prising a malignant tumor vary considerably, growth patterns
of tumors are highly irregular and unpredictable.
Humans are exposed continually and simultaneously to a
broad spectrum of biological, chemical, and physical forces. To
complicate matters, each individual reacts differently to these
forces. Everyone’s reactions are conditioned by heredity, age,
sex, and a multitude of other factors. If the evidence now in
hand suggests one conclusion more strongly than any other, it
is that there probably are multiple causes for every type of can­
cer.
Death rates from around the world suggest marked differ­
ences in the occurrence in oral cancer, which may reflect differ­
ent combinations of ethnic and environmental factors. Occur­
rence rates also reflect differences according to geographic lo­
cation.
The Immune System
Immune competence and immune cell surveillance dimin­
ish with age. This fact undoubtedly contributes to the associa­
tion between age and malignancy. Furthermore, studies have
shown that there are increased risks of cancer developing in
individuals whose immune systems are either congenitally de­
fective or have been suppressed by chemotherapy or by certain
diseases. The association between increased cancer occurrence
and immunosuppression has been demonstrated in the acquired
immunodeficiency syndrome, where progressive immunosup­
pression is characteristic of the infection. However, for persons
in the general population who develop oral cancers and who
are not otherwise known to have or be at risk for immunodefi­
ciency, it is not clear whether differences found in some immu­
nologic variables are a cause or a result of the malignancy.
* Section on etiology and predisposing factors contributed by Sol Silverman, Jr.
Viruses
Many factors can cause cells to become malignant, but the
role of viruses is being increasingly examined. The phenom­
enon of viral carcinogenesis is well established in experimental
animal systems, and there is little doubt that several viruses
would cause cancer in human beings if given the opportunity.
Herpesviruses Any enveloped virus containing double-stranded
DNA with an icosahedral capsid about 100-150 nm in diameter
is known as a herpesvirus. The characteristic morphology is
easily recognized under the electron microscope. There are 6
that cause human disease: herpes simplex virus type-1 (HSV-
1), herpes simplex virus type-2 (HSV-2), Epstein-Barr virus
(EBV), cytomegalovirus (CMV), varicella zoster virus (VZV),
and human herpes virus 6. Each of these viruses causes an acute
human infection, and HSV, EBV, and CMV have been impli­
cated in certain malignant diseases as well.
EBV is almost certainly a cause of Burkitt’s lymphoma
and nasopharyngeal carcinoma, since the virus is epidemiologi-
cally associated with those diseases and can transform the tar­
get cell type. More recently, it has been found that EBV can
infect oral epithelial cells16and is present in hairy leukoplakias17.
However, EBV has not been reported in association with oral
squamous cell carcinomas.
CMV can transform human cells to a malignant pheno­
type. It may seem paradoxical that a virus could either lyse cells
or convert them to malignancy, but, in fact, many oncogenic
animal viruses are capable of performing either function, de­
pending on the conditions that prevail..
HSV can cause acute and recurrent infections at 2 princi­
pal sites, the genital and the oral epithelia. In 1967, it was pro­
posed that the virus isolated from oral lesions be termed HSV-1
and the virus from genital lesions be termed HSV-2. This pro­
posal has been generally adopted, although the 2 types are re­
markably similar. Genital infections with type 1 are often seen,
although oral infections with type 2 are rare18.
Recurrent herpetic infections are not due to exogenous re­
infection with HSV, but are due to release of virus from latency,
followed by its passage along the sensory nerves to the skin. An
important finding is that the reactivation of the virus is not al­
ways accompanied by epithelial lesions. Therefore, oral epithe­
lial cells are repeatedly exposed to HSV without being killed—
the long-term effects of this are not known. In our clinical expe­
rience, there is no association between recurrent herpes labialis
and cancer of the lip or mouth. In 51 consecutive patients with
oral cancer studied at UCSF, only 1 had a history of herpes
labialis, and that patient’s tumor was not associated with the
lip19. Attempts to culture HSV from swabs taken from the tu­
mor surfaces of oral carcinomas were not successful and, clini­
cally, there was no evidence of a herpetic infection. A compre­
hensive electron microscopic examination of oral carcinomas
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
in this study showed cytoplasmic disorganization, but no virus
particles. Additionally, there has been no change in antibody
titers demonstrated in oral cancer patients. Neutralizing anti­
bodies to HSV-1 are higher in smokers than nonsmokers.
Carcinogenicity o f H SV When the earliest clinical stud­
ies began to reveal an association between HSV and human
carcinomas, experimental work was begun by various research­
ers to find out if the virus can be carcinogenic under any par­
ticular conditions. It was found that, if the cytolytic properties
of the virus were inhibited by exposure to ultraviolet light, the
virus became capable of transforming hamster cells in a cul­
ture. These cells grew as carcinomas if they were reintroduced
into the original host. Cells from a variety of species, including
human, have now been transformed, both by HSV-1 and HSV-
2. Experiments in animals have not yet demonstrated a direct
carcinogenic effect of HSV in vivo, but a co-carcinogenic ef­
fect has been shown.
HSV cannot be detected in animal tumors established from
cells that were transformed by the virus, and no tumor antigens
nor DNA fragments are retained by these cells. For these rea­
sons, it is now accepted that HSV transforms cells by “hit-and-
run” mechanisms, leaving behind no traces of its former pres­
ence. This makes it extremely difficult to establish the role of
HSV in oral cancer.
Papillomaviruses Papillomaviruses are the cause of warts20.
Unfortunately, human papillomaviruses do not grow in cell cul­
tures or in laboratory animals, which has limited the pace of
research. However, the availability of powerful new techniques
of molecular biology has resulted in many new important find­
ings regarding these viruses. It has long been suspected for that
some oral cancers and leukoplakias (such as verrucous carci­
noma and atypical verrucous hyperplasia) might be caused by
papillomaviruses because of their clinical appearances and slow
growth.
The number of human papillomaviruses is very laige. More
than 70 types were recognized by the end of 1993. Some of
these types are found mainly in benign lesions, while others are
more prevalent in malignant skin tumors and anal and cervical
carcinomas21.
Many oral carcinomas contain papillomaviruses. In verru­
cous carcinomas, about one-third of the tumors contain HPV-2,
which is commonly found in warts22, while about half of squa­
mous cell carcinomas contain types 16 or 18, which are also
associated with anal and cervical cancers23,24.
Under experimental conditions, papillomaviruses can trans-
fbnn cells to benign or malignant phenotypes. It is, therefore,
qoafiepossible that these viruses, like HSV, could be involved in
f e etiology of oral cancer. Indeed, it is possible that the 2 vi-
rases could interact with each other to produce tumors by af­
fecting cellular growth and/or suppressor factors.
117
Tobacco
Smoking may be viewed as a worldwide epidemic, caus­
ing serious disease and immense health problems. Apart from
its effect on mortality, smoking results in a considerably in­
creased morbidity rate, with consequent losses in working days
and productivity, excessive demand on medical services, and
increased health expenditures.
Tobacco components Thousands of substances have been iden­
tified in tobacco. In the combustion mainstream of 1 cigarette,
there are approximately 500 mg of gas (92%) and particulate
matter (8%). Eighty-five percent of the gaseous phase is carbon
dioxide, oxygen, and nitrogen. Even though the percentage of
carbon monoxide is low, it is enough to raise blood levels sig­
nificantly, in turn influencing the hemoglobin exchange sys­
tem. ‘Tars” (aromatic hydrocarbons) range from less than 1 up
to 35 mg. The most potent carcinogens are in this group of com­
pounds. Nicotine, which contributes to habituation, platelet ad­
hesion associated with cardiovascular disease, ulcer suscepti­
bility from decreased pancreatic bicarbonate, and hypertension,
ranges from less than 1 to more than 3 mg25. Effective filtering
can reduce these substances26; however, reductions in nicotine
(the habituation factor) and tars (the basis for tobacco “taste”)
often lead to increased smoking, negating the potential advan­
tage. In addition, many “filters” do not effectively filter. To­
bacco substitutes (i.e., vegetable and wood products) and smoke­
less cigarettes have not been popular, and have therefore been
financial as well as therapeutic failures.
Tobacco use and health Reports from the US Surgeon Gen­
eral and others conclude that cigarette smoking is the main single
cause of cancer mortality in the United States, contributing to
an estimated 30% of all cancer deaths and substantially to can­
cers of the head and neck27,28'29. A federal law requires that warn­
ings be printed on all cigarette packages sold in the US.
About 25% of adult Americans smoke regularly (Table 5-
2). Although smoking habits tend to decrease after middle age,
smoking among school children is consistently increasing. A
recent federal report describing smoking trends among Ameri­
cans aged 12 to 14 years indicated that 19% of both boys and
girls smoked regularly. The percentage of dentists and physi­
cians who smoke has dropped from more than 30% to about
20% over the past 2 decades.
Cancer risk and smoking Hie association between cigarette
use and oral carcinoma appears to have been established from
epidemiologic studies30,31,32, revealing that there are more than
twice as many smokers among oral cancer patients as among
control populations. A study of oral cancer patients at the Uni­
versity of California San Francisco (UCSF) found that more
than 8 out of 10 of them were smokers (Table 5-3), demonstrat-
118 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Table 5-2. Smokers, USA, 1991— Percentage of Persons Who Smoke Regularly, According to Sex and Age.*

A dults (%) Under 18 (%)

Males 27 - ~ 15 ' -
Females 23 21 ' -
Mean 25 19

* Statistical data from U.S. Center for Disease Control, Atlanta, GA. Morbidity; Mortality Weekly Report. 42:231 ;1993.

Table 5-3. Number of Tobacco Users Among Oral Cancer Patients Treated at the University of California, San Francisco.*

Number^ Percentage
Cancer Site Patients Smokers

S oft Palate 26 96
| - F loor o f the Mouth 127 90
Oropharynx -v85;V.
Tongue 82
Buccal Mucosa 26 ^6 ? r-
,G ingiva, Alveolar Mucosa ' 42 . '%6
LiP 19
Hard Palate 11 55
487/ p liffij

* Source: Silverman S, Gorsky M, Greenspan D. Tobacco usage in patients with head and neck carcinomas: a follow-
up study on habit changes and second oral/pharyngeal cancers. J Amer Dent Assoc. 106:33;1983.

ing the very high risk for tobacco users33. In addition, the smoker
who has oral cancer has been found, on the average, to be a
much heavier user of tobacco than the smoker who does not
have cancer.
Numerous laboratory studies have shown that some hy­
drocarbons isolated from tobacco products have induced buc­
cal carcinomas in animals under certain experimental condi­
tions. Benzo(a)pyrene, the most potent of these carcinogens,
binds to nuclear proteins, and is mutagenic as well as carcino­
genic. The association between tobacco use and oral malignan­
cies also appears to include cigars, pipes, and chewing prepara­
tions.
Another study was carried out on 277 patients with head
and neck carcinomas at UCSF to assess the association between
tobacco use and the development of second primary oropha­
ryngeal multiple carcinomas (Table 5-4)6. Almost 68% had
smoked. This rate of smoking is more than double the current
rate found in the general population and indicates that, for ciga­
rette smokers, the risk of developing oral carcinoma exceeds
about 5 times that for nonsmokers.
In almost 1 in 5 patients (17.7%), second primary oral or
oropharyngeal cancers developed in a mean time of 5 years.
Those who did not change their original tobacco habits incurred
the greatest risk, as a second primary cancer developed in 25.6%
of that group. Discontinuing smoking appeared to have the same
beneficial effect found in nonsmokers.
A similar degree of correlation between smoking and sec­
ond primaries has been reported in other studies15,3433,36. One
concerned a group of 203 oral and laryngopharyngeal cancer
patients in whom the disease had been eradicated for more than
3 years34. Of 120 patients who continued to smoke, 37% devel­
oped second primary cancers, while only 6% of 81 ex-smokers
developed second primaries.
The combined effects of tobacco and alcohol were illus­
trated in another study of 351 patients treated for tongue can­
cer35. Forty-three patients abstained from both tobacco and al­
 Acquired Defects o f the M andible: Etiology, Treatment, and Rehabilitation 119

cohol, and 308 were users of either or both. The abstainers had
a mortality of 14% in 5 years; whereas the users rate was 31%.
A second primary occurred in 11% of the abstainers, as com­
pared with 20% of the users.

Pipes, cigars, snuff, and chewing tobacco Carcinogenic agents

have been isolated from pipe, cigar, and smokeless tobaccos.
Although studies of these forms of tobacco use have not been
as extensive as those of cigarettes, the data show a strong asso­
ciation between non-cigarette forms of tobacco and mouth can­
cer37.
The carcinogenic hazard of snuff dipping and tobacco chew­
ing is of special concern because of the marked upswing of
smokeless tobacco consumption in the United States (Figure 5-
1)38,39,40,41,42,43,44 jt been estimated that more than 12 million
Fig. 5-1. Chewing tobacco induced precancerous lesion.
Americans (3 million under age 21) use smokeless tobacco. Its
use among teenagers is increasing, posing a danger for increased
oral cancer incidence in the future. In the southeastern region of lated by the Food and Drug Administration, and the nitrosamine
the United States, where women frequently use snuff or chew­ levels far exceed those permitted in foods (as preservatives).
ing tobacco, there is a higher than expected incidence of cancer Both sugar and fluoride content are higher in chewing tobacco
in women, together with a higher mortality. A case-control study than in other forms of tobacco46. However, a relationship be­
in North Carolina of 255 women with oral and oropharyngeal tween different tobacco forms and dental caries has not been
cancer showed as much as a 50-fold risk for cancers of the gin­ established. Nicotine levels are high and serve as a potent fac­
giva and buccal mucosa in long-term habitual snuff dippers45. A tor in habituation, addiction, and hypertension. Since smoke­
report on 201 oral cancer patients at MD Anderson Hospital in less tobaccos contain salt, they also contribute to high blood
Texas showed that 46 (23%) used snuff or chewing tobacco. pressure. The most common conditions found are gingival re­
Twenty of these patients reported that, for an average of 44 years, cession, hyperkeratosis, and staining. In addition, the risk of
they had consistently held the tobacco at the site where the can­ oral epithelial dysplasia or carcinoma increases with long-term
cer arose. use of smokeless tobacco products.
Nitrosamines, nitrosonomicotine being the most potent,
have been identified as noncombustible products in snuff and Smoking and survival The hazards of smoking can also be
chewing tobacco products that possess carcinogenic activity. demonstrated by the survival time of oral cancer patients after
Other carcinogens are found in smaller quantities (hydrocar­ diagnosis and treatment In a UCSF study of 874 patients with
bons and polonium). O f interest, tobacco products are not regu- intraoral squamous carcinoma, the 5-year survival rate for non­

Table 5-4. Smoking Habits Among 277 Oral Cancer Patients, Oral Medicine Clinic, University of California, San Francisco,
1989.*

Smoking Status Cancer Status

A t T im e o f S econd P rim ary
T obacco Cancer One Year P ost O ropharyngeal
Usuage D iagnosis Treatm ent C ancer +

Yes 187 (67.5%) 90 ( 48%) 23 (25.6%)

D iscontinued 97 (>52%) 13 (13.4%)
1f 90 (32.5%) 90 (100%) 13(14.4%)

+ F ollow -up mean = 5 years

++ Never sm oked o r sto p p e d > 1 year

* Source: Silverman S. Oral Cancer, 3rd ed. 1990, Atlanta, GA; American Cancer Society.
120 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
smokers was 43%, compared to 27% for smokers47. In the study
o f203 oral and laryngopharyngeal cancer patients cited earlier,
65% of the nonsmokers were alive at the end of 13 years, while
only 30% of the smokers survived the same period34.
Other Carcinogenic Habit Forms Social customs that can
lead to cancer are complex and far-reaching. Some customs,
such as betel- and tobacco-dipping, are widespread and seem to
satisfy important human desires. In the areas of the world where
these habits are practiced, the incidence of oropharyngeal tu­
mors is comparatively high. There are considerable variations
in prevalence in different countries, depending on the manner
in which the ingredients are prepared for chewing.
Reports from India reveal that oral carcinoma accounts for
a high percentage of total cancers, ranging from 15% to 65%48.
A relationship appears to exist between this extremely high oc­
currence of oral malignancy and the use of various forms and
combinations of tobacco, slaked-lime, betel nuts, and spices.
In many areas throughout the world, members of the low
economic groups smoke rolled tobacco leaves or small cigars
with the lit end placed in the mouth. In some of these areas, the
incidence of palatal carcinoma is high49.
Summary The use of tobacco in all forms (cigarettes, cigars,
pipes, chewing preparations, and snuff) increases the risk of
eventually developing oral carcinoma, which appears to be caus­
ally related. This is based on the following facts:
• Carcinogenic agents have been isolated from tobacco con­
densates.
• Tobacco can induce cellular change and tissue atypia.
• There is a greater use of tobacco in patients with oral carci­
noma than among persons in control groups.
• Tobacco used in various forms has been associated with an
unusually high prevalence of carcinoma of specific oral
sites.
• Continued smoking is a factor in the development of mul­
tiple oral carcinomas.
• There is an increased mortality ratio from oral carcinoma
for smokers as compared with nonsmokers.
Alcohol
Alcohol intake has been related to an increased risk of de­
veloping oral cancer and a higher than expected mortality32-50.
More than 30 years ago, a study determined heavy alcohol con­
sumption to be a significant factor in the development of mouth
cancer51. It was found that, of 543 male oral cancer patients,
one-third drank more than 7 ounces of whiskey per day, as com­
pared with 12% of a control group.
The association between alcoholism and oral and laryn­
geal cancer was further affirmed in a study showing a large
excess mortality, with an observed-to-expected ratio greater than
3:1, in a group of alcoholics with oropharyngeal carcinoma52. A
report from Utah, a state whose population is approximately
70% Mormon (a religious group abstaining from alcohol), in­
dicated an incidence of oropharyngeal cancer less than that of
the western United States or the nation as a whole53.
One group of investigators found that 44% of 108 patients
with cancer of the tongue and 59% of 68 patients with cancer of
the floor of the mouth, palate, or tonsillar fossa had unequivo­
cal evidence of hepatic cirrhosis, and approximately 75% drank
alcohol excessively54. Another investigator, studying 2,177 male
oral cancer patients, found no relationship between liver cirrho­
sis and tongue cancer, however, he did find an association be­
tween cancer of the floor of the mouth and cirrhosis55. In an
additional study of 408 oral cancer patients with age-matched
controls, the same investigator confirmed the correlation of cir­
rhosis of the liver with cancer of the floor of the mouth in find­
ing clinically diagnosed liver cirrhosis in 20% of the cases of
floor of mouth carcinoma in contrast to 9% of controls56. He
concluded that liver cirrhosis, heavy drinking, and smoking were
associated with cancer of the floor of the mouth (Figure 5-2).
Fig. 5-2. Patient was a heavy smoker and a chronic alco­
holic. Note epidermoid carcinoma.
Of 213 patients studied at the University of California for
whom the information was available, 41 (19%) had laboratory-
diagnosed cirrhosis and an additional 26 (12%) demonstrated
clinical cirrhotic changes47. In the 41 patients with diagnosed
cirrhosis, 40% had carcinoma of the tongue (only slightly more
than the distribution of tongue cancer in the entire group), but
46% had floor of mouth carcinoma (significantly higher than
the rate in the entire group). In patients with cancer of the floor
of the mouth (information available for 54 patients), 35% had
cirrhosis.
The underlying mechanisms for this association are poorly
understood57. The cause might be related to the dehydrating ef-
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
feet of alcohol, rendering the mucosa more susceptible to car­
cinogens contained in alcoholic beverages (nitrosamines, hy­
drocarbons), or to liver-induced cellular changes in target tis­
sues (e.g., increased acetaldehyde content). Experiments in ani­
mals have confirmed the clinical association between alcohol
ingestion and tumorigenesis58.
Patients with liver cirrhosis often demonstrate what appear
to be smooth, erythematous, and glossy-appearing oral muco­
sae (atrophic mucous membranes). Interestingly, in the past,
patients with Plummer-Vinson disease (atrophic-appearing oral
mucous membranes, dysphagia, and iron-deficiency anemia)
had a high incidence of cancer of the tongue and pharynx.
It should be pointed out that most heavy drinkers are also
smokers, and many of the predisposing factors may work in
combination rather than independently. Several studies confirm
an independent relationship between oral cancer and the dual
consumption of tobacco and alcohol, indicating a synergistic
function between the 2 substances3032’50’59’6061. Another study has
shown that the risk of developing head and neck cancer for
heavy consumers of alcohol is increased almost 10-fold with
the heavy use of tobacco36.
Leukoplakia and Erythroplasia
White and red lesions of the oral mucosa are the most com­
mon precancerous oral lesions. Although not all oral cancers
are preceded by premalignant mucosal changes, such changes
give a warning of risk and present an opportunity for preven­
tive measures. Early cancer can even appear as an innocuous
white or red lesion. Although white changes (leukoplakia) are
the most common premalignant lesion, red changes (erythro­
plasia), or white changes with a red component (speckled leu­
koplakia, erythroleukoplakia), carry a greater risk.
The term, leukoplakia, is used to designate a clinical white
patch or plaque On the oral mucous membranes that cannot be
removed by scraping and cannot be classified clinically or mi­
croscopically as another disease entity. Most of these lesions,
which can occur in all areas of the oral cavity, are reflections of
benign hyperkeratosis. Although tobacco or trauma may induce
hyperkeratosis, causes for the occurrence of many leukoplakias
are unknown.
Epidemiology o f leukoplakia The age range and the tobacco
habits of patients with oral leukoplakia are similar to those of
patients with oral carcinoma. These facts indicate possible bio­
logic similarities and comparable risks. The relationship of to­
bacco to the causation of leukoplakia is not always clear, since
abstinence from tobacco may not lead to remission of the le­
sions, and some patients with leukoplakia are nonsmokers.
The prevalence of oral leukoplakia in the general popula­
tion is unknown. Prevalence studies have been attempted in
121
certain parts of the world, but the results are variable and do not
support any generalizations as to rates. In a Minnesota study of
27,443 adults, the occurrence of leukoplakia was found to be
0.1 %62, yet in a study of more than 180,000 Army recruits rang­
ing in age from 17 to 26 years, 1.5% had oral leukoplakia63. A
study of 51,000 villagers in India found the prevalence rates in
4 states ranged from 0.2% to 5%64. A study from Ahmedabad,
India, indicated that, in a selected population consisting of 57,518
textile mill workers (a low socioeconomic class) over 35 years
of age, the occurrence of leukoplakia was close to 12%65.
Precancerous classification Oral leukoplakia is a premalig­
nant lesion64-66-67’68-69-70,71,72. This conclusion is based on the find­
ings that (1) a large number of oral carcinomas have been asso­
ciated with leukoplakic changes (Figure 5-3) and (2) there has
been a significant occurrence of malignant transformations in
oral leukoplakias observed over a period of time (Tables 5-5 to
5-7).
Fig. 5-3. This epidermoid carcinoma arose from a preex­
isting leukoplakia.
Tobacco, leukoplakia, carcinoma Tobacco usage increases
the risk for individuals to develop oral cancer. Paradoxically, in
patients with oral leukoplakia, nonsmokers are at higher risk.
This was shown in a study of patients from the UCSF oral medi­
cine clinic in a previous report (Table 5-8), and has also been
reported by others. Einhom and Wersall cited an 8-fold risk66,
and Roed-Petersen a 5-fold risk67, for nonsmoking leukoplakic
patients to develop a carcinoma. Although an explanation for
this finding is not clear, it might be speculated that, in the ab­
sence of tobacco as a causative irritant, there may be a more
lethal initiating or potentiating factor. Banoczy confirms this
increased risk in nonsmokers in her long-term reports on
leukoplakic patients68.
122 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Table 5-5. Leukoplakia Associated with Carcinoma.*

Total Number Number (%) Patients

Site o f Carcinoma Patients w ith Leukoplakia

Buccal Mucosa 35 8 (23)

Gingiva, Alveolar Mucosa 43 9 (2 t)
Lip 249 38(15)
Tongue 261 '.37(14)
F loor o f the Mouth 126 17(13)
Oropharynx, Palate 160 18(11)

Total 874 . 127(15)

* Source: Chierici G, Silverman S, Forsythe B. A tumor registry study of oral squamous carcinoma. J Oral Med.
23:91 ;1968.

Table 5-6. Malignancies and Premalignant Changes Found in Biopsy Specimens Clinically Diagnosed as Leukoplakia.**

Frequency o f Malignancy or
Source (Country) Year Number Patients Premalignant Changes"

ji|S%Can2inqma:N^
^ P irid b o rg (Denmark) 1963 Iflfj
"12%fD£splasi£^>

Silverman (USA) 1968 117 1O%j£0emom&'

3% C arcinom a'-
Waldron (USA) 1975 | 2 5 | ; ..

10% Carcinoma
Banoczy (Hungary) 1976 ,S00:
24% Dy£$a§ia

5-7. Malignant Transformation in Oral Leukoplakias Observed Over A Period of Time.**

Number Malignant
Source (Country) Year Patients Transformation Years Mean

Silverman (Gujarat, India) 1976| 4762 0.13 2

Gupta (Bhavnagar, India) 1984 | 360 0.3 1-10 M B i»
Gupta (Ernakulan, India) 1980 | 410 2.2 1-10
m m l
Roed-Petersen (Denmark) 1971j 331 3.6 >1
(4 3 )1
\Einhorn (Sweden) 1967 j 782 4.0 1-20
Pinfborg (Denmark) 1968 | 248 4.4 1>9
Kramer (England) 1969 | 187 4.8 1-16
Banoczy (Hungary) 1977 j 670 5.9 1-30 j (9.8) 1
Silverman (USA) 1968 I 117 6.0 1-11 (3 .5 )1
Silverman (MSA) 1984 I 257 17.5 1-39 a g m
accbrdihg-tb^seleiction' of patfents
o /e ra lb n g e rp e rib b

* * Source: Silverman S. Oral Cancer, 3rd ed. Atlanta, 1990; American Cancer Society.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 123

Table 5-8. Association Between Tobacco Habits and Follow-Up Changes In Leukoplakia In 257 Untreated Patients.*

Tobacco Use Leukoplakia

Unchanged or ^Improved or Transformed to
Number Patients A t Diagnosis A fte r Diagnosis Extended % Disappeared % Carcinoma %

. 74'. ■ H jjljjj 2,4

133 s , % H- -f ' 4 7 jf WMjmm 16 i
50 44 • 44 12

+ Current tobacco users

- Never smoked o r stopped perm anently at tim e o f diagnosis

* Source: Silverman S, Gorsky M, Lozada F. Oral leukoplakia and malignant transformation: a follow-up study of 257
patients. Cancer. 53:563;1984.

Table 5-9. Progression of Dysplasia in Clinical Leukoplakia to Carcinoma.*

Number (%)
Source (Country) Y e a r Number Patients Malignancies (Years)

Mlncer(USA) 1972 451 5(11) 1-8

Banoczy (Hungary) 1976 68 f f 9(13) 1-20 .
Pindborg (India) 1977 21 t t t 3(14) :; 7 '
Silverman (USA) 1984 -'22— 8 (36) U 1-39

t 17 persisted, 3 disappeared spontaneously, and 20 were excisedKpl which 7 recurred)

ft • 45 of the 68 lesions.were excised; 8 of 9 malignant changes were-in the 23 lesions not subjected to sUrgery:
ttt In a control group of 40 dysplasias not associated with leukoplakia, only 1 became malignant
h h b h h h h b h h h h h h b h h h h h h h h h h b h h h h h h h h h h ih h h h h h h h i
* Source: Silverman S. Oral Cancer, 3rd ed. Atlanta, 1990; American Cancer Society.

Table 5-10. Transformation Rates of Leukoplakic Forms.*

Number Subsequent Transformation

Leukoplakia Patients Carcinoma Rate (%)

Homogeneous f 107 7 6.5

Erythroleukoplakia f t 128 30 23.4
Dysplasia t t t SBi 36.4

f All white appearance

ft Bed component
ttt 20/22 appeared clin ica lly as erthroleukoplakia

* Source: Silverman S, Gorsky M, Lozada F. Oral leukoplakia and malignant transformation: a follow-up study of 257
patients. Cancer. 53:563;1984.
124 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Dynamic nature o f oral leukoplakia The precancerous nature
of oral leukoplakia was confirmed in a 2-year follow-up study
of 4,762 people with oral leukoplakia residing in Gujarat, In­
dia65. Although there was essentially no change in habits in the
people with oral leukoplakia during the 2-year interval, almost
one-third experienced complete regression of their lesions.
The prevalence rates for oral leukoplakia in the entire
Gujarat study group at the beginning and end of the 2-year pe­
riod were similar, 11.7% and 12%, respectively. This indicates
that development and regression rates were comparable, and so
the occurrence of oral leukoplakia in this population was rela­
tively constant. (The incidence was 2.6% per year.) Since oth­
ers have found incidence of complete regression in oral leuko­
plakia in different Indian population groups, ranging from 26.4%
to 45.3% in 5-year intervals73, this remission phenomena ap­
pears to be real. Similarly, a Danish study found that 37.4% of
Fig. 5-4. Note progression
of cellular changes from focal
keratosis (a) to leukoplakia
with atypia (b) to carcinoma in
situ (c) to epidermoid carci­
noma (d). Cellular maturation
patterns are normal in focal keratosis when compared to the
remaining specimens. Note increasing incidence of cellular
atypia in progression of sections from leukoplakia with aty­
pia to epidermoid carcinoma. All sections were obtained from
biopsy specimens of oral white lesions.
214 leukoplakic lesions were totally or partially reversed with­
out any intervention during a follow-up period that ranged up
to 15 years74, and a study of 520 Hungarian patients with oral
leukoplakia observed from 1 to 25 years found regressive
changes in 9%68.
Dysplasia and oral carcinoma Some clinical leukoplakias
demonstrate microscopic cellular changes that warrant a classi­
fication of dysplasia (Figure 5-4). The diagnosis of dysplasia is
an interpretation based on abnormal tissue patterns and cell
morphology, combined with individual judgment. The signifi­
cance derives from studies that document the increased risk for
malignant transformation of dysplastic leukoplakic lesions on
an unpredictable basis (Table 5-9)70-75-76-77. Cellular growth and
suppressor factors, as well as certain viruses such as strains of
HPV, must play a key role.
Diagnosis o f leukoplakia and risk factors Patients with leu­
koplakia are usually asymptomatic. The lesion is often discov­
ered upon routine examination or by patients feeling roughness
in their mouths. There are no consistent or reliable clinical signs
and symptoms associated with oral leukoplakia that allow dif­
ferentiation or prediction of a premalignant, or early malignant,
change. Since the clinical appearance of oral leukoplakia—thick
or scant, large or small—does not reliably indicate its biologic
potential, clinicians should be suspicious of all white patches,
and should carefully evaluate and observe patients with such
lesions.
Erythroleukoplakia and erythroplasia Leiikoplakia that clini­
cally has an erythematous or red component (erythroleukoplakia)
is far more likely to undergo dysplastic or malignant epithelial
changes than other forms of leukoplakia (Figure 5-5). In the
UCSF study, the risk of malignant transformation in the
erythroleukoplakia group was seen to be almost 4-fold that of
the patients with homogeneous leukoplakia (Table 5-10)70. With
this in mind, clinicians should take biopsy specimens from
erythematous areas, particularly if the choice is between white-
and red-appearing mucosa (Figure 5-6). In the UCSF study
group, 53% of the patients with leukoplakia had an associated
erythematous area, whereas 82% of the patients who eventu­
ally developed a carcinoma demonstrated a red component.
Other investigators have also found this increased risk associ­
ated with erythroleukoplakia. Roed-Petersen reported a 7-fold
risk for malignant transformation for individuals whose leuko­
plakia had an erythematous component?7. His patients showed
a 1.3% transformation rate in homogeneous leukoplakia versus
a 9.1% rate in red-and-white lesions. In a study limited to
leukoplakias of the tongue and mouth floor, Kramer and co-
workers reported a 15% transformation rate in an average pe­
riod of 4.3 years79. The risk for formation of carcinoma in the
red-and-white lesions was 5 times that of the homogeneous
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 125

leukoplakias. Banoczy described an erosive form of leukoplakia

lesions with an erythematous component, which had a 5-fold
greater risk o f m alignant transform ation than other
leukoplakias68.
The high risk of malignancy in erythroplasia was reaffirmed
further in a microscopic review of 58 clinically red lesions, of
which 91% were found to be either invasive carcinoma, carci­
noma in situ, or severe dysplasia80. Another series of studies
showed that persistent erythroplasia, rather than leukoplakia, in
high-risk sites is the earliest and predominant sign of carcinoma.
In a prospective study of 222 asymptomatic oral carcinomas:
28% were red only; 62% were red and white; 97% occurred in
the mouth floor, oral tongue, and oropharynx; and 84% were
less than 2 centimeters in their largest diameter.

Proliferative verrucous leukoplakia (PVL) This form of leu­

koplakia, fortunately, is rare because its course is invariably one Fig. 5-5. P atient presented w ith eryth ro le u ko ­
of progression, and it is often associated with dysplasia and plakia. (Source: Silverman S, Galante M.
malignant transformation81. It can usually be recognized clini­ Oral Cancer, 5th revision. San Fran­
cally by the irregular exophytic, wart-like and papillary fea­ cisco,1976; University of California.)
tures, and its capacity to extend its margins (Figure 5-7). A red
component is sometimes present. Microscopically, there is no
dysplasia at first, but there is an irregular, extensive epithelial
hyperplasia (pseudoepitheliomatous hyperplasia) and often dys­
keratosis. A heavy subepithelial lymphocytic infiltrate is fre­
quently found (which sometimes causes PVL to be confused
with lichen planus). Since the lesions are extensive, multiple
microscopic changes, from simple hyperkeratosis to dysplasia
to carcinoma, may be present simultaneously. Therefore, ad­
equate tissue sampling and careful follow-up are essential.
Candidal organisms are often associated with PVL, but
antifungal treatment has not been beneficial. No cause, whether
it is irritative, nutritional, viral, or genetic, has been identified.
Some strains of the human papillomavirus may play a cofactor
role. Interestingly, while leukoplakia seems to be more com­
mon in men, the female-male ratio for PVL is about 4:1. Fig. 5-6. Erythroplasia.
The lesion tends to recur after excision. Irradiation has been
helpful in extensive cases, but the best management is earliest
possible recognition and aggressive excision, if possible.

Candidiasis, leukoplakia, and erythroplasia Candidiasis

(thrush, moniliasis) is caused almost always by an overgrowth
of the fungus Candida albicans. Although this fungus is found
in more than one-third of normal appearing mouths, overgrowth
does not occur unless the balance of the oral flora is disturbed,
for example, by a debilitating or acute illness, immune suppres­
sion, xerostomia, or antibiotic therapy. The diagnosis of can­
didiasis is suspected when there are creamy white or erythema­
tous mucosal changes, and may be confirmed by smear, cul­
ture, and biopsy, or by response to antifungal therapy.
Studies in the oral medicine clinic at UCSF indicate that
candidiasis is a potential risk factor for or at least a complica- Fig. 5-7. Proliferative verrucous leukoplakia.
126 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
tion of leukoplakia. Although cultures showed that 31% of the
clinic’s leukoplakia patients fostered this fungal organism in
their mouths70, a rate similar to the occurrence in normal popu­
lations82, 53% of the leukoplakia patients who developed carci­
nomas were Candida-positive prior to tumor formation. How­
ever, mutagenicity and carcinogenicity of Candida albicanshas
not been shown.
Other studies have reported similar incidences of Candida
in leukoplakia83,84,85. These studies also demonstrated a higher
prevalence of Candida in speckled leukoplakia than in homo­
geneous leukoplakia. Specifically, Renstrup found that, while
55 of 235 patients with leukoplakia (23.4%) were Candida-
positive, further analysis showed that, in the homogeneous
group, 4 of 152 (2.6%) were positive, but, in the speckled leu­
koplakia group, 51 of 83 (61.4%) were positive84. The UCSF
oral medicine clinic experience confirms the greater risk of fun­
gal infection in the red-and-white lesion. It seems that the
candidal organisms in these situations are secondary transients,
since treatment will most often only convert erythroleukoplakia
into the homogeneous form. It is possible, but infrequent, that
candidal organisms stimulate hyperkeratosis (hyperplastic can­
didiasis), since adequate treatment of die candidal infection rarely
leads to disappearance of the clinical lesion.
These reports show that candidiasis may complicate the
observation and management of oral leukoplakia, but there has
been no study documenting a cause and effect relationship be­
tween candidal-associated leukoplakia and malignant transfor­
mation.
Hairy leukoplakia Oral hairy leukoplakia (HL) is associated
with human immunodeficiency virus infection (HTV-seroposi-
tivity) and describes white-appearing lesions that almost always
occur unilaterally or bilaterally on the borders of the tongue86.
HL frequently appears as hairlike projections and/or corruga­
tions, but HL may also have a plaque-like appearance. HL will
appear occasionally on other mucosal sites, such as the buccal
mucosa, oropharynx, and mouth floor. There is no evidence that
HL is biologically similar to hyperkeratotic leukoplakia that has
premalignant connotations.
Microscopically, HL appears as an epithelial hyperplasia
with aparakeratotic surface and vacuolated cells, often referred
to as koliocytes (cells suggestive of viral infection). The pres­
ence of Epstein-Barr vims (EBV) in these vacuolated cells has
been confirmed by electron microscopy and DNA probes. Since
sometimes non-HL lesions can have similar clinical appearances,
ultimate confirmation is by suggestive microscopic findings and
demonstration of EBV. Connective tissue inflammation may
vary from moderate white cell infiltrates to the appearance of a
noninflammatory lesion. In about half the cases, candidal or­
ganisms can be demonstrated in the epithelial surface; how­
ever, antifungal treatment does not appreciably alter HL. The
cause of HLis unknown. Whether EBV is acause or result is as
yet unclear. HL can occur in all HTV-infected groups, although
it is by far more common in both homosexual and bisexual men
than in women.
Treatment is elective. These lesions are usually asymptom­
atic but chronic. They are treated only if they are bothersome in
some way to the patient, but this in no way alters the ultimate
prognosis of the patient
Erythroplasia with ulceration Another rare but high-risk pre­
malignant lesion is the chronic erythematous change associated
with constantly occurring erosive changes. These lesions can
be mistaken for recurrent aphthous stomatitis of the herpeti-
form variety or a nonspecific erosive disease. A biopsy of the
early lesion may show only hyperkeratosis and inflammation
not suggestive of any specific disease. Clinical responses to
empirical corticosteroid therapy may help to rule out a prema­
lignant status by indicating a benign inflammatory response
associated with a vesiculoerosive disease. In the lesion that has
been present for some time, an initial biopsy might reveal a
carcinoma or dysplasia, thereby mandating treatment. However,
even a non-dysplastic pattern in this type of unclassified, enig­
matic lesion deserves close follow-up, or attempted removal,
because clinical experience indicates a risk exists that it will
eventually develop into a carcinoma. Again, the key to appro­
priate assessment requires clinical experience, a representative
biopsy, and clinical response to a proper course of corticosteroids.
Management The first step in management of leukoplakia is
the removal of all irritants. If the leukoplakia is not reversible,
excision is the most efficient and effective treatment. However,
since these lesions may spread over a large area, they cannot
always be surgically excised. In addition, recurrence after exci­
sion is common, due possibly to continuation of an irritant or
the biologic potential in adjacent tissue that morphologically,
and even microscopically, appears normal. The use of carbon
dioxide or Nd:YAG lasers has proved extremely useful and ef­
fective87. Electrodesiccation and cryosurgery have not been
uniformly efFective in permanently removing keratotic lesions.
Proteolytic enzymes have been of no value since keratin is re­
sistant to them.
Vitamin A in high dosages (more than 300,000 units per
day in troche form) has been effective in some patients in re­
versing hyperkeratosis88. The mechanism of action is unknown
and, upon withdrawal of vitamin A, the hyperkeratosis returns.
Vitamin A tolerance is short-lived with the required high dos­
ages because of limited liver storage and detoxification. Com­
mon side effects from the toxicity are dry skin, rash, and pruri­
tus. In a few instances, oral squamous carcinomas have devel­
oped. Whether this is coincidental or vitamin A, under certain
circumstances, serves as a co-carcinogenic agent is unknown.
The roles of vitamin A analogues (13-cis retinoic acid) or
beta carotene are inconclusive. Dosages and control have not
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 127

been established. Side effects and recurrences are common.
While vitamin Aanalogues may play a role in chemoprevention
(prevention of second oral malignancies in patients who have
already been successfully treated for 1 oral cancer), this poten­
tial has not been established by prospective studies. In this re­
gard, animal studies have shown protective effects. Some hu­
man studies have indicated beneficial effects of 13-cis retinoic
acid on oral leukoplakia in short-term observations89.
The risk for malignant transformation in oral leukoplakia
is always present. Since many methods of managing leukoplakia
are not always feasible or effective, these patients must be ob­
served periodically. The only definitive diagnostic method is
tissue biopsy. The follow-up examination includes careful clini­
cal observation and an occasional biopsy when changes in signs
or symptoms occur. Exfoliative cytology and vital staining with
toluidine blue are helpful to supplement clinical judgment, and
serve as an adjunct to biopsy.
Sum m ary Because leukoplakia and carcinoma can occur si­
multaneously, and because an established prognostic clinical
guide is lacking, all white lesions characterized as leukoplakia
must be microscopically diagnosed and either removed or moni­
tored with care (Tables 5-11, 5-12). Again, biopsy is the only
definitive way to establish the exact nature of oral leukoplakias.
When seeking dysplastic or malignant areas in leukoplakic
lesions, it is important to remember that erythematous and speck­
led regions are more likely to be cancerous than thick or homo­
geneous white regions. It must also be remembered that the

Table 5-11. Occurences of Carcinomas Related to Follow-Up Periods In 257 Patients with Leukoplakia.*

O ccurences o f Patients Rate o f Rate o f

C arcinom a in 45 Follow ed fo r C arcinom a In Carcinom a
Follow-Up Patients Each Period P atients Followed Per Year
(Years) (%) (%) (%) (%)

0.5-1 9 100 2 4
I I -2 24 84 5 5
2 -5 20 : 70 5 1.6
5-10 : 22 • 46 8 1.6 ;:'
10-20 . 16 27.
1
2 0 -39 9 8 19 1

Table 5-12. Profile of 45 Patients with Transformation of Leukoplakia to Carcinoma.*

Age at Onset of Transformation

Leukoplakia (Yrs) Time (Yrs) Tobacco Usage t
Transformation % Total Pre-Existing
Site F M Lesions Range Mean Range Mean Dysplasia Cigarette Pipe Cigar Snuff

Tongue 9 28.9 37-79 - 55 5 ^ -1 8 6.4 '■■i2 1

Gingiva 6 5 24.4 46-84 66 1 -2 1 8.6 2 -■ 1
Floor 5 15.6 30-69 50 0 5-30 10.2 2 1
Buccal 2 11.1 48-71 60 . 1 -1 6 8.8 1 1
Palate 4 1 11.1 38-76 54 2 -3 9 9.3 ( 1 %J 2 . I B
Lip 2 8.9 45-65 54 ' 3 -1 1 66 0 3
Total mm 19 ^ 100 30-84 57.3 0.5-39 8.1 •v 8 16 i 3 , -A, 1

t Of the 24 nonsmokers, 18 had never smoked and 6 stopped smoking when diagnosed

* Source: Silverman S, Gorsky M, Lozada F. Oral leukoplakia and malignant transformation: a follow-up study of 257
patients. Cancer. 53:563;1984.
128 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

diagnosis of a previously biopsied benign white patch must be
periodically reaffirmed, since a leukoplakia may unpredictably
transform into a malignancy. Moreover, although a leukoplakic
lesion may regress and disappear when an irritant is reduced or
removed, it can recur and may subsequently become cancer­
ous.
In determining the aggressiveness of treatment, consider­
ation of risk factors is essential. These factors are (1) an
erythematous component, (2) microscopic dysplasia, (3) a clini­
cal appearance of proliferative verrucous leukoplakia, (4) asso­
ciated candidiasis, (5) a nonsmoking patient, and (6) pain.
Oral lichen planus
Lichen planus is a complex, chronic, inflammatory dis­
ease; mucosa and skin both may be affected, microscopic fea­
tures vary, and the oral lesions appear in different forms. The
prevalence of lichen planus is unknown, but it may be present
in as much as 1% of the adult population.
The etiology of this inflammatory (probably autoimmune)
mucocutaneous disease is unknown, and there is no definitive,
curative treatment, although corticosteroids are beneficial for
control. The oral lesions are frequently asymptomatic and
chronic, persisting indefinitely in most patients. Our experience
has shown spontaneous remission in less than 3% of patients.
Lichen planus is primarily a disease of adults, with the average
age of onset being about 50 years. It is rarely found in persons
less than 30 years old. Women predominate, about 2 to 1. Li­
chen planus can be found in all ethnic groups, and there is little
evidence of familial clustering.
of that expected in a comparable sample of the general popula­
tion. There is no association with gender, smoking, or site of
oral lichen planus. Other investigators also have reported find­
ing oral carcinoma in patients with lichen planus, confirming
an association, particularly in erythematous (erythroplastic)
portions91'92.
It is of interest to compare lichen planus with leukoplakia.
The similarities between patients with lichen planus and those
with leukoplakia include comparable age of onset and hyperk-
eratotic propensity of the epithelium. Red areas seem to increase
the risk for dysplasia and carcinoma in both lesions. The 2 dis­
eases differ in that lichen planus seems to be more common in
women, is primarily inflammatory, and bears no relation to to­
bacco use.
In summary, to use the term precancerous with lichen pla­
nus is only a semantic issue—and doing so possibly raises emo­
tional concern among patients. However, there is no question
that there is a risk of malignant transformation beyond that ex­
pected in the general population, and that these patients must be
followed periodically.

Diagnosis Oral lichen planus can usually be recognized by the

unique clinical features of reticular, annular, or punctuate kera-
totic (white) patterns on the mucosal surface (Figure 5-8). The
diagnosis, however, can be confusing, since these keratotic
changes may be associated with pseudomembrane-covered ul­
cerations and marked erythema. Because many lichen planus
patients are asymptomatic, signs are sometimes recognized un­ Fig. 5 -8. Clinical appearance of erosive oral lichen planus
expectedly during routine oral examination or by chance obser­ can be similar to that of epidermoid carcinoma.
vation. Although lichen planus can occur in any oral site, the Biopsy of this lesion revealed oral lichen planus.
buccal mucosa is by far the most common location. The major­
ity of oral lichen planus patients do not have skin involvement.
Diagnosis is confirmed by biopsy.
Dentures
M alignant association There is inadequate evidence relating
to malignant transformation to substantiate that lichen planus is Although many carcinomas appear to develop in areas cov­
a precancerous lesion. However, a risk exists beyond that ex­ ered by a prosthesis, adequate studies have not been designed
pected in the general population. In a large follow-up study of to conclusively demonstrate whether this is coincidental or a
570 patients at the UCSF oral medicine clinic, 1.2% of the pa­ cause-and-effect relationship. Careful histories in some oral
tients with oral lichen planus developed oral carcinomas90. Con­ carcinoma cases indicate that the initial changes resemble trau­
sidering a mean age of the group of 52 years and a mean dura­ matic denture ulcers, beginning in the areas where the prosthe­
tion of lichen planus of 5.5 years, this prevalence was in excess sis was chafing or injuring the mucous membrane.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 129

Denture irritation, at most, must only be a co-carcinogenic
factor in specifically predisposed individuals. This supposition
is based on the fact that more than 35 million Americans over
30 years of age wear 1 or 2 complete dentures, and yet carcino­
mas of the palate and alveolar mucosa account for only about
10% of all oral cancers (less than 0.3% of all cancers). This
raises concern that, in some patients, even though the risk is
low, irritation, in addition to other unidentified factors, may serve
to promote neoplastic activity.
In the University of California Oral Medicine Clinic, 400
patients with oral cancer were studied to determine if there ap­
peared to be a risk related to denture wearing93. Forty-three per­
cent of the group wore dentures. There seemed to be no correla­
tion between the wearing of dentures and any specific cancer
site (Table 5-13). Furthermore, there was no difference between
denture wearers and other patients relative to age, sex, time from
first signs or symptoms to diagnosis, tumor stage, or tobacco
use. Other studies have also shown no difference between den­
ture wearers and control groups in the occurrence of oral can­
cer51,94. Therefore, it does not presently seem plausible to con­
sider denture irritation as a significant carcinogenic aggravat­
ing factor. However, since chronic denture irritation and oral
cancer have been associated, care should be taken by patients,
as well as the dentist, to minimize local irritation and to exam­
ine any changes with utmost care.
The same principle might be thought to apply to patients
who have poor oral hygiene, jagged teeth, or fillings that may
act as irritants. There is, however, little controlled evidence to
support this supposition, although it is frequently mentioned in
almost all of the articles dealing with etiologic factors of oral
cancer. In animal experiments testing various carcinogenic
agents, oral tumor induction has been facilitated by trauma95.
Denture material, per se, has not been shown to be carcino­
genic.
Palatal Papillary Hyperplasia
This lesion, which is moderately common among denture
wearers, is manifested by grape-like clusters of erythematous
tissue on palatal mucosa that is covered by either a plastic or
metal prosthesis. It is found mainly in patients who do not have
good adaptation. Paradoxically, poor adaptation does not nec­
essarily indicate that a subsequent tissue hyperplasia will de­
velop.
The microscopic picture may sometimes be confusing, since
the chronic tissue irritation can cause a reactive-type hyperpla­
sia with resultant nuclear pleomorphism and hyperchromatism.
Therefore, lack of familiarity with this lesion may lead to an
erroneous interpretation of carcinoma.
Numerous years of observing patients, plus the lack of re­
ports in the literature correlating this lesion with carcinoma,
lead to the conclusion that palatal papillary hyperplasia is not a
premalignant change96,97.
Management demands careful follow-up and elimination
of irritation. In case of doubt, periodic cytology and occasional
biopsy is advised. Removal of the lesion is elective. However,
when indicated for denture adaptation, hygienic purposes, or
discomfort, many surgical techniques and prosthodontic ap­
proaches have been useful in modifying the hyperplastic tissue.
Candidiasis can complicate the diagnosis by producing palatal
erythema and symptoms of burning or pain.

Table 5-13. Comparison of Cancer Site and Use of Dentures In 400 Cancer Patients.*

Type of Denture
Complete Complete
% o f Total Denture Upper and Upper or Other Combi
Cancer Site Lesions Wearers (%) . Lower (%) Lower (%)'•;’ nations (%)

. Tongue 42 60 30 10
Floor of Mouth fllSSS 49 56 27f 17
Oropharynx :;;;i2 0 :f-.. 35 54 36 10
Gingiva 10 43 , | 61 28 . - ■ • iO
Buccal mucosa .6 / 54 62\ 23 S IS !!
..Palate 3 43 0 ' 67 33, ;
:u P 4 29 75 0 25

Total’ 100 43 56 30 pi

<< f 7 in maxilla

* Source: Gorsky M, Silverman S. Denture wearing and oral cancer. J Prosthet Dent. 52:164;1984.
130 MAXILLOFACIALREHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Nutrition
Dietary factors, such as fat intake, appear to be a factor in
some cancers, indicating that food selection may play a role in
carcinogenesis98". However, no dietary characteristics have been
recognized that distinguish patients with cancer of the oral cav­
ity, although there have been some indications that low veg­
etable and fruit intake create some undocumented degree of
risk. While there have been suggestions that poor dental health
and denture status might be related to oral cancer risk by caus­
ing chewing difficulties that could adversely affect nutrition,
studies have not confirmed this indirect relationship.
The role of the antioxidant vitamins (beta-carotene C and
E), which neutralize intracellular free radicals, is currently be­
ing studied. Human studies have not identified deficiencies in
relationship to oral dysplasias or malignancies, but supplemen­
tal intake may have protective effects. Vitamin C (ascorbic acid)
appears to participate in blocking the conversion of nitrites to
nitrosamines (potent carcinogens). The roles of vitamin A,
retinoids, beta-carotene and, in some instances, their combined
effects when taken with vitamin E (alpha tocopherol), relative
to prevention or control of epithelial dysplasia and/or second
malignancies, are unclear at this time.
Minerals also have been studied with respect to the devel­
opment of oral cancers. Iron deficiency anemia is part of the
Plummer-Vinson syndrome, which has been associated with an
increased risk for developing carcinomas of the tongue. Iron
deficiency has not been shown to be a common finding in pa­
tients presenting with oral cancer, although high iron storage
has been indicated as a possible marker or factor in cancer. Zinc
and copper also have been implicated in head and neck cancer,
but a recent study of zinc and copper in oropharyngeal cancer
patients found that serum levels of these elements were not dif­
ferent from those of controlled subjects and were not useful as
markers78. While hypercalcemia indicates a poor prognosis in
patients with head and neck cancer, alterations in calcium me­
tabolism have no cause-effect relationship.
Nutrition is an important factor in the management of pa­
tients during treatment and in rehabilitation. Poor nutrition and
abnormal weight loss is usually associated with cachexia, inter-
current infections, and a poor prognosis. On the other hand,
obesity appears to be equally associated with poor survival.
Obviously, factors that encourage adequate food intake and a
nutritious diet are important to survival in conjunction with tu­
mor control.
Dental Radiation
There is no evidence at the present time to indicate that
exposure to radiation from periodic routine diagnostic dental x-
ray examination is mutagenic or carcinogenic100. However, to
minimize any potential risk to patients, it is advisable that all
procedures that will reduce radiation exposure, consistent with
patients’ diagnostic requirements, be used.
Fluoridated Water
hi September 1977, the director of the National Cancer
Institute made the following statement to the House Committee
on Government Operations in the United States Congress: “No
trends in cancer rates can be ascribed to the consumption of
water that is artificially or naturally fluoridated”. Numerous stud­
ies and comprehensive reviews that compare mortality data
between communities with fluoridated and non-fluoridated water
document this statement. No study has shown that fluoridation
poses any hazard to health or increased the risk for cancer101.
Tumors of the Region—Treatment and Disability
As previously mentioned, epidermoid carcinomas account
for more than 90% of all oral tumors. Most of these carcinomas
are located in areas which require the resection of the tongue,
floor of mouth and/or mandible. The degree of functional dis­
ability and cosmetic disfigurement is dependent upon the loca­
tion of the tumor and the extent of the surgical resection. Simi­
larly, the prognosis varies with the location, extent, and differ­
entiation of the lesion. The following section will discuss tu­
mors of specific anatomic locations. In each section, the dis­
abilities which are unique to the required surgical resection will
be pointed out, as will be the difficulties encountered during
rehabilitation. The categories discussed will be: (a) carcinomas
confined to the tongue, (b) carcinomas confined to the anterior
floor of mouth, (c) carcinomas confined to the tonsillar and ad­
jacent regions, and (d) carcinomas confined to the alveolar
ridges.
Presurgical Consultation with Patient and Surgeon
After the diagnosis of a malignant oral tumor has been
made, the patient should be seen immediately by the rehabilita­
tion team. If optimal rehabilitation is to be achieved, it is essen­
tial that the dentist examine the patient and discuss the pro­
posed surgical resection and the plan for rehabilitation with the
surgeon. At this time, answers to queries should be given forth-
righdy, yet the team should attempt to provide the patient with
some hope for the future. At this consultative appointment, ap­
propriate radiographs, diagnostic casts, and jaw relation records
should be gathered. With this data, the clinician is prepared to
discuss the myriad of factors relating to a successful primary
resection, and a future rehabilitative effort, with the surgeon.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
Carcinoma of the Tongue*
Clinical and Pathological Considerations
After the lip, the tongue is the second most common site
for oral cancer, accounting for more than half of all intraoral
malignancies. Nearly all of these tumors are squamous cell car­
cinomas, with only 3% to 6% derived from minor salivary glands
or supportive tissue. Squamous cell carcinoma of the tongue is
especially prevalent during and after the 6th decade of life, with
85% of the patients ranging between 60 and 90 years of age.
However, a small percentage of cases can occur in significantly
younger individuals and, therefore, biopsying tongue lesions in
young patients is warranted in order to avoid a delay in diagno­
sis102.
Lingual squamous carcinoma is predominantly a disease
of men, although there has been an increasing number of women
affected over the last several decades. This rising incidence of
women with carcinomas is not limited to tumors involving the
tongue but can also be seen at other oral sites. This is thought to
be due to a larger number of chronic smokers among women
and a greater ratio of women to men in older populations.
From the standpoint of oncology, the tongue is divided into
anterior and posterior segments. This division is not arbitrary,
Fig. 5-9.
Epidermoid carci­
nomas of oral
tongue may be in­
filtrative (a), ulcer­
ative (b and c), or
exophytic (d).
* Section on carcinoma of the tongue contributed by Jeffrey W. Bailet and Rinaldo F. Canalis.
131
since tumors developing in different areas of the tongue exhibit
distinct histologic patterns, require different modalities of treat­
ment, and have a differing associated prognosis. The anterior
segment constitutes the oral or mobile tongue, the tip, the under
or ventral surface of the tongue, the lateral borders, and the dor­
sum. (The dorsum is the region anterior to the circumvallate
papillae exclusive of the tip and lateral borders.) The posterior
segment, or base of the tongue, is the portion situated posterior
to the circumvallate papillae. Carcinoma of the oral tongue ac­
counts for 65% of all tongue tumors. The lateral borders and
ventral surfaces are the most common areas. Tumors of the base
of the tongue account for the remaining 35%m'm . Patients with
lingual cancer complain most frequently of the presence of a
painful mass. Dysphagia and pain radiating to the ipsilateral ear
occurs in about one-fourth of the patients. These are particu­
larly important symptoms in lesions arising in the base of tongue.
The presence of a neck mass is uncommon for oral tongue le­
sions, but is noted in one-fifth of base of the tongue tumors.
Bleeding and speech difficulties are less frequent and are usu­
ally related to advanced lesions.
Lingual carcinoma may exhibit an infiltrative, ulcerative
or exophytic behavior and have a variable growth rate (Figure
5-9). Histologically, tumors of the oral tongue tend to be mod­
erately well differentiated, whereas base of the tongue lesions
132 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
are usually poorly differentiated. In general, infiltrative, poorly
differentiated tumors tend to grow more rapidly than well dif­
ferentiated, markedly exophytic tumors. Despite the accessibil­
ity of these tumors to examination and biopsy, most are larger
than 2 cm when first diagnosed. An average time lapse of more
than 4 months between the onset of symptoms and establish­
ment of the diagnosis has been reported105. Locally, lingual car­
cinoma tends to infiltrate deeply into the intrinsic musculature
and local lymphatics, and extend into the floor of the mouth.
Tumors arising on the ventral surface almost always involve
the mucosa of the floor of the mouth. Lateral lesions of the
middle third gain ready access to the lateral floor of the mouth,
the glossopalatine folds, the retromolar trigone area, tonsillar
pillars, and tonsil, and sometimes can involve the entire tongue
and portions of the palate. Those arising within the base of the
tongue tend to be deeply infiltrating and, frequently, their ex­
tent may not be accurately assessed. Occasionally, the resect­
ability of such lesions may be established only on surgical ex­
ploration.
Early cervical metastases are frequent in lingual carcinoma
and must be assumed to have occurred, even in the absence of
palpable nodes. The overall incidence of tumor-positive cervi­
cal nodes at the time of diagnosis varies between 40% and 60%.
This incidence increases during the course of the disease to ap­
proximately 80% of all cases103,104. Bilateral cervical metastases
are present in 20% of the patients at the time of diagnosis106.
When tumors of the base of tongue are studied separately, the
incidence of clinically positive ipsilateral nodes at initial pre­
sentation rises to almost 70%104,107. For lingual cancer in all sites,
the most common initial regional extension is thejugulodigastric
area. The size of the primary lesion does not correlate with the
presence of regional metastasis. In one series of patients, with
tongue lesions no larger than 4 cm, 42% of these individuals
were found to have metastases108. Distant metastases are less
common and most frequently involve the lungs and the liver.
Classification and Staging
Currently, lingual carcinoma is classified according to the
TNM system established by the American Joint Commission
for Cancer Staging and End Results Reporting as follows109:
T. Primary Tumor
Tx Carcinoma in situ
T, Tumor 2 cm or less in greatest diameter
t2 Tumor 2 cm to 4 cm in greatest diameter
t3 Tumor greater than 4 cm
t4 Tumor invades adjacent structures such as cortical bone,
or deep tongue musculature
N. Regional Lymph Node Involvement
N0 No clinically palpable nodes
N, Single ipsilateral node, 3 cm or less
N2 Single ipsilateral node 3-6 cm; or multiple ipsilateral nodes,
none greater than 6 cm; or contralateral nodes, none greater
than 6 cm
N^ Single ipsilateral node 3-6 cm
N2b Multiple ipsilateral nodes, none greater than 6 cm
N2c Contralateral nodes, none greater than 6 cm
N3 Node greater than 6 cm
M. Distant Metastasis
Mx Not accessible
M0 No distant metastases
M, Distant metastases
Staging
Stage I: T„ N0, M„
Stage II: T2,N 0,M„
Stage III: T3,N 0,
T, orT2 orTj, N,, Mo
Stage IV: T4, N0orN,, Mq
any T, N2 or N3, M0
any T, any N, M,
Prognostic Factors
The prognosis for patients with carcinoma of the tongue is
influenced by the size of the primary lesion, its location, and
the presence or absence of metastases. The degree of histologi­
cal differentiation, as a prognostic parameter, has not been clearly
established, although some authors have noted a better progno­
sis with well-differentiated lesions110. In patients with anterior
tongue lesions, the presence of perineural invasion on histo-
pathological analysis had a higher likelihood of occult metastases
in one study involving 136 patients with clinically N0necks111.
Flow cytometric analysis and the presence of a variety of bio­
logic markers, such as p53 and tumor necrosis factor-alpha, have
shown promise in predicting the likelihood of regional nodal
spread, which has enhanced the survival of patients with tongue,
and other oral cavity, squamous carcinomas,,2,n3’n4.
Lesions, 2 cm or less in diameter (Tj), of the anterior tongue
have the best prognosis, regardless of the method of treatment.
Five-year survival rates of 46 to 80 percent have been re-
ported115,116,117. Larger tumors are not well controlled if treated
by a single modality, and usually warrant combination therapy.
The overall 5-year survival rate for lesions between 2 and 4 cm
(Tj) approaches 60%, and tumors 4 cm or larger (Tj), in the
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
absence of regional metastasis, have a survival rate of less than
3 0 % n 5 ,n 6 ,ii8 >
The presence of regional metastasis directly affects the
outcome. In a large series reported by Frazell and Lucas, the
cure rate for patients who remained free of metastasis during
the clinical course of the disease was 67%, whereas, for those
developing positive nodes, it was only 31 %m . Subsequent stud­
ies show similar survival statistics despite improved surgical
and radiotherapeutic techniques116,119. In a series of 61 cases of
carcinoma of the anterior tongue treated by radium implanta­
tion and radical neck dissection, the presence of regional me­
tastasis decreased the survival rate from 67% to 25%120. In an­
other study of 166 patients with either T^Nq or T,_2N1_3 of the
mobile tongue, the 5-year survival rate was 47% and 8%, re­
spectively121.
TVeatment
At present, there are 3 basic approaches to the manage­
ment of squamous cell carcinoma of the tongue: surgery, radia­
tion therapy, or combined treatment; either by initial irradiation
followed by resection or vice versa. The value of chemotherapy
and immunotherapy in the management of these tumors has yet
to be clearly established. Currently, these modalities are used in
some centers as adjuvants to the primary modalities of treat­
ment or for palliative purposes. However, recent organ preser­
vation protocols, utilizing chemotherapy in combination with
radiation therapy, have shown promise in some advanced le­
sions.
There remains some debate between radiotherapists and
surgeons as to the best approach to the treatment of lingual car­
cinoma. In general terms, irradiation has the advantages of pre­
serving the functions of the tongue and mandible while avoid­
ing some of the cosmetic deformities associated with radical
surgery. However, irradiation is not free of complications and
appears to be less effective than surgery in the management of
bulky lesions, tumors involving bone or cartilage, and in those
cases in which nodal metastases are clinically evident.
Glossectomy, either partial, hemi, or total, is the usual mode of
surgical resection. Wedge excision plays a role in small, super­
ficial, well-circumscribed lesions arising on the tip, dorsum, or
lateral margin of the tongue. Radiation treatment is usually ad­
ministered by interstitial implants in combination with external
beam therapy.
Primary irradiation of lingual cancers is indicated in many
Tj and some early T2lesions of the mobile tongue that do not
have clinically positive nodes. Surgery plays a major role in the
management of most T2and T3carcinomas of the mobile tongue
and in most resectable cases that have cervical metastasis. The
basic operation for these lesions is a partial- or hemiglossec-
tomy in continuity with an ipsilateral neck dissection. Because
of the high incidence of occult contralateral metastasis expected
133
in patients with positive ipsilateral nodes, either a modified con­
tralateral neck dissection or postoperative irradiation is indi­
cated to complete treatment. Because irradiation has proved
effective in the sterilization of occult metastasis, this should be
the favored treatment in such cases since it avoids the potential
complications of a bilateral neck dissection.
The controversy in the management of lingual cancer is
more pronounced in lesions arising in the base of the tongue.
Because of the poor differentiation of these tumors and the dif­
ficulties in establishing their extent, irradiation with surgical
salvage has played the major role in their management122. How­
ever, the cure rate has been poor using surgical resection for
radiotherapy failures. Therefore, surgery followed by postop­
erative radiation has become more popular. The 5-year survival
rate in a series of 166 patients with tongue base lesions treated
by primary radiotherapy was 27%123, while, in a smaller series
of 31 patients treated with surgery and postoperative radio­
therapy, the 5-year survival rate was 52%m . Regardless of the
therapeutic modality selected, base of tongue carcinomas con­
tinue to have an associated overall poor survival rate.
The composite resection The surgical treatment of carcinoma
is based on the composite resection of the primary tumor in
continuity with a portion of the mandible and a radical neck
dissection. This operation is applicable for most tumors involv­
ing the tongue, floor of the mouth, mandibular alveolar ridge,
retromolar trigone, tonsillar area and, occasionally, to tumors
of the buccal mucosa and deeply infiltrative lesions of the skin
overlying the mandible. Obviously, the indications for mandibu­
lar resection and the extent of surgery will depend on the size
and location of the primary tumor. As in other head and neck
malignancies, the ideal tumor-free margin should be about 2
cm. Natural barriers to cancer spread such as fascial layers; pe­
riosteum or bone are also important in planning the resection.
In tumors of the anterior third of the tongue, the amount of
tissue from the base of the tongue that needs to be resected is
frequently minimal, whereas, for cancers of the middle third, a
complete hemiglossectomy and partial resection of the lateral
pharyngeal wall is often necessary. Conversely, in tumors of
the base of the tongue, it may be possible to accomplish a wide
resection, preserving some of the anterior ipsilateral tongue.
Resection of a major portion of the mandible is indicated when
there is clinical or radiographic evidence of tumor invasion, or
when invasion is strongly suspected. Invasion of the inferior
alveolar canal is a most important consideration, since the tu­
mor may extend along the inferior alveolar nerve and jeopar­
dize an apparently safe margin of resection. As elsewhere in the
resection, questionable margins must be evaluated with mul­
tiple frozen sections.
The development of myocutaneous and, more recently,
microvascular flaps has allowed for preservation of mandibular
continuity, return of vital oral functions, and limitation of the
134 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

cosmetic deformity. The pectoralis major myocutaneous flap is

the “work horse” of myocutaneous flaps, due to its reliable blood
supply, the relative ease in creation, and the large surface area
of healthy, well vascularized soft tissue for closure of surgical
oropharyngeal defects (Figure 5-10). The pectoralis flap, as first
suggested by Ariyan, is based on the pectoral branch of the
thoracoacromial artery125. The thick fan-shaped pectoralis muscle
is elevated from the ribs and fascia of the pectoralis minor
muscle. Multiple variations in shape and size of the overlying
skin paddle, including double side-by-side paddles, are possible,
depending on the resected defect. Care is taken to preserve the
fascia surrounding the neurovascular pedicle as the flap is tun­
neled underneath the chest wall skin and brought over the
clavicle into the previously dissected neck. The flap provides
coverage for the cervical portion of the carotid artery and re­
stores the defect from the neck dissection and partial
mandibulectomy. The skin paddle is rotated into the oral cavity
and meticulously sutured in place to prevent oral-cutaneous fis­
tula formation. The donor site is almost always closed prima­
rily. When bulk is a problem, the flap can be de-epithelialized,
creating a myofascial flap that can be covered with a split-thick-
ness skin graft or allowed to epithelialize by secondary inten­
tion126. Since its blood supply is distant from the tumor, it is an
ideal method of closure in postradiation patients.
Other myocutaneous flaps include the deltopectoral, latis-
simus dorsi, sternocleidomastoid, platysma, and trapezius flaps.
Both the latissimus dorsi and trapezius flaps provide a large
pedicle for resurfacing; however, they are used infrequently,
since the patient has to be repositioned intraoperatively follow­ Fig. 5-10. a: Pectoralis major myocutaneous flap. All
ing flap harvest. The platysma and sternocleidomastoid flaps or part of outlined area can be carried by a
are used infrequently because of their tenuous blood supplies. thin layer of muscle, with its blood supply
In addition, the sternocleidomastoid muscle is often included in provided by the thoracoacromial artery.
the neck dissection. The deltopectoral flap, although popular in Flap can be used to resurface and recon­
the past, has the disadvantage of requiring a multi-staged pro­ struct many oral cavity defects, b: Oral
cedure, and the blood supply is less reliable than the pectoralis defect reconstructed with a pectoralis ma­
flap. jor myocutaneous flap.
The advent of microvascular surgery has created a multi­
tude of reconstructive possibilities for the tongue as well as for
other intraoral resected tissues. Their utilization requires spe­ of the classical neck dissection is necessary prior to discussing
cialized training in microvascular techniques and necessitates surgical modifications.
the use of a multi-team approach to limit operating time. Spe­ The basic principles and technique of this operation were
cific flaps and their surgical applications are covered in a sepa­ first described by George Washington Gyle in 1906. The op­
rate section within this chapter. eration aims to eradicate nodal metastases enveloped within the
superficial and deep layers of the deep cervical fascia. The lym­
The radical neck dissection Surgical resection of oral carci­ phatics included within these fascial layers drain all the struc­
noma, with its high metastatic rate, is nearly always performed tures of the head and neck. Terminal lymphatic vessels collect
in conjunction with a radical neck dissection. In the recent past, the lymph in a capillary system and transfer it into larger affer­
a radical neck dissection was usually performed. However, re­ ent vessels. Following passage through a node, the lymph passes
finements in technique, and a better understanding of how tu­ via efferent vessels toward the thoracic duct in the left neck and
mors spread via the cervical lymphatics, have resulted in some a smaller lymphatic duct in the right neck. Cells may escape
modifications in the dissection. Nonetheless, a basic knowledge from the node into the systemic circulation and thus bypass the
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 135

efferent system. This phenomenon occurs when efferent lym­ posterior to the carotid bulb. This incision arches to end at the
phatic channels become occluded. There are approximately 150 point where the lateral third of the clavicle meets with its me­
nodes in the neck, divided into closely interrelated deep and dial two-thirds. The upper limb may be readily extended into a
superficial systems. The superficial lymphatics are located im­ lip-splitting incision that provides an excellent exposure to the
mediately deep to the fibers of the platysma muscle, and they mandible and intraoral structures (Figure 5-12b).
drain the skin and its appendages. The deep system has a prin­
ciple lymphatic chain and several accessoiy groups. The prin­
ciple chain is composed of the nodes adjacent to the internal
jugular vein, and it, in turn, is divided into high or jugulodigastric
nodes, the middle and the inferior chains, the inferior being in
close relationship with the prescalenic nodes.
Among the accessory systems, the most anterior is com­
posed of a small group of submental nodes just lateral to the
mid-raphe and attached to the fascia of the anterior belly of the
digastric muscle. The submental group drains the upper lip and
the superficial structures within the nasolabial fold. Immedi­
ately posterior to the submental nodes is the submandibular
group adjacent to the facial artery, which is divided into vascu­
lar and retrovascular nodes. The submandibular nodes prima­
rily drain the lower lip, the floor of mouth, the alveolar ridge,
and portions of the mobile tongue. Of greatest importance, es­
pecially in nasopharyngeal and scalp tumors, is the lymphatic
chain associated with the cranial accessory nerve. This chain is
located in the posterior triangle of the neck just anterior to the
trapezius muscle. Other important lymphatic groups are the
pretracheal and thyroid plexuses and the superficial mastoid,
occipital, preauricular, and lower parotidean nodes. The latter 4
groups drain the scalp, the lower lid, including the conjunctiva
and lacrimal apparatus, and the parotid gland.
More recently, these nodal groups have been incorporated
into regions or levels within the neck to standardize nodal loca­ Fig. 5-11. Level system for describing position of neck
tion and to classify neck dissections (Figure 5-11). The levels nodes: Level I, submental and submandibular
range from I to VI, with level I being the submental and sub­ group; Level II, upper jugular group; Level III,
mandibular group; levels II, HI, IV the upper, middle, and lower middle jugular group; Level IV, lower jugular
jugular groups, respectively; level V the posterior triangle group; group; Level V, posterior triangle group; and Level
and level VI the anterior compartment group. VI, anterior compartment group.
The radical neck dissection includes all these lymphatic
groups except for the preauricular, occipital and mastoid nodes,
the thyroid plexus, and the superficial system. In order to ac­ A unilateral neck dissection alone produces little disabil­
complish the removal of these lymphatic groups effectively, the ity. The most notable problem is the shoulder drop resulting
sternocleidomastoid and omohyoid muscles are sacrificed, as from sacrifice of the cranial accessory nerve. This is character­
well as the deep and superficial jugular veins, the cranial acces­ ized by impaired abduction of the shoulder girdle, which may
sory nerve, the submandibular gland, and the lower pole of the become quite painful. Cosmetically, the usual result is satisfac­
parotid gland. tory except for flattening of the operated neck. Nonetheless,
A variety of incisions have been developed to gain access modifications to the classical radical neck dissection are being
to these cervical structures in conjunction with resection of the utilized with increasing frequency to reduce the morbidity in
primary tumor. In cancer of the oral cavity, die incision designed selected cases.
by Frazier offers excellent exposure and is the one most com­ Conceptual guidelines for classifying neck dissections have
monly used (Figure 5-12). This incision is composed of 2 limbs: recently been adopted127, so there are essentially 3 additional
a horizontal limb that curves gently from the tip of the mastoid, types of neck dissections being utilized: modified radical, ex­
from about 4 cm from the lower edge of the mandible, ending tended radical, and selective neck dissections. A modified radi­
at the mid-portion of the chin; and a vertical limb, developed cal dissection involves the excision of all lymph nodes, rou­
136 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 5-12.
a: Outline of incision
commonly used in re­
section of intraoral le­
sions combined with
radical neck dissec­
tion. b: In this patient,
upper limb of incision
has been extended,
resulting in splitting
the lip and improving
surgical exposure of
the tumor.
b series, patients who were not irradiated had a 15% incidence of
tinely removed by the radical neck dissection, with preserva­
tion of one or more of the following structures: the cranial ac­
cessory nerve, internal jugular vein, and the sternocleidomas­
toid muscle. When all 3 structures are preserved, this operation
corresponds to the functional neck dissection popularized by
Bocca128.
The extended radical neck dissection refers to the removal
of one or more additional lymph node groups not encompassed
by the radical neck dissection. Examples of these lymph node
groups include the parapharyngeal, superior mediastinal, and
paratracheal nodes. Additional non-lymphatic structures include
the carotid artery, hypoglossal and vagus nerves, and paraspinal
muscles.
A selective neck dissection refers to any type of cervical
neck dissection where one or more lymph node groups, nor­
mally removed during a radical neck dissection, is preserved.
The 4 subtypes of selective dissections and the corresponding
levels of nodes removed are: supraomohyoid dissection (levels
I-m), posterolateral dissection (levels Il-V), lateral dissection
(levels n-IV), and anterior compartment dissection (level VI).
Complications The complications of the surgical treatment of
oral cancer are primarily related to the intraoral resection of the
tumor, and somewhat less so to the radical neck dissection. The
overall complication rate in non-irradiated radical neck dissec­
tions is approximately 3% when there is no communication
between the oral cavity and neck. When resection of the oral
primary lesion requires extension into the neck, the incidence
of complications rises to 10%. The most important complica­
tion related to the intraoral part of the operation is the develop­
ment of an orocutaneous or pharyngocutaneous fistula. Com­
plications related to the radical neck dissection may occur in-
traoperatively or during the early postoperative period. The
hypoglossal, vagus, phrenic and laryngeal nerves, branches of
the facial nerve (particularly the marginal mandibular nerve),
and portions of the brachial plexus may occasionally be dam­
aged during the resection. In left neck dissections, laceration of
the thoracic duct can result in a significant complication. How­
ever, excessive bleeding, pneumothorax, and damage to the
subclavian vessels are uncommon. Among the postoperative
complications, hemorrhage, flap necrosis, and infection are rela­
tively infrequent. Chylous fistulae, carotid artery rupture and,
rarely, airway obstruction are all potentially lethal.
The most important factor favoring the development of
postoperative complications in the treatment of lingual and other
intraoral malignancies is the use of preoperative radiotherapy.
In a series of4500patients, Joseph and Shummrick have shown
that the average healing time for a radical neck dissection after
a full course of radiation therapy was delayed by 60%129. In this
wound dehiscence and an 8% incidence of fistula formation.
Carotid necrosis did not occur. This group contrasted sharply
with irradiated patients; the contrast being especially marked
for individuals in whom radiotherapy had been delivered as an
initial attempt for cure and not as a planned combined radio-
therapy-surgery treatment. In the planned combined therapy
treatment group, the incidence of dehiscence, fistulae, and ca­
rotid necrosis was 12%, 23%, and 2.8%, respectively. In the
radiation failure group, the incidence of wound dehiscence rose
to 77%, fistula formation to 73%, and carotid necrosis to 50%.
Due to these high complication rates, planned preopera­
tive fiill-course radiotherapy is used infrequently. Most patients
requiring combined surgery and radiation therapy receive their
radiation therapy postoperatively. Nonetheless, these irradiated
patients are still at risk for developing complications, such as
osteoradionecrosis of the mandible, non-healing oral ulcers, fis­
tulae, xerostomia, and wound dehiscence.
Surgical modifications In limited lesions of the mobile por­
tion of the tongue that do not extend into the floor of the mouth,
resection may be accomplished with preservation of mandibu­
lar continuity. Such a goal may be accomplished by the so-called
“pull-through” procedure, by sacrifice of the intraoral cortex of
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
the mandible, or by a mandibulotomy followed by immediate
reapproximation.
In the pull-through type of operation, after a radical neck
dissection is completed, the cervical portion of the specimen
remains attached to the floor of mouth. Thereafter, the lingual
tumor is resected intraorally without splitting the mandible, thus
maintaining its continuity with the radical neck specimen. A
cuff of mucosa overlying the mandible is preserved, later to be
sutured to the tongue defect. Upon completion of the tumoral
resection, the specimen is delivered by pulling it through the
floor of mouth. The main disadvantage of this operation is that
it provides limited exposure to the primary tumor. A superior
approach to posterior lingual lesions is possible if the mandible
is split prior to resection of the primary tumor. Sectioning of the
mandible is either performed, through the symphysis or the
mandibular body, in a stepladder fashion. Following resection
of the tumor, the 2 ends are reapproximated and held in position
with fixation plates or wires (Figure 5-13). Cosmetically and
functionally, the result compares favorably with a pull-through.
Care is taken to conceal the incision by curving it around the
chin, and by splitting the lip using a z-plasty. Meticulous
reapproximation of the skin is also extremely important. Fol-
Fig. 5-13. Mandible was split to achieve better exposure. It
was reapproximated and held in fixation with a
reconstruction plate.
137
lowing surgery, the patient is maintained with nasogastric tube
feedings for the first 7 to 10 days and is then started on a me­
chanically soft diet to prevent a fibrous union of the osteotomy
site. Intermaxillary fixation is usually not necessary.
Preservation of the outer cortex of the mandible is used
only in carefully selected cases where the tumor has limited
extension into the floor of mouth and is not contiguous with the
mandible. In such cases, the resection of the primary tumor is
accomplished in a similar manner as a pull-through, but with
extension into the mandible proper. Closure is more difficult,
and coverage of the raw bony surface usually requires mobili­
zation of a buccal mucosa as well as a tongue flap (Figure 5-
14). A myocutaneous flap may occasionally be needed for clo­
sure.
F ig . 5-14. Tongue flap was used to cover mandible, and is
connected to buccal mucosa.
Mandibular reconstruction is usually accomplished at the
time of initial resection. Mandibular continuity can be main­
tained using rigid fixation with a mandibular tray and bone graft
or a rigid plating system in conjunction with an osseous free
tissue transfer. Mandibular reconstruction is covered in more
detail later in the chapter.
Minor alterations in the surgical resection may improve
the prospects of rehabilitation. In edentulous patients, if recon­
struction of the mandible is not anticipated, the condyle and
ascending ramus should be removed. If a condylar-coronoid
fragment remains, it is often retracted medially and anteriorly,
and approximates the maxillary tuberosity. This obviously pre­
vents proper extension of the maxillaiy complete denture into
the buccal pouch area, which is so important for retention and
stability (Figure 5-15).
If mandibular reconstruction is planned at a later date it is
vital to maintain the presurgical position of each mandibular
fragment. These fragments are prone to displacement by scar
contracture and/or contraction of the muscles of mastication. In
138 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 5-15. a and b: Condyle and ramus fragment were retained but not maintained in position. Result: right buccal pouch area
is obliterated.

a resection of the lateral portion of the mandible, the posterior

resection line should be made vertically, from sigmoid notch to
angle rather than horizontally across the ramus (Figure 5-16)130.
When the mandible is resected horizontally, the unopposed con­
traction of the temporalis muscle displaces the fragment
superomedially beneath the zygomatic arch, making it very dif­
ficult to retrieve later during reconstruction. When the man­
dible is resected vertically the fragment remains in a relatively
normal anatomic position. When the mandible is resected in
this way the placement of a musculocutaneous flap will keep
the 2 residual mandibular fragments in good position until a
free graft can be placed. If there is a soft tissue deficit at the
resected site some form of fixation is useful to stabilize the re­
sidual mandibular fragments. Internal fixation devices include
Kirschner wires, braided stainless steel wire and reconstruction
plates of various designs. These serve as temporary means of
fixation because they can fracture or loosen if left over an ex­
tended period of time (Figure 5-17). External pin fixation is a
popular means of stabilizing mandibular fragments particularly
in those patients undergoing mandibular resection secondary to
osteoradionecrosis.

Fig. 5-16. Lateral mandibular resection. If reconstruction is

planned, the condyle should he preserved. Pos­
terior resection line should be oriented vertically
(top) rather than horizontally (bottom). (Redrawn
from: Schwartz H. Mandibular reconstruction of
the head and neck cancer patient. In: Head and
Neck Oncology; Kagan R, Miles J, eds. New Fig. 5-17. Mandibular fragments maintained in position with
York, 1989; Pergamon Press). reconstruction plate.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation

As in a maxillectomy, bony cuts through the dentuious acromial flaps needed to be staged, and the forehead flap left
portion of the mandible should be intraseptal rather than inter- the patient profoundly disfigured (Figure 5-19).
proximal. This will result in higher levels of bone for the tooth
adjacent to the surgical defect, thus making the tooth more suit­
able as a partial denture abutment In addition, bony resections
through the body of the mandible should be made as far poste­
riorly as possible. The more mandible remaining, the better the
prosthetic prognosis, particularly in edentulous patients. Eden­
tulous patients with resections to the midline have an extremely
poor prosthetic prognosis.
The presence and the condition of teeth profoundly influ­
ences the rehabilitation of patients with mandibular discontinu­
ity defects. For example, mandibular guidance procedures are
ineffective in the absence of teeth. Prior to surgery, key teeth to
be salvaged should be identified. Retention of the mandibular
cuspids is especially beneficial.

Surgical closure The functional disabilities associated with a

tongue - mandible resections are primarily dependent upon the
amount of tongue resected and the method of closure. If the
surgical wound is closed primarily (primary closure) by sutur­
ing the edges of the wound together (for example, connecting
the midline of the residual tongue to the buccal mucosa) (Fig­
ure 5-18), the functional disabilities are compounded As a re­
sult, the cure may be worse than the disease itself, leaving many
patients incapacitated, lacking the ability to control their saliva,
speak, swallow, or appear presentable.

Fig. 5-18. Tongue was sutured to buccal mucosa following

hemiglossectomy.

In the 1960s, the search for other means of wound closure

led to the development of the thoracoacromial (deltopectoral)
flaps131 and the forehead flaps132. The use of these flaps permit­ b
ted the oncology surgeon to be more aggressive, resulting in
improved survival rates. However, they had little beneficial Fig. 5-19. a: Forehead flap used to reconstruct oral defect.
impact on postsurgical tongue function. In addition, these 2 b: Resultant facial disfigurement may be undesir­
methods each possessed distinct disadvantages: The thoraco­ able.
140 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

The introduction of the myocutaneous flap in the late 1970s created by resection of the mandible and tongue because of the
ameliorated some of the disabilities and deformities, and thus large bony and soft tissue defect (Figure 5-22). The degree of
Ais flap has become a popular means of wound closure follow- facial disfigurement varies with the extent of surgery, the facial
mg toogue-mandible resections. From a prosthodontic perspec­ form exhibited by the patient, and the method of closure. Around
tive. these flaps were preferred over the methods previously or ovoid facial form with abundant soft tissues serves to cam­
zi'aflable because they could replace the resected tissues, such ouflage the cosmetic disparities resulting from the surgical pro­
as die missing portion of the tongue, thus resulting in less man­ cedure, regardless of the method of closure. When the wound is
dibular deviation. The mobility of the tongue was improved, closed with a myocutaneous flap or a free flap, the soft and hard
andthe tongue was centered more normally beneath palatal struc­ tissues resected with the tumor can be replaced. There may be
tures (Figure 5-20). The result was improved speech, swallow­ some residual facial asymmetries, but the large facial concavity
ing. and saliva control. Skin paddles of appropriate size could associated with primary closure is prevented.
be left attached to the muscle pedicle and used to reline exten­
sive areas of the oral cavity. The muscle portion of the flap pro­
vided the bulk necessary to replace the resected tissues, which
Id some tongue-mandibular resections can be quite extensive.
Free tissue transfers (free flaps) were introduced in the mid
1980s as a means of restoring the large soft and hard tissue
defects associated with resection of tongue-mandible tumors.
Like die musculocutaneous flaps, the technique provided re­
placement of the lost tissues due to the resection of the tumor.
The most significant advantage of this flap over the others was
b improved blood supply—not only for the tissue being trans­
ferred but also to the recipient site. The improved blood supply
improves wound healing and ensures the survival of the flap,
even in irradiated tissues. Free flaps are suitable for restoring
fioagne as well as combination tongue-mandible defects (Fig­
ure 5-21). A number of donor sites have been used to restore Fig. 5-21. Hemiglossectomy defect reconstructed with a free
oral cavity defects, including the radial forearm, the iliac crest, flap. Radial forearm was donor site.
sc^xila and fibula.

Disability—Resection of Tongue Lesions

Tumors of the tongue and lateral floor of the mouth region

ofen require extensive resection of bone and soft tissue, which
resuks in obvious cosmetic disfigurement. A concave defect is

Fig. 5-20. Hemiglossectomy defect reconstructed with a Fig. 5-22. Composite resection defect. Intraoral wound was
pectoralis major myocutaneous flap. closed primarily.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 141

If a significant amount of the tongue is resected, and the

remaining portion is used for primary closure, the speech de­
formity can be severe. The loss of large portions of the tongue
prevents appropriate valving and/or interaction with other oral
structures. This loss, combined with the loss of motor and sen­
sory innervation and impaired mobility, compromises the ar­
ticulation of speech phonemes. Other articulators, such as the
lower lip, may also be affected by the resection. Although the
lower lip is rarely resected, the motor and sensory control of the
lower lip is often compromised by resection of the marginal
mandibular and inferior alveolar nerves (Figure 5-23). Tongue
function is less affected if the resected portion is restored with
either a myocutaneous flap or a free flap. The myocutaneous
flap restores lost bulk and prevents the severe mandibular de­
viation seen in patients closed primarily. The residual tongue
and flap is centered beneath the palatal structures, permitting
the reconstructed tongue to articulate phonemes more effec­
tively. Myocutaneous flaps, however, can become scarred and
immobile, and thus limit the mobility of the residual tongue;
speech articulation may remain poor, also. In contrast, patients
whose tongues are reconstructed with free flaps have the poten­
tial of achieving near normal speech. The flap restores lost bulk,
as does the myocutaneous flap, but it does not become heavily
scarred and immobile. Thus, the mobility of the residual tongue
is improved dramatically, and the quality of speech articulation
approaches normal limits (Figure 5-24).
Like speech, the degree to which deglutition is adversely
affected depends upon the extent of surgery and the method of
closure. In normal patients, the tongue, in conceit with the soft
palate, directs the bolus posteriorly into the oral pharynx with a
synergistic squeezing action. This act is performed with far less
efficiency in patients with tongue resections, although, eventu­
ally, most patients learn to swallow quite acceptably. Patients
subjected to primary closure experience the most difficulty
swallowing, followed by those whose wounds are closed with
myocutaneous flaps. Patients reconstructed with free flaps ex­
perience the least difficulty, and many are able to swallow in a
near normal fashion.
In patients closed primarily following surgical resection,
the remaining mandibular segment will retrude and deviate to­
ward the surgical side at the vertical dimension of rest (Figure
5-25). Upon opening the mouth, this deviation increases, lead­
ing to an angular pathway of opening and closing. It is not un­
common to note 1-2 cm of deviation laterally and 5-10 mm
retrusion posteriorly during maximum opening. When tracing
the incisal point of the mandible, this diagonal pathway of clo­
sure is quite obvious133. During mastication, the entire envelope
of motion occurs on the surgical defect side (Figure 5-26)133. F ig . 5-23. a: Following a composite resection, lip was re­
Some patients are unable to affect lateral movements toward tracted and corner of mouth lowered, b and c:
the non-defect side and are incapable of making protrusive Resection of marginal mandibular nerve may pre­
movements. Patients closed with a myocutaneous flap demon­ vent effective lip closure.
strate much less deviation.
142 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 5-24. a: Hemiglossectomy-lateral mandibular defect closed primarily. Mandibular defect has not been restored and tongue
function is poor, b: Hemiglossectomy— lateral mandibular defect. Mandibular continuity was restored with a free
graft, but tongue function was poor, c: Partial glossectomy— lateral mandibular defect. Mandibular continuity and
resected soft tissues were restored with a myocutaneous flap and a free graft. Tongue function remained poor
because the tongue was unable to elevate and interact with palatal structures or occlusal surfaces provided by a
complete denture, d: Hemiglossectomy— lateral mandibular defect. Tongue was reconstructed with myocutaneous
flap, but mandibular continuity was not restored. Tongue function was good, providing improved speech and masti­
cation, as compared to patients depicted (a, b, and c). e: Hemiglossectomy defect. Tongue reconstructed with radial
forearm free flap. Tongue function was improved so speech and mastication were near normal.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 143

Loss of the proprioceptive sense of occlusion leads to un­

Fig. 5-25. Note severe deviation of mandible following com­
posite resection of lateral floor of mouth lesion.
coordinated, less precise movements of the mandible. In addi­
tion, the absence of the attachments of the muscles of mastica­
tion on the surgical side result in a significant rotation of the
mandible upon forceful closure. When viewed from the frontal
plane, teeth on the surgical side of the mandible move away
from their opposing maxillary teeth after their initial contact on
the nonsurgical side has been established. As the force of clo­
sure is increased, the remaining mandible actually rotates through
the frontal plane. Hence, the termfrontal plane rotation (Figure
5-27). This factor, with the addition of impaired tongue func­
tion, may totally compromise mastication in some patients. Fron­
tal plane rotation is seen in most patients with lateral mandibu­
lar discontinuity defects, regardless of whether they have been
closed primarily, with a myocutaneous, or a free flap.

before surgery |p |p af,er surgery

Right Left (resected side)

Fig. 5-26.
Note envelope of motion as
f\ v<— Lateral viewed in (a) frontal and (b)
sagittal planes in normal
\ \ mandibulectomy
Normal subject ^J subject patient (solid lines), as com­
pared to patient with a lat­
eral mandibujar resection
(broken lines), c: Position of
remaining mandible in open
Vertical axis (shaded) and closed posi­
tions. Note character of lat­
eral m ovem ents tow ard
resected side. This lateral
after surges |p |p before surgery
movement is somewhat re­
Posterior Anterior producible.
/

Normal subject

Lateral
mandibulectomy
subject Vertical axis
144 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Rotation point
F ig . 5-27. a and b: As force of mandibular closure is in­
creased, mandible rotates around occlusal con­
tacts on unresected side, and remaining teeth on
resected side drop further out o f occlusion. This
movement is called frontal plane rotation.
The severity and permanence of mandibular deviation is
highly variable, and is dependent upon a number of complex
factors, such as amount of soft and hard tissue resected, the
method o f closure, and so forth. Patients closed with a
myocutaneous or free flap soon attain an acceptable interocclusal
relationship, without adjunctive therapy, while some patients
closed primarily are never able to achieve an appropriate and
stable interocclusal position. When a usable occlusal relation­
ship is achieved, the mandibular teeth often will occlude distal
to the presurgical pattern of cuspal interdigitation. On the non-
surgical side, the buccal slopes of the mandibular buccal cusps
function with the central fossae of the maxillary teeth because
of mandibular rotation in the frontal plane (Figure 5-28). Scar
contracture, tight wound closure, and muscle imbalances sec­
ondary to the primary resection all contribute to mandibular
deviation. Mandibular deviation is most severe following pri­
mary closure of base of the tongue lesions.
Un resected Side
F ig . 5-28. Occlusal relationship displaying lateral disconti­
nuity defect on unresected side. Note difference
before and after surgery.
Control of saliva is profoundly affected by most resections
of the tongue and mandible. These resections obliterate the lin­
gual and buccal sulci and, consequently, a means of collecting
and channeling secretions posteriorly no longer exists. In addi­
tion, the motor and sensory innervation of the lower lip on the
resected side is often lost, adversely affecting oral competency
and preventing the patient from detecting secretions escaping
from the mouth. Impaired tongue control and mobility also con­
tributes to poor control of saliva. Normal patients are capable
of identifying escaping secretions and using the tongue to di­
rect these secretions posteriorly for swallowing. With compro­
mised tongue function, this manipulation often is impossible.
Drooling is compounded on the defect side by the drooping of
the comer of the mouth. Cracking and laige fissures develop
that may become infected with Candida albicans (Figure 5-
29). Impaired salivary control is most frustrating to the patient,
and improvement is impossible without vestibuloplasty and
tongue release.
Most patients who submit to lateral resections of the man­
dible present with varying degrees of trismus following sur­
gery. Trismus is most severe in those patients requiring either
preoperative or postoperative radiation therapy. Early initiation
of a well-organized mandibular exercise program is the most
effective means of alleviating this disability. Dynamic bite open­
ers are rarely effective in these patients because of the instabil­
ity of the resected mandible.
A number of structures resected during the course of a clas­
sical radical neck dissection may have prosthetic implications.
The internal jugular vein is resected, predisposing to local venous
congestion and edema, which may compromise the peripheral
extensions of a mandibular complete denture. Resection of the
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
b moid carcinomas of the anterior half of the floor of the mouth,
Fig. 5-29. a and b: Candida albicans infections develop at
corner of mouth, where cracks and fissures oc­
cur in presence of persistent drooling.
marginal mandibular branch of the facial nerve results in a uni­
lateral loss of the motor innervation of the muscles controlling
movements of the lower lip. Consequently, additional prosthetic
support for the lower lip may be required.
Section on carcinoma of the floor of the mouth contributed by Jeffrey W. Bailet and Rinaldo F. Canalis.
145
Additional morbidity contributed by radiation therapy
A high percentage of patients with lateral tongue lesions
receive either pre- or postoperative radiation therapy. This re­
sults in more severe scarring of the tissue bed, which becomes
more unyielding and, in patients closed primarily, the clinician
will encounter difficulty during mandibular guidance therapy.
In addition, radiation therapy predisposes the patient to dental
disease because of compromised salivary flow and the ascen­
dancy of oral cariogenic microorganisms (Chapter 4). Oral hy­
giene becomes increasingly difficult because of the shoulder
and arm disability produced by the resection of the spinal ac­
cessory nerve, trismus, and compromised motor control of the
mandible. Difficulty with oral hygiene procedures is more pro­
nounced if the composite resection is performed on the patient’s
favored side. Electric toothbrushes are invaluable aids for these
patients. Obviously, topical fluoride applications are essential
for control of caries.
In edentulous patients, complete denture use is further com­
promised by reduction in volume and change in the consistency
of saliva, in addition to impaired mucosal tolerance. These fac­
tors assume greater importance when one notes the consider­
able reduction in denture bearing surface following many re­
sections. Lymphedema and venous pooling are accentuated by
radiotherapy, and may compromise the extension of the man­
dibular denture or predispose to tongue and cheek biting. Tris­
mus may also be accentuated if the radiation fields include the
temporomandibular joint, ascending ramus, and the muscles of
mastication.
Carcinoma of the Anterior Floor of the Mouth*
Clinical and Pathological Considerations
Clinically, the floor of the mouth is described as a U-shaped
space overlying the mylohyoid and hyoglossus muscles. It ex­
tends from the inner surface of the mandibular alveolar ridge to
the root of the tongue and is limited posteriorly by the anterior
tonsillar pillar. The floor of the mouth is divided into anterior
and posterior halves at the level of the second molar.
Although this section is primarily oriented towards epider­
it must be stressed that, statistically, most current studies pro­
vide little precise information regarding the distribution of tu­
mors of this region. Usually, these lesions have been evaluated
in conjunction with tumors of the posterior half of the floor of
the mouth, or within series of lingual or other intraoral malig­
nancies. Nevertheless, this division is clinically relevant, since
tumors arising from the posterior half are managed in a manner
similar to those arising from the middle third of the tongue;
whereas those lesions involving the anterior half present unique
treatment and rehabilitation problems. This more general over­
146 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
view is representative of the behavior of most tumors arising in
this location. Among lesions in the anterior half, most will de­
velop lateral to the midline. In a group of 53 patients with floor
of the mouth cancer, Feind and Cole found that 6 had tumors in
the posterior third, 39 in the lateral anterior third, and 8 in the
anterior m idline134. In 48 patients studied by Keim and
Lowenberg, 16 (33%) had anterior tumors, 4 (8%) had poste­
rior lesions, and 24 (50%) had tumors occupying both areas135.
The anterior midline was crossed by tumors in 12 (27%) of the
cases.
Cancer of the floor of the mouth accounts for approximately
10% to 15% of all intraoral malignancies. With the exception
of a few tumors developing from minor salivary glands, and
rare sublingual gland lesions, floor of the mouth cancers are
moderately well-differentiated squamous cell carcinomas. The
disease affects primarily men at a ratio of 5:1 or higher136. More
than 70% of the patients are between 50 and 60 years old135,137.
O f all the intraoral sites, individuals with cancer of the floor of
mouth have the highest incidence of multifocal carcinomas, with
a second primary rate of 20%138.
The most common initial complaint is a painful ulcerated
mass, usually present for several months (Figure 5-30). Lesions
of the anterior floor of the mouth initially tend to be somewhat
rounded, differing from those of the posterior regions, which
are usually elongated, and are wedged between the tongue and
the mandible. Anterior lesions usually develop lateral to the
midline, but can involve the frenulum and submandibular ducts
over time. They often originate from superficial exophytic le­
sions related to leukoplakia, which later extend deeply into the
loose connective tissue of the submandibular and submental
spaces. Frequently, the tumor infiltrates tissues well beyond the
exophytic area to involve the mucosa of the alveolar ridge and
neighboring tongue. Advanced tumors are characterized by in­
vasion of the root of the tongue, extending into the extrinsic
lingual musculature and along the mandibular periosteum. Even­
tually, the tumor may extend directly into the submandibular
triangle.
Fig. 5-30. a: An early squamous carcinoma of the anterior floor of mouth, b: Small exophytic epidermoid carcinoma, c: Large
infiltrating epidermoid carcinoma.
Regional metastasis are not uncommon. However, with
carcinomas of the floor of the mouth, they tend to develop some­
what later in the course of the disease when compared to in­
traoral carcinomas arising in other locations. The presence of
cervical metastasis range from 39% to 70%, and the likelihood
of occult metastasis is high among individuals with advanced-
stage disease135,139. The most commonly involved regional nodes
are those of the submandibular and upper jugular nodes. In a
study of 273 patients with carcinoma of the floor of the mouth,
50% had stage HI and IV disease140.
Classification and staging
The TNM system is used to classify floor of the mouth
tumors. The guidelines for classification and staging are the same
as those previously described above for carcinoma of the tongue.
Prognostic Factors
The overall survival rate for patients with carcinoma of the
floor of the mouth is approximately 40%. Large tumors with
mandibular invasion, or root of the tongue extension, and re­
gional metastases are all negative prognostic factors. Lesions
which are 2 cm or less (Tj), without regional metastasis, have a
favorable prognosis with a cure rate of approximately 70% to
89%135'141,142, whereas stage IV lesions exhibit a 5-year survival
rate between 7% and 32%136’142-143.
Treatment
Surgery and/or irradiation remain the primary treatment
modalities for carcinomas of the floor of the mouth. Chemo­
therapy is used almost exclusively in the palliative treatment of
advanced lesions. The choice of treatment modality of epider­
moid carcinomas of the anterior floor of the mouth depends
greatly on the extent of the primary lesion and the presence or
absence of cervical metastasis. In general, lesions 2 cm or smaller
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 147

have a more favorable prognosis and may be treated with equal

success by either surgery or radiation therapy. In most exten­
sive lesions, with or without clinically suspected cervical me­
tastasis, surgery plays the major role in treatment. The value of
adjuvant radiotherapy in these cases has not been clearly estab­
lished, although in a study by Kolson of 70 patients, preopera­
tive radiation therapy did not appear to significantly influence
the outcome139. Postoperative irradiation appears to improve Fig. 5-31.
local control in advanced lesions, but improving survival in these The a n te rio r body of
patients remains unclear137,141. Nonetheless, most surgeons con­ m andible w as resec­
tinue to favor combined therapy for low-curability lesions. The ted, resulting in severe
difficulties in achieving successful reconstruction following facial deformity. Sev­
resection increases in irradiated cases. Therefore, the clinician eral attempts of recon­
must carefully evaluate the potential benefit of combined treat­ struction failed, b: Typi­
ment in each individual case. cal result of resection of
anterior floor of mouth
Composite Resections and Surgical Variations lesion when the wound
is closed primarily.
The major disadvantage of surgery in the management of
tumors involving the anterior floor of the mouth has been the
tremendous disability created in the course of extensive resec­
tions (Figure 5-31). The tendency of these tumors to invade
periosteum and bone often necessitates sacrifice of the anterior
mandibular arch, which results in the most debilitating defect a
encountered in the management of intraoral malignancies. The
use of free flaps has dramatically changed this situation. Free
flaps from the fibula can be used to immediately restore the lost
hard and soft tissues and most patients emerge with excellent
function and acceptable appearance (Figure 5-32).
In early lesions without evidence of bony invasion, resec­
tion of anteriorly situated cancers may be adequately accom­
plished with preservation of a functional portion of the man­
dibular arch. The primary concern in resection of floor of the
mouth lesions by marginal mandibulectomy is the potential for
local recurrence; therefore, patients must be carefully selected.
It is a serious mistake to simply dissect the mucosal lesion from
the adjacent periosteum. Adequate resection always requires
generous margins and, in these cases, it is important to include
neighboring bone. With these techniques, results comparable to
those obtained by more radical approaches have long been re­ b
ported135,137144’145. Depending on the location of the tumor, ei­
ther the inner cortical table of the mandible is resected or, as is
the case of superficial alveolar tumors, the alveolar ridge is
resected. In addition to these techniques, a monoblock resec­ In most advanced cases, a conventional composite resec­
tion, first championed by Barton146, has been used for Stage I tion of the mandible is needed. As stated above, when the ante­
and Stage II floor of the mouth lesions. In this procedure, the rior arch is excised, a severe cosmetic and functional defect
contents of the entire submandibular triangle, the anterior belly results. In addition to the mandibular arch, which is usually sac­
of the digastric muscle, and portions of the mylohyoid and hyo- rificed from one mental foramen to the other, resection of the
glossus muscles, in continuity with the primary tumor, are re­ submental structures, including the digastric muscle and extrin­
moved. It must be stressed that the techniques described do not sic muscles of the tongue, along with portions of its intrinsic
represent local excisions, and patients must be carefully selected musculature, compounds the functional problems and the diffi­
by a thoroughly experienced surgeon. culties of reconstruction.
148 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Radical Neck Dissection

A radical neck dissection, either classical or modified, is

indicated in conjunction with excision of the primary tumor
when nodes are clinically present or when the size of the lesion
makes it likely for metastasis to have occurred. For anterior
lesions approximating the midline with unilateral metastases,
removal of the contralateral neck is required. These bilateral
neck dissections lead to severe lymphedema and venous con­
gestion. In addition, a neck dissection is frequently indicated
for the treatment of irradiation failures. In the management of
earlier staged floor of the mouth cancers without palpable neck
nodes, a suprahyoid, rather than a conventional radical neck
dissection, is preferred by some. In this operation, only the struc­
tures of the submandibular triangle, including the pre- and
retrovascular nodes, are removed. The indications for this pro­
cedure are primarily for staging purposes and, although it has
less associated morbidity than a conventional neck dissection,
it does not exclude the existence of metastatic disease lower in
the neck. Furthermore, should tumor be found in the subman­
dibular nodes, the limited resection is not oncologically sound,
and additional therapy is required. The complications of the
surgical treatment of these lesions (which are increased in irra­
diated patients) are similar to those described for composite re­
section of lingual cancer.

Initial Reconstructive Steps

Reconstruction of the mandibular defect may be under­

b
taken at the time of initial resection, or as a secondary proce­
dure. Given the predictability of free tissue transfers, it is highly
preferable to reconstruct anterior mandible discontinuity defects
primarily. The fibula is the preferred donor site unless the soft
tissue deficit is unusually large. The osteotomized fibula pro­
vides sufficient length and bulk of bone. At a later date,
osseointegrated implants can be placed in order to retain and
support a prosthesis (Figure 5-32). If bony reconstruction is to
be delayed, 2 objectives must be achieved to prepare the area
forreconstruction: (1) stabilization of the mandibular fragments
by placement of a fixation device (Figure 5-33), and (2) ad­
equate soft tissue coverage. These objectives can be achieved
with the use of a myocutaneous or a free flap.

Disability—Treatment of floor of mouth lesions

c
Fig. 5-32. a, b and c: Anterior mandibular defect restored
with fibula free flap and an implant-supported
prosthesis.
When removal of these lesions requires resection of the
mandible anteriorly, the disabilities are quite severe unless man­
dibular continuity is maintained or restored at surgery. If man­
dibular continuity is not restored, the 2 remaining posterior frag­
ments are pulled medially by the residual mylohyoid muscles
and superiorly by the muscles of mastication. Facial disfigure­
ment is quite severe. With loss of the anterior mandible, the
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
patient appears as if he or she has lost the entire lower third of
his or her face. The displacement of the mandibular remnants
prevents intercuspation of teeth in dentulous patients and pre­
cludes construction and use of dentures in edentulous patients.
In addition, with loss of its anterior attachment, the tongue tends
to retrude posteriorly and may occlude the airway. Primary clo­
sure of intraoral wounds leads to impaired mobility of the tongue
and loss of vestibules in the anterior region. Mastication is im­
possible, speech is unintelligible, and the patient drools con­
stantly.
If continuity of the mandible is maintained, the degree and
nature of the disabilities are proportional to the amount of tongue
tissue resected anteriorly. In these resections, motor and sen­
sory innervation is usually intact bilaterally, and the functional
deficits are dependent upon tongue mobility. These patients
continue to experience difficulty in controlling their saliva. Sen­
sory and motor innervation of the lower lip may be compro­
mised bilaterally, affecting oral competency and making con­
trol of oral secretions difficult for many patients.
Fig. 5-33.
a: Reconstruction plate maintains proper
position o f residual m andibular frag­
ments and gives the patient a more ac­
ceptable facial profile, b and c: External
pin fixation is also effective.
149
Many lesions are treated with full course radiation therapy,
either preoperatively or postoperatively. The incidence of os­
teoradionecrosis may be particularly high following an inner
table resection, where salvage surgery is necessary because of
radiation failure. The risk is minimized if either a myocutaneous
or free flap is used to reconstruct the area because both tech­
niques bring a new blood supply to the resected area.
If the patient has not been irradiated, inner table resections
that retain continuity of the mandible result in far less morbid­
ity and little facial disfigurement. Oral competency is main­
tained, which results in improved speech and salivary control.
Mastication is less affected, particularly if the patient retains
key posterior teeth. In edentulous patients, the prosthodontic
prognosis is much improved. Most edentulous patients, follow­
ing inner table resections, are able to function with complete
dentures, particularly if they are retained by osseointegraled
implants (Figure 5-34). Disabilities are proportional to the
amount of tongue resected as well as the mobility and control
of the residual tongue.
b
c
150 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 5-34. a: Anterior floor o f the mouth was resected, and
this area was resurfaced with a split thickness skin
graft. Patient was able to function satisfactorily
with conventional complete dentures, b: Follow­
ing resection of anterior floor of the mouth tumor,
a skin graft vestibuloplasty was performed and
osseointegrated implants were placed. Patient
functioned satisfactorily with im plant-retained
overlay denture.
Carcinoma of the Tonsillar Region*
General and Pathologic Considerations
Cancer of the tonsil is the second most common malig­
nancy arising within the oropharynx147,148. The tonsillar region
is formed by the tonsil proper and bordered by the anterior ton­
sillar or palatoglossus muscle and the posterior tonsillar pillar
or palatopharyngeus muscle. Lesions arising from these struc­
tures have different clinical behaviors despite their proximity.
* Section on carcinoma of the tonsillar region contributed by Jeffrey W. Bailet and Rinaldo F. Canalis.
Tumors originating in the tonsil itself are the most common and
are characterized by poor histological differentiation, rapid
growth* and early metastasis. Lesions arising from the pillars
are better differentiated and exhibit a less aggressive clinical
course. Unfortunately, in most clinical situations, these lesions
are already advanced, and it is difficult to identify their exact
site of origin (Figure 5-35).
The majority of tonsillar malignancies (90% to 97%) are
squamous cell carcinomas149. The remaining tumors are pre­
dominantly lymphomas. Carcinoma of the tonsil is predomi­
nantly a disease of men, with an approximate incidence of 85%.
The disease has a peak incidence in the seventh decade of life,
although tumors appearing in women and lymphoepitheliomas
tend to appear earlier148,149,150. The most common complaint in
patients with tonsillar cancer is chronic sore throat. In advanced
tumors, when palate, pharynx, and tongue are involved, dysph­
agia and ipsilateral otalgia are prominent symptoms. A meta­
static neck mass is the initial symptom in approximately one-
fourth of the cases. The tumor presents most frequendy in the
upper pole of the tonsil and may be exophytic or infiltrative.
Extensions into the tonsillar pillars, base of the tongue, and soft
palate may develop rapidly. Involvement of the lateral pharyn­
geal wall, retromolar trigone, and buccal mucosa are common
in advanced cases. Carcinoma of the tonsil tends to metastatize
early to regional nodes. The incidence of positive nodes at the
time of diagnosis has been quoted to be between 50% and 78%,
with a high incidence of bilateral involvement150,151,152,153. The
risk of distant metastasis increases with age and ranges from
5% for Stage I lesions to 27% for Stage IV lesions154. The lung
and liver are the most common sites for distant metastasis.
Fig. 5-35. Carcinoma of tonsil, involving lateral pharynx and
palate. Tumor extended down into base of the
tongue.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 151

Classification and Staging
The staging system used is based on the TNM system es­
tablished by the American Joint Commission for Cancer Stag­
ing and End Results Reporting to classify tonsillar tumors, and
is the same staging as for lingual carcinomas presented earlier
(AJC, 1992).
Treatment and Prognosis
Tonsillar carcinomas are treated with surgery, irradiation,
or combined therapy. Chemotherapy is used as an adjuvant
modality or for palliation. For stage I and small stage II lesions,
the results are comparable with surgery or radiation therapy.
The management of more advanced carcinomas has changed
over the last several decades. Survival figures by stage for pa­
tients undergoing primary radiotherapy revealed that individu­
als with stage I and II lesions had a relatively favorable progno­
sis, with 5-year survival rates ranging from 60% to 75%. How­
ever, patients with stage m and IV lesions, who received pri­
mary radiotherapy, had a dismal prognosis, with survival rates
less than 30% at 5 years150,155. Extension onto the base of tongue
and the presence of regional metastases were particularly poor
prognostic findings, with the presence of positive neck nodes
reducing the survival by half, regardless of T-stage156.
Whicker reported a 48% overall survival for patients treated
with surgery compared to a 16% survival among irradiated in­
dividuals107. Later studies comparing combined surgery and
preoperative radiotherapy showed an advantage over radiation
alone or surgery alone for advanced lesions157,158. Five-year sur­
vival rates for patients treated with combined therapy ranged
from 27% to 45% and 17% to 20% for stages III and IV dis­
ease, respectively153,158.
Preoperative radiation therapy has since fallen out of favor
due to higher complication rates, such as poor wound healing,
an increased rate of fistulas, and flap failures. Currently, com­
bined modality treatment, with surgery followed by postopera­
tive radiotherapy, yields the best long-term results for advanced
lesions.
Composite Resection
The surgical treatment of tonsillar carcinoma is, in gen­
eral, similar to that of carcinoma at the base of the tongue. The
posterior location of these tumors frequently require sacrifice
of the ramus of the mandible, often including the condyle. Oc­
casionally, small lesions that do not involve mandibular perios­
teum may be resected without sacrifice of a portion of the man­
dible by using a mandibulotomy at the jaw angle for exposure.
Following resection, the mandible is reapproximated using wires
or rigid fixation plates. Important to this approach is the amount
of soft tissue resected, since it is preferable to close with local
tissues rather than with regional or myocutaneous flaps. A rota­
tional tongue flap may be used to cover small lateral pharyn­
geal defects without producing any cosmetic or functional de­
fect (Figure 5-36a).
Advanced T3lesions usually require partial pharyngectomy,
partial glossectomy, and partial mandibulectomy in conjunc­
tion with a radical neck dissection. Frequently, a portion of the
soft palate, and even the hard palate, must be resected. When
the tumor invades the base of tongue, generous margins should
be obtained in this area, since it is the most common site of
local recurrence. There remains considerable debate as to
whether positive microscopic margins are effectively treated
by postoperative radiotherapy, but a recent study showed pa­
tients with positive margins could be cured when the radiation

a b c
Fig. 5-36. a: Small tonsillar defect closed with a tongue flap. Tongue function is not affected, b: Large tonsillar defect closed
with a tongue flap. Tongue function is dramatically affected, c: Large tonsillar defect closed with myocutaneous flap.
Tongue function was not affected. Velopharyngeal defect was restored with an obturator prosthesis.
152 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
dose was greater than 60 Gy159. Following composite resection,
the defect can be closed primarily, but there is considerable com­
promise of tongue function and facial appearance (Figure 5-
36b). Typically, these larger defects are closed with a
myocutaneous flap based on the pectoralis major muscle (Fig­
ure 5-36c) or a free flap. The velopharyngeal defect can be re­
stored with an obturator prosthesis (see Chapter 7).
Complications
The complications of the surgical management of tonsillar
cancer are similar to those described for the treatment of poste­
riorly located lingual tumors. As in all tumors in close proxim­
ity to the mandible, osteitis and osteoradionecrosis are serious
and debilitating problems that frequently fail to respond to any
form of treatment. At surgery, care should be taken to avoid
unnecessary trauma to the mandible, and to provide healthy
soft tissue coverage to prevent postoperative bone exposure.
Initial Reconstructive Steps
In the past, defects secondary to resection of tonsillar tu­
mors were closed either With tongue flaps or, occasionally, with
a forehead flap. These methods of closure predisposed the pa­
tient to both functional disabilities and significant cosmetic de­
Fig. 5-37.
a and b: Tonsillar defect reconstructed
with a myocutaneous flap. Tongue func­
tion is normal, c: Obturator prosthesis re­
stores velopharyngeal defect, d and e:
Removable partial dentures restore oc­
clusion on unresected side.
formity. The use of tongue flaps was particularly disabling. A
large portion of the tongue was no longer available for func­
tion, and that which remained was relatively immobile and not
properly centered beneath the palate. Speech, swallowing, and
salivary control were inevitably compromised (Figure 5-36b).
Since the early 1980s, myocutaneous flaps have been used
to close and reconstruct these defects (Figure 5-36c). The most
common musculocutaneous flap was based on the pectoralis
major muscle. This flap is well suited for the reconstruction of
the tonsillar region, as the resected tissues are easily replaced
with this flap. Mandibular deviation is prevented and, if the
tongue was not involved in the resection, its entire bulk remains
available for speech and swallowing. If a segment of the man­
dible was removed during the resection, it need not be recon­
structed. The musculocutaneous flap provides sufficient bulk
to maintain a reasonably symmetrical lateral facial contour, and
it also prevents deviation of the mandible. If the patient is den­
tulous, functional occlusal relationships can be maintained quite
easily. If the patient is edentulous, osseointegrated implants can
be placed to retain and support removable overlay dentures.
Velopharyngeal defects are restored with an obturator prosthe­
sis. The functional and cosmetic results are quite acceptable
and most patients are capable of normal speech, swallowing,
and near normal mastication efficiency (Figure 5-37).
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 153

Disabilities—Treatment of Tonsillar Area Lesions TUmors of the Alveolar Ridge and Mandible*

The disabilities resulting from resection of tumors in this Tumors requiring segmental or radical resection of the
region are similar to those seen in lateral tongue-floor of the mandible may arise in the alveolar mucosa, in the periosteum
mouth resections and are related to the method of closure and and bone of the mandible, or from the dental elements. Among
reconstruction. There are some important differences, however, these lesions, squamous cell carcinoma of the alveolar mucosa,
that impact on prosthodontic and surgical rehabilitation. First, ameloblastoma, and osseous sarcomas figure prominently. Since
mandibular resections are more posterior, resulting in the loss the resection is usually less radical for ameloblastomas, these
of fewer teeth in dentulous patients and retention of more den­ tumors will be discussed first.
ture-bearing surface in edentulous patients. Facial disfigurement
is not as noticeable, with fewer patients requesting mandibular Ameloblastoma
reconstruction based on cosmetic parameters, particularly if the
defect was closed with a myocutaneous flap. As previously The ameloblastoma is a rare odontogenic tumor that tends
mentioned, speech articulation will be impaired when signifi­ to be locally invasive. It is found 4 times more often in the
cant portions of the tongue are resected or when a portion of the mandible than in the maxilla. Although midline lesions have
tongue is used to close the wound primarily. If the defect is been reported, ameloblastoma of the mandible usually presents
reconstructed with a musculocutaneous flap, tongue mobility as an indolent mass in the third molar area. All ages may be
and control remain near normal limits and articulation remains affected, with the disease being most prevalent during the third
largely unaffected. If the lesion extends superiorly up the ton­ and fourth decades. There is a nearly equal incidence among
sillar pillar, a portion of the soft palate may require resection, males and females160161. The typical radiographic finding in
resulting in velopharyngeal incompetence and hypemasal ameloblastoma is that of a rounded, multilocular radiolucent
speech. Even if a significant portion of the palate is not resected, area (Figure 5-38). A less common unilocular ameloblastoma
often the tongue is sutured to the tonsillar pillar, which prevents exists that is biologically less aggressive. A radiograph is not
appropriate velar elevation. Hypemasality and/or fluid leakage considered diagnostic, and a biopsy is needed to confirm the
indicate(s) the need for prosthetic obturation (Chapter 7). diagnosis.
As described for lateral tongue-floor of mouth resections,
swallowing is impaired in patients with tonsillar area resections
because of poor mobility and control of the residual tongue. In
addition, if velopharyngeal incompetence is present, nasal re­
gurgitation may be evident Aspiration is most severe when the
resection of the tongue crosses the midline. Mandibular devia­
tion is similar to that seen with anterolateral resections. The
severity of mandibular deviation is primarily dependent on the
method of closure. We prefer myocutaneous flaps because man­
dibular deviation is essentially eliminated and the function of
the residual tongue is unaffected. Reconstruction of tonsillar
defects with free flaps offers little advantage. Control of saliva
is not compromised as much as in anterior floor of mouth or
lateral tongue-floor mouth resections, since most vestibular
channels remain intact. Trismus may be severe as well as com­
pounded by postoperative radiation therapy.
The radiation fields employed to treat lesions in the tonsil­ Fig. 5-38. Radiograph demonstrating typical findings in
lar area include both parotids plus significant amounts of the ameloblastoma of the jaw.
body of the mandible, which predisposes to a high incidence of
dental caries and osteoradionecrosis. These radiation fields also
increase the severity of trismus. Increased scarring of the local These tumors are relatively slow growing, but they exhibit
tissue bed and the neck (from radiotherapy) compromises the a marked tendency to destroy the involved bone. Only rarely do
success of mandibular guidance therapy. The difficulties listed they invade into adjacent soft tissues. These tumors are consid­
in the section on lateral-tongue floor of the mouth resections ered locally malignant since distant metastases are rare. When
relative to denture use, and difficulty with oral hygiene proce­ dissemination occurs, the most frequent site of involvement is
dures, apply to these patients as well. the lungs160.

Section on tumors of the alveolar ridge and mandible contributed by Jeffrey W. Bailet and Rinaldo F. Canalis.
154 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
The treatment of mandibular ameloblastoma is by surgical
excision, with a minimum of a 1.0 to 1.5 cm free margin. Curet­
tage is not curative. The recurrence rate after curettage varies
from approximately 50% to 60%162,163to a high of 91 %164. How­
ever, in patients with the unicystic variant, the recurrence rate
following curettage is low, 18%, and, therefore, this treatment
modality is the method of choice in this select group of pa­
tients165. Frequently, the diagnosis of ameloblastoma is uncer­
tain when seen in frozen section. Definitive treatment must be
undertaken after paraffin-embedded sections have been evalu­
ated. For small lesions, a marginal resection of the mandible is
justified. Although some surgeons favor intraoral resections, the
external approach, via a submandibular incision, should be used
in most cases. Surgical reconstruction may be undertaken im­
mediately or, if preferred, 6 weeks after resection.
Squamous Cell Carcinoma
Squamous cell carcinomas of the gingiva and the alveolar
mucosa comprise about 10% of all oral malignancies. They occur
more frequently in the lowerjaw and affect primarily the molar
region (Figure 5-39). These tumors are more common in men
(about 4:1). Cady and Catlin reported that, in 88% of male pa­
tients, the tumor occurred at between 50 and 80 years166. These
tumors arise most commonly in edentulous areas. The presence
of an ulcer and pain are the most common symptoms.
The lesions may be flat, ulcerative, or exophytic and they
tend to spread rapidly. They are usually well differentiated his­
tologically167. The search for a second primary tumor is impor­
tant in these patients, since the incidence of additional intraoral
epidermoid carcinomas has been reported to be between 11%
and 18%166. Mandibular involvement occurs in about 50% of
the cases, and it does not always correlate with radiographic
findings. The tumors tend to expand into the floor of the mouth
and buccal mucosa. Regional metastasis are present initially in
approximately 30% of the patients, and first involve the sub­
mandibular nodes. These lesions are classified according to the
TNM system in the same manner as other oral cancers.
Fig. 5-39. Localized squamous cell carcinoma of the alveo­
lar ridge. (Courtesy: Sol Silverman, Jr.)
The treatment of squamous cell carcinoma of the mandibu­
lar alveolar ridge is predominantly surgical, usually with a mar­
ginal mandibular resection in early lesions and a segmental re­
section for advanced lesions with extensive bony involvement168.
The resection should be performed in conjunction with a radi­
cal neck dissection if regional metastasis are suspected. In ad­
vanced cases, postoperative radiation therapy may be indicated.
For most cases, resections do not require the sacrifice of large
amounts of soft tissue, so repair can be accomplished using lo­
cal tissues or skin grafts (Figure 5-40). With large bony defects,
immediate reconstruction with a fibula free flap is recommended
by some clinicians. Others prefer to reconstruct these large de­
fects as a secondary procedure. The latter permits a better un­
derstanding of the true extent of the disease after surveying per­
manent histologic sections.
The prognosis for squamous cell carcinoma of the gingiva
varies according to the stage of the disease. Overall survival
rates as high as 65% have been reported166168. The expected 2-
year survival for stage I disease is 80% and, for stage n disease,
70%166’168. For stage III and stage IV disease, the 2-year sur­
vival rates are 60% and 50%, respectively168.
Osteosarcoma
Osteosarcoma is the most common primary osseous ma­
lignancy, but the mandible or maxilla is involved only 6% to
7% of the time. The peak age of onset for jaw lesions is be­
tween 25 to 40 years, being 1 to 2 decades later than lesions
involving long bones169. In the mandible, the premolar and molar
regions are the most common sites of involvement, followed
by the symphysis, angle, and ramus. The most common symp­
tom of osteosarcoma of the mandible is a diffuse swelling or a
palpable, sometimes painful mass. Twenty-five percent of indi­
viduals present with dental complaints, such as a pain, loosen­
ing, or separation of the teeth. Paresthesia of the chin or lip due
to involvement of the inferior alveolar nerve is common. The
average duration of symptoms prior to establishing the diagno­
sis is 3 to 4 months.
On radiographic examination, osteosarcoma appears as a
destructive, poorly defined, intraosseous lesion with or without
an adjacent soft tissue mass. They may be lytic, sclerotic, or
mixed. A prominent sun burst appearance is seen in one-fourth
of the cases. The presence of new bone formation within over-
lying soft tissue, in conjunction with non-diagnostic osseous
changes, suggests the possibility of osteosarcoma170.
Surgical resection is the treatment of choice for mandibu­
lar osteosarcoma. A segmental resection of the mandible with
removal of adjacent involved soft tissues is required. The natu­
ral history of osteosarcomas of the jaws is characterized by fre­
quent local recurrence and late metastases, usually pulmonary.
The recurrence rate ranges from 40% to 70%, and recurrence is
typically within 9 months of treatment. Distant metastases may
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
a b
Fig. 5-40. Alveolar resection defects can be repaired with local flaps (a), skin grafts (b), or free flaps (c).
occur within the first 2 years following therapy at a rate varying
from 6% to The overall 5-year survival rate for man­
dibular lesions ranges from 35% to 70%, with an average of
35% to 45%I69-172J73,174. Death is caused by extensive local dis­
ease, or massive dissemination to the lungs.
Disability—Resections Confined to the Mandible
In squamous cell carcinoma confined to the alveolar ridge,
resection of the primary tumor results in only minimal soft tis­
sue loss. Consequently, the resulting disabilities are less severe.
In a simple marginal resection, in which mandibular continuity
is retained, little morbidity results other than obliteration of the
buccal or lingual sulci (Figure 5-40). In discontinuity defects,
the usual deviation of the mandible occurs secondaiy to scar
contracture and muscle imbalances. Tongue function, however,
is rarely affected. In these lesions, the tongue may be used for
closure, but little of the tongue is resected and, consequently,
the hypoglossal nerve on die resected side remains intact. With
normal bulk and unimpaired motor control, the minimal im­
pairment of the mobility of the tongue secondary to surgical
closure is not sufficient to result in significant dysfunctions of
salivary control, speech, or swallowing. Salivary control, if af­
fected, is usually secondary to compromise of the motor and
sensory innervation of the lower lip on the resected side. The
deviation of the mandible is secondary to muscle imbalance
and compromised proprioception, and is easily resolved with
mandibular guidance therapy. Few of these lesions are treated
with radiation therapy, so scarring is less severe.
Benign tumors requiring primarily bony resection likewise
result in little soft tissue loss, and have a similar favorable prog­
nosis for rehabilitation. In this instance, the disability is almost
entirely related to the amount of mandible resected. Mandibu­
lar guidance therapy is very effective in discontinuity defects,
and the prognosis for bony reconstruction, with either free grafts
or free flaps, is excellent. In patients with benign odontogenic
tumors, immediate surgical reconstruction with a free graft is
usually indicated.
* Section on free grafts contributed by Earl Freymiller.
155
c
Surgical Reconstruction
Free Grafts*
Reconstruction of the mandible is a complex and challeng­
ing endeavor. The primary goals are to restore facial form and
mandibular continuity. Recent advances have improved the
surgeon’s ability to achieve these goals, and the use of
osseointegrated implants provide anchorage for dental prosthe­
ses. It has been shown that grafted bone successfully osseo-
integrates with endosseus implants17S,n6,IT7,178,179. Not only should
mandibular continuity be restored but, in addition, appropriate
volume and quality of bone should be provided for the place­
ment osseointegrated implants.
Free flaps have revolutionized the reconstruction of tongue-
mandible defects. However, mandibular reconstruction with free
bone grafts yield excellent results and, in some instances, offer
several advantages over microvascular grafts. Free grafts re­
quire less extensive surgeiy, the procedures are less technique-
sensitive, and the procedures do not rely on specialized equip­
ment or instrumentation. Finally, a free bone graft can be better
shaped to meet the final geometric goals more easily because
maintaining the periosteal blood supply and the viability of the
bone graft is not a consideration. In patients who have a well
vascularized soft tissue recipient bed, a free bone graft is a pre­
dictable reconstructive option.
Advances in medical imaging techniques permit many pa­
tients to be reconstructed immediately. The final reconstructive
result is improved because scarring and tissue contraction will
not adversely affect the recipient graft site. In the past, recon­
structive procedures were delayed to allow clinical monitoring
of the tumor resection site. With the advent of computerized
tomography and magnetic resonance imaging, recurrent disease
can be detected within the grafted tissues. In addition, most tu­
mor recurrences occur on tissue surfaces and are rarely masked
by the reconstruction.
156 MAXILLOFACIALREHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Goals of Mandibular Reconstruction
The main goals of mandibular reconstruction are the resto­
ration of form and the restoration of function. The mandible
maintains facial contours through support of the overlying soft
tissues. The shape, size, and position of the final grafted man­
dible are crucial factors in maximizing esthetics. The grafted
bone must be positioned as nearly as possible in the identical
position as was the original native mandible. The most impor­
tant anatomic consideration is the position of the graft along the
lower border of the mandibular body and symphysis region,
since the soft tissue drape over the lower border contributes
significantly to facial form. In addition, if bony support is prop­
erly positioned and contoured, prosthetic rehabilitation of the
alveolus and teeth will be easier, with more accurate support of
the cheeks and lips to further improve esthetics.
If a free bone graft is considered, extraoral and intraoral
soft tissue defects must be addressed first in order to provide a
vascularized tissue bed for the future bone graft. This can be
accomplished with pedicled myocutaneous flaps. In the absence
of significant soft tissue defects, the accurate repositioning of
the overlying muscle, fascia, and connective tissue layers, fol­
lowing a tumor resection, will facilitate reconstructive proce­
dures.
Proper positioning of the mandibular bone graft is essen­
tial for a good, functional result. Both the grafted bone and the
remaining native mandibular segments must be in the proper 3-
dimensional location. This will insure accurate intercuspation
and occlusion of remaining teeth, and establish the necessary
relationships required for future prosthetic reconstruction. This
will also result in correct positioning of the condyles within the
glenoid fossae, enabling normal temporomandibular joint func­
tion.
Prior to dental implants, the primary goal was the restora­
tion of bony continuity. The introduction of reliable and pre­
dictable dental implants has affected the way that mandibular
bone graft reconstruction is planned and executed. The grafted
bone must be accurately positioned if implants are to be placed
in their proper locations. Otherwise, a functional prosthesis may
be compromised or even impossible.
The reconstructive surgeon must also consider the final
volume and quality of the grafted bone. This will affect the choice
of donor sites for both vascularized and non-vascularized man­
dibular bone grafts. For example, if a significant amount of bone
is required for reconstruction, the posterior iliac crest, instead
of the anterior iliac crest, should be used, as the posterior iliac
crest yields a greater quantity of bone.
Dental implants have also changed the way that the recon­
structive surgeon approaches the intraoral soft tissues. The health
of the peri-implant soft tissues is more easily maintained if these
tissues are keratinized and attached to the periosteum. There­
fore, both the reconstructive surgeon and prosthodontist must
be aware of the potential and limitations of mandibular recon­
struction, and must cooperate to achieve the best possible re­
sults for patients requiring mandibular resection and reconstruc­
tion.
The Biology of Bone Grafting
The biology of bone regeneration after free autogenous
grafting is quite complex, but the concept is relatively straight­
forward. If autogenous bone is harvested and placed into a dis­
tant recipient bony defect which is surrounded by a vascular­
ized soft tissue bed, new living bone will form to bridge the
defect. The bone cells come from the adjacent native bone
(osteoconduction), are induced from pluripotential cells located
in the surrounding soft tissue (osteoinduction), or come from
the few donor cells that survive the transplant. Probably all of
the processes play a role, but the predominant factors may de­
pend on the type of bone transplanted (i.e., cortical versus packed
cancellous bone).
The 2-phase theory of osteogenesis proposed that some
bone cells survive transplantation and form the initial osteoid in
a random pattern during the first phase180. This is followed by
the second phase in which the osteoid is resorbed and replaced
by bone derived from cells in the recipient bed. Therefore, the
initial cellular concentration of the bone graft is very important,
since the higher the transplanted cell density, the greater the
number of cells which will survive to lay-down bone during
phase 1. For this reason, cancellous or marrow bone graft has a
greater osteogenic potential.
When cortical bone is grafted, fewer cells are transplanted,
so fewer cells survive. The final living bone is probably the
result of resorption of the graft by osteoclasts from the adjacent
native bone, followed by new bone deposition by osteoblasts
from the adjacent viable bone. This is the concept of
osteoconduction, or creeping substitution, which was initially
described by Phemister181.
The concept of osteoinduction implies that some factor in
the grafted bone induces mesenchymal cells in the surrounding
soft tissue bed to transform into osteoblasts. This process is well
documented, showing the proteins responsible for the induc­
tion are found in the organic, demineralized bone. These pro­
teins have been termed bone morphogeneticproteins by Urist182.
For the reader interested in a more detailed review of the biol­
ogy of bone grafting, an excellent overview has been published
by Ellis183.
Source of Bone for Grafting
Although bone substitutes or synthetic bone grafting ma­
terials have been used, the most common grafts used for man­
dibular reconstruction are autogenous bone harvested from the
same individual. Sources for bone include the outer table of the
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 157

cranium, rib, and iliac crest Of these, the iliac crest is the most
common. Advantages include the overall amount of either can­
cellous or cortical bone that can be obtained, and the relative
safety and minimal morbidity of the procedure. Calvarial bone
is used for onlay grafting and orbital reconstruction when smaller
amounts of purely cortical bone are needed. Rib bone under­
goes a greater amount of resorption than the other 2 sources,
and is used when a cartilaginous cap, covering the cut end of
the bone, is desired, such as in reconstruction of the mandibular
condyle.
Either the anterior or posterior ilium can be used, and each
has its advantages and disadvantages. The primary advantage
of the posterior iliac crest is the greater amount of bone that is
available. Morbidity, with respect to gait disturbances, pain, and
blood loss, is minimal184. The primary disadvantage is the need
to have the patient in the prone position in order to harvest the
bone and in the supine position for the resection and recon­
struction of the mandible. This necessitates turning the anesthe­
tized patient in the middle of the operation. The advantage of
the anterior ilium is its convenient location when working on
the mandible. However, the anterior ilium does not possess suf­
ficient quantities of bone required to reconstruct large defects.
For more detailed description of the types of available bone
grafts, the reader is referred to Ferraro and August185. The surgi­
cal techniques involved in procurement of the various autog­
enous bone grafts is beyond the scope of this text, but this infor­
mation can be found in a technical article by Marx'86.
and native bone during healing of the bone graft. The recon­
struction plates offer sufficient rigidity to prevent mobility.
However, other forms of fixation, such as miniplates and wire,
do not provide the necessary stability, so intermaxillary fixa­
tion with arch bars or external pin fixation devices are needed.
When the reconstructive surgeon opts for bony reconstruc­
tion of a mandibular defect with a compressed cancellous-mar-
row graft, some type of confoimer, such as a tray, is necessaiy
to provide both contour and rigidity for the harvested amor­
phous cancellous bone and marrow. Prefabricated titanium re­
construction trays of various sizes are available. These are fixed
to the remaining mandibular segments with multiple small bone
screws (Figure 5-42). Others advocate the use of cadaveric bone
(from a bone bank) to hold the harvested autogenous bone. Trays
can be fabricated from cadaveric mandibles, or cadaveric ribs
can be bent, shaped, and adapted to hold the compressed, au­
togenous bone graft187. Some surgeons prefer the use of Dacron-
urethane trays to hold the bone graft130-188.
Several important principles must be followed regardless
of the type of bone or fixation chosen by the surgeon: The bone
graft must be surrounded by a well vascularized soft tissue bed.
The graft must be isolated from the oral cavity. The bone graft

Techniques of Free Bone Graft Reconstruction

The technique used for free bone graft reconstruction of

the resected mandible depends on the type of bone selected by
the surgeon for the reconstruction. If the surgeon chooses an
autogenous block graft, as opposed to a compressed cancellous
or marrow graft, the graft is shaped and adapted to span the
bony mandibular defect, approximating, as closely as possible,
the position of the original resected mandible (Figure 5-41).
This may involve using several large blocks of bone for large
defects, or several smaller blocks for defects where the man­
dible curves rapidly, such as for the mandibular symphysis. The
block grafts are usually fixed to the adjacent native bone with
several small plates, screws, or wires. Alternatively, a large re­
construction plate can be adapted to span the entire defect with
the block graft secured with screws to the medial aspect of the
plate. If the reconstruction is being performed as a delayed pro­
cedure after the initial resection, the reconstruction plate can be
placed at the time of the tumor resection, and used to maintain
the positions of the 2 segments of the mandible during the inter­
val between resection and reconstruction. During the subsequent
reconstructive procedure, the block bone graft is harvested and b
placed behind the reconstruction plate without the need to re­ Fig. 5-41. a: Iliac crest block graft was shaped to restore
move it. It is crucial that there is no mobility between the grafted this (b) small, lateral mandibular defect.
158 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
must be immobilized during the healing phase. If there is insuf­
ficient soft tissue available to cover the graft, as a result of the
surgical resection, then soft tissues must be augmented, with
either a myocutaneous flap or free flap, before free bone graft­
ing. And, if there is sufficient soft tissue coverage for the graft,
but with limited vascularity (as is commonly seen after man­
dibular resection for osteoradionecrosis), hyperbaric oxygen may
be considered prior to ftee bone grafting.
Fig. 5-42. Titanium tray was used to confine a compressed
cancellous-marrow graft. (Courtesy: Dr. Bruce
Sanders.)
Immediate versus Delayed Reconstruction—Timing of
Implant Placement
There is no unanimity of opinion concerning the timing of
the multiple surgical procedures that must be performed to re­
construct the patient who is scheduled to undergo mandibular
resection. Several questions arise: Should the bony reconstruc­
tion be performed at the time of the resection, or should it be
delayed? Should dental implants be placed into the bone graft
at the time of reconstruction, or should they be delayed? and If
the implants are delayed, how much time should pass prior to
the placement of the implants? The answers to these and other
questions must be addressed by the surgical and prosthodontic
team.
Advocates of delayed bony reconstruction with free bone
grafts argue that the increased risk of infection and loss of the
graft due to the oral communication that occurs at the time of
resection, coupled with the risk of recurrence of the tumor and
thus the need for further resection, radiation, or chemotherapy,
also with possible loss of the graft, outweigh the benefits of
immediate reconstruction. A study by Manchester demonstrated
a greater than 40% infection rate in grafts that communicate
with the oral cavity189. Lawson reported that immediate bone
grafting was only about half as successful as delayed grafts,
primarily because of infection190. If delayed reconstruction is
planned, the residual, native bone segments should be main­
tained in proper anatomic location by use of a reconstruction
plate.
Proponents of immediate reconstruction feel that, if suffi­
cient tissue remains after the resection to allow for a tight, me­
ticulous, multilayer oral closure that is not under tension, the
risk of infection is greatly decreased. These surgeons claim that
immediate reconstruction will give a superior cosmetic result
because scar contracture is limited or prevented. Furthermore,
the more vascular, non-scarred soft tissue bed will be a better
recipient site for a bone graft The psychological benefits, with
respect to appearance and self esteem, and the combined psy­
chological and medical benefits of eliminating a second major
operation are arguments used by those in favor of immediate
reconstruction.
Should dental implants be placed into free bone grafts at
the time of mandibular reconstruction? Although this has been
successfully performed191 from a purely biological standpoint,
it is likely that dental implants would have a greater probability
of becoming osseointegrated when placed into viable bone, as
opposed to a non-vascularized bone graft.
We prefer to delay implant placement for 6 to 12 months to
allow the graft to become vascularized and viable. During this
period, a temporary dental prosthesis can be fabricated that is
designed entirely for cosmetic purposes and lip support. If such
a prosthesis is used, the soft tissues overlying the bone graft
must be monitored closely in order to minimize the chance of
soft tissue perforation and graft exposure. Prior to implant place­
ment, a surgical template is fabricated by a prosthodontist to
ensure that the implants are positioned properly. If removal of a
reconstruction plate or tray is desired, this can be performed
during the implant surgery. Debulking excessive soft tissues
overlying the graft can be performed at this time. Consideration
may also be given to repositioning the buccal mucosa and floor
of the mouth into more ideal locations. Final debulking and
thinning of the tissues overlying the implants can be accom­
plished at the second-stage implant uncovering procedure.
The decision regarding removal of the reconstruction plate
or tray is controversial. Some feel that there is no need to re­
move hardware unless it presents a problem. Others feel that
the large reconstruction plates are so rigid that they shield the
underlying bone graft from the normal physiological forces that
act to maintain it resulting in disuse atrophy of the bone. This
concept is known as stress shielding. Some surgeons who use
compressed cancellous bone grafts in titanium trays also elec-
tively remove the trays after the grafts have consolidated. These
trays are not nearly as rigid as the reconstruction plates, and
some flexion of the tray can occur. Some patients will require
removal of a reconstruction plate because it may limit the buc­
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 159

cal flange of the prosthesis, or prevent the placement of im­ Reconstruction of the Mandibular Body
plants in their proper position. During chewing, especially in
patients reconstructed with dental implants, the mandible flexes Surgical resection of a carcinoma of the lateral tongue, if
slightly due to the increase in bite force. Although these natural extensive, may require resection of a portion of the body of the
forces are probably beneficial for maturation of the bone graft, mandible. The anatomic shape of the mandible in this region
the constant flexion and extension of the tray can weaken the makes it one of the easier areas to reconstruct with free bone
metal, leading to eventual fatigue fracture. grafts, due to the relatively straight contour of the mandible
between the angle and the canine. A reconstruction plate or tray
Complications Associated with Free Bone Grafting can be used to stabilize the bone graft. As with all mandibular
resection and reconstruction, appropriate care must be taken to
In the immediate post-grafting period, wound infection is insure that the remaining native mandibular segments maintain
the most worrisome complication, as it may lead to loss of the their original positions for the best cosmetic and functional re­
entire bone graft. Even after the patient has apparently recov­ sults.
ered from the surgical procedure, close attention should con­ The grafted bone is placed at the position of the original
tinue as late infection can occur. If there is any concern on the inferior border of the mandible to enhance esthetics (Figure 5-
part of the prosthodontist, immediate contact should be made 43). The posterior teeth lie somewhat lingual to the lower bor­
with the surgeon, as early intervention is crucial. If infection der of the mandible; this concept is important in mandibular
occurs, appropriate antibiotics and drainage of any fluid must
be performed early, along with meticulous irrigation and wound
care, in an attempt to prevent loss of the graft.
Soft tissue dehiscence is another concern, especially for
patients wearing tissue-borne prostheses over the grafted area.
Wound dehiscence can introduce oral bacteria into the grafted Fig. 5-43.
site, resulting in infection. If a prosthesis is to be worn early, the a: Free ilia c crest
underlying soft tissues must be monitored. Frequently, the area block graft used to
may be insensate, and initial areas of soft tissue breakdown may restore lateral man­
go unnoticed by the patient. The prosthodontist and surgeon dibular defect. Pa­
must follow the patient closely, and adjust or remove the pros­ tie n t lost mandible
thesis if problems develop. secondary to osteo­
Fracture of the graft is always a concern, but is a relatively ra d ionecrosis and
rare complication. Graft fracture is usually the result of an inad­ received a course of
equate quantity and quality of the initial bone graft, although hyperbaric oxygen
even the most robust graft will fracture under sufficient force. before grafting, b:
As with other mandibular fractures, reduction and fixation, with Note some resorp­
immobilization of the fracture segments, is required. tio n o f g ra ft, c:
Exposure of a titanium tray, used in combination with the Osseointegrated im­
free bone graft during the immediate postsurgical period, can plants were placed 9
lead to loss of the graft. Conservative management (irrigation, months after bone
antibiotics, and so forth) should be attempted for up to 8 weeks g ra ftin g , d and e:
in the hope that osteogenesis will occur. The tray can then be Completed implant-
removed, leaving the grafted bone. This therapy is indicated for retained prosthesis.
both oral and extraoral exposures. External fixation devices may
be required for a period following removal of the tray to pro­
vide stability for the graft. The delay in removal of the tray
allows the graft to mature. Early removal may disrupt osteo­
genesis, and non union or loss of the graft may result.
Complications associated with the bone graft donor site
can occur. A complete discussion of these complications is be­
yond the scope of this text, but the interested reader is referred
to an article by Dodson and Kaban192.
160 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

reconstruction, especially when dental implants are being con­
sidered. For this reason, the grafted bone should be positioned
with the superior aspect tipped somewhat lingually. Otherwise,
dental implants placed in the most posterior aspects will not
only exit the bone on the lingual aspect of the mandible, but
will also require a very significant lingual inclination to prevent
a posterior crossbite, and occlusal forces will not be directed
along the long axis of the implants.
Reconstruction of the symphysis region
The symphysis region is more difficult to reconstruct than
the mandibular body, due to the abrupt curvature of the bone in
this area. If ample amounts of well vascularized soft tissue are
available, compacted cancellous bone graft can easily be packed
and molded around the curve of the symphysis with the aid of a
crib (Figure 5-44).
The bilateral native mandibular segments should be main­
tained in their original location. If interdental fixation is em­
ployed for this purpose, care must be taken to confirm the man­
dibular segments do not rotate buccally. Since the wires used to
keep the mandibular teeth in correct occlusion with the maxil­
lary teeth are on the buccal aspect of the teeth, the direction and
location of these forces have a natural tendency to rotate the
mandibular segments buccally. This problem can easily be
avoided with the aid of a cast metal splint. This splint, fabri­
cated from casts made prior to the resection, provides sufficient
rigidity to prevent this problem, since it maintains stability dur­
ing the healing of the bone graft (Figure 5-45). Denture teeth
may be added to the splint for the purpose of esthetics.
As with the mandibular body reconstruction, the bone graft
for the symphyseal reconstruction should be placed in the same
position as the original mandible and chin for the best esthetic
result. Since the normal bony chin always lies anterior to the

Fig. 5-44. Anterior symphysis defect restored with titanium tray and compacted cancellous-marrow graft, a: Soft tissues were
reconstructed at time of tum or resection with pectoralis major myocutaneous flap, b: Mandibular fragments ex­
posed. c: Titanium tray used to restore symphysis region, d: Cancellous-marrow graft being compacted into tray, e:
Postsurgical facial contours.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 161

with reconstruction if only the posterior border of the ramus

and angle are restored.
If the resection is so extensive as to include the condyle, a
costochondral rib graft is indicated. After a rib graft is placed,
joint mobility must be initiated early. However, if a compressed
cancellous bone graft is also needed to reconstruct the ramus
and angle regions, this part of the graft should be relatively im­
mobile during healing. This conflict can be resolved by staging
the reconstruction. During the first reconstructive procedure, a
titanium tray packed with compressed cancellous bone can be
used to reconstruct the posterior border of the mandibular ra­
mus and angle. The titanium tray can be fitted with a titanium
condyle placed into the glenoid fossa. This artificial condyle
will function within the fossa and maintain a space for a future
costochondral rib graft. A second procedure is performed 6 to
12 months later to remove the original metal tray and condyle,
and to secure a costochondral rib graft to the posterior aspect of
the now solid ramus bone graft. The cartilaginous cap of the rib
is shaped and positioned to fit into the fossa. Physical therapy
can now be instituted.

Reconstruction of Mandible-Tongue Defects with Free Flaps*

A major advance in mandibular reconstruction has been

b surfaces) can now be autogenously grafted and remain viable.
Fig. 5-45. a and b: Cast lingual splint designed to stabilize
mandible and prevent buccal rotation of residual
segments.
mandibular incisors, implants in this region can have a signifi­
cant lingual inclination unless this aspect is addressed at the
time of bone graft reconstruction. Increasing the width of the
grafted bone in the symphyseal region will solve this potential
problem.
Every effort should be made to attach the genioglossus and
suprahyoid musculature to the reconstruction tray in order to
maintain tongue position and hyoid suspension. Both are im­
portant factors in maintaining the airway. This will also im­
prove neck esthetics and swallowing.
Reconstruction of the Ramus-Body Region
The angle and ramus of the mandible is often resected dur­
ing treatment of a tonsillar carcinoma. If the native condyle can
be spared, jaw mobility will be enhanced following the grafting
procedure. Although the natural mandibular ramus is flat and
wide, excellent cosmetic and functional results can be obtained
* Section of reconstruction of mandible-tongue defects with free flaps contributed by Bernard Markowitz and Thomas Calcaterra.
the development of improved techniques in microvascular sur­
gery which allow for composite grafting of larger volumes of
tissue. In microvascular free tissue transfer (free flaps), bone,
muscle, connective tissue, and skin (or other epithelial lined
This has greatly improved reconstructive outcomes since the
grafted tissues are no longer limited to the anatomic constraints
of adjacent pedicled flaps. Previously, bone grafting procedures
were staged to follow soft tissue reconstruction by pedicled flaps.
Now, simultaneous grafting of hard tissue, soft tissue, and skin
can be accomplished. Reconstruction with traditional free bone
grafts requires a well vascularized soft tissue recipient bed. This
was a limiting factor when significant soft tissue defects ex­
isted, or when vascularity was compromised by radiation
therapy.
The application of microvascular surgical techniques, rigid
internal stabilization, and better definition and use of compos­
ite osseous donor sites has greatly facilitated the reconstruction
of these complex head and neck defects. The advantages of
immediate reconstruction using well-vascularized osseous and
soft tissue are well documented. Predictable healing, even in
the face of radiated tissue and oral contamination, allows for
the early return of form and function, which greatly enhances
quality of life.
Prior to embarking on major reconstructive surgery, nu­
merous variables, including patient age, tumor stage, and physi­
cal and psychological statuses, must be carefully evaluated.
Although most patients undergoing composite resections are
162 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

elderly with compromised health, the majority are candidates
for free flap reconstruction. Patients with good prognoses and
life expectancies are aggressively reconstructed with the goal
being complete oral and facial rehabilitation (i.e., articulate
speech, the ability to chew and swallow solid foods, and con­
trol of saliva). Their reconstruction employs a composite os­
seous flap and, at a later stage, prosthetic rehabilitation. Pa­
tients who are elderly, and those with poorer prognoses, are
usually managed with mandibular reconstruction plates cov­
ered by soft tissue free flaps.
Donor Sites
Numerous free flaps have been described for-the recon­
struction of composite mandibular defects. Although the au­
thors favor those that will be described, the iliac crest, dorsalis
pedis or second metatarsal, lateral arm, ulnar artery, and other
free tissue transfers have been successfully used in other cen­
ters.
The surgical reconstruction is planned with the aid of ra­
diographic studies and the fabrication of a surgical stent. A lat­
eral cephalogram and full scale axial CT of the mandible is
obtained from which templates are made. These templates, along
with the resected specimen, guide the intraoperative contour­
ing of the osseous portion of the free flap. A surgical stent is
used to properly position residual mandibular fragments and
correctly align the graft segment (Figure 5-46)193’194. Following
surgical resection, the stent is placed on the maxillary arch, and
the residual mandibular segments are keyed into the stent. When
the remaining mandibular segments are dentate, the remaining
dentition is keyed to the occlusal index of the stent (Figure 5-46
c,d). When the patient is edentulous, residual mandibular seg­

c d
Fig. 5-46. Surgical templates help surgeon properly position residual fragments and correctly align graft segment, a and b:
Surgical template. Note maxillary and mandibular occlusal indices, c: Lateral composite resection defect. Prior to
resection, template was positioned, mandible placed in centric occlusion, THORP -type plate adapted, and screw
holes placed, d: THORP plate secured. Free flap has been inset. Note presence of template. Preoperative
maxillomandibular relationships have been maintained.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
tibeai artery
Intermuscular septum
Posterior tibeai artery
Peroneal artery
Medullary artery
Fig. 5-47. a: Principle blood supply to fibula is peroneal artery. Segmental periosteal vessels circle fibula along its length, b:
Fibula osteocutaneous flap-vasculature of lateral leg. Note perforating septocutaneous vessels. Skin island is cen­
tered over these vessels. (Redrawn from: Swartz W, Janis J. Head and Neck Microsurgery. Baltimore, 1992; Will­
iams and Wilkins.)
ments engage the tissue surfaces of the stent, and are manually
stabilized until the osseous portion of the flap is properly sized,
contoured, and connected. After the osseous reconstruction is
complete, the mandible is opened and closed with the stent in
position to verify arch alignment and position.
Fibula The composite fibula flap is nourished by the peroneal
vessels (Figure 5-47). The flap may be transferred with bone
alone, or with skin and muscle (Figures 5-48 and 5-49). The
composite flap may include up to 25 cm of bone, over 250 cm2
of lateral leg skin surface, a portion of the soleus muscle, and
the entire flexor hallicus longus muscle.
The bone’s length and extensive periosteal blood supply
allows for the reconstruction of the entire mandible195. Multiple
osteotomies may be performed, without devascularizing the bone
segments, to replicate the contour of the resected mandible. At
least 8 cm of bone is left distally in order to maintain ankle
stability. The fibula’s cortical nature and thickness make it an
excellent recipient of osseointegrated implants (Figure 5-50),
and the success rates appear to be quite good (Table 5-14)196.
The ipsilateral leg to the side of the resection is preferred. When
the recipient vessels on the side of the defect are not available,
the contralateral leg is used, and the pedicle is lengthened by
using the distal bone.
The skin island is based on septocutaneous perforators,
emanating through the posterior crural septum from the pero­
neal vasculature. The cutaneous portion of the flap may be used
for intraoral, external, and combined defects. The flexor hallicus
longus muscle is routinely harvested with the flap. Its position
along the inferior border of the bone make it an ideal substitute
for the submental and submandibular soft tissues, and it acts as
a partition between the oral cavity and neck.
163
Extensor hallucis muscle
Septocutaneous perforating
artery and vein
Trans-soleus perforator
artery and vein
The composite fibula flap is the preferred donor site for
most complex orofaciomandibular defects. For defects of the
lateral mandible which do not involve a significant amount of
oral mucosa, the osseous flap may suffice, but the osteocutaneous
flap is preferred. The addition of a skin island allows for an
absolute tension-free intraoral closure which enhances tongue
mobility. It also permits monitoring of the otherwise buried flap
more effectively. The donor site may be closed directly when
less than 4-5 cm of skin are included with bone.
The fibula osteomyocutaneous flap is also recommended
for lateral and symphyseal composite defects which include
substantial amounts of intraoral mucosa, tongue, and external
skin (Figure 5-51). As the mucosal defect enlarges, skin require­
ments grow exponentially. Skin islands 10-12 cm wide are avail­
able for the more extensive defects. A skin graft is necessary to
close the donor site.
Radial forearm The radial forearm fasciocutaneous flap is
supplied by the radial artery, its venae comitantes, and superfi­
cial veins (Figure 5-52). The flap may be harvested with or with­
out bone, and may include both tendon and muscle. The com­
posite flap may include 10-12 cm of bone, the entire skin of the
volar or radial forearm, the palmaris longus tendon, and parts
of the flexor radialis and flexor pollicis longus muscles. The
medial and lateral cutaneous nerves may be included to make it
a sensate flap.
Approximately one-third of the radius’ circumference (ra­
dial aspect) is harvested as a mono-cortical graft. Several radial
artery perforators traverse the flexor pollicis longus muscle to
supply the bone’s periosteum, which maintains the graft’s vi­
ability. A single osteotomy is all that is advised. The bone can
164 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

g h
Fig. 5-48.
a: Fibula osteomyocutaneous free flap outlined. Note skin island and course of peroneal artery, b: Flap perfused in situ,
osteotomies performed in situ with flap vascularized, and osteotomies stabilized with miniplates and screws. Note septocutaneous
perforators, c: Template prepared for use. d: Composite anterior resection defect. Posterior mandibular fragments have been
positioned in template, e: Fibula flap inset. Skin island rotated over superior aspect of bone component for intraoral closure.
Flexor hallucis muscle used to replace resected submental musculature and separate oral cavity from neck, where microvas­
cular anastomosis has been performed (arrow), f: Same patient 6 months after surgery. Note plane of reconstructed mandible is
parallel to occlusal plane, and residual mandibular fragments are in excellent position, g: Complete dentures, h: Esthetic result.

IP 8 ||lip s T Fig. 5-50.

Fig. 5-49.
Cadaver specimen from a pa­ Its size and thick cortical plate make
tient whose entire mandibular fib u la id e a l fo r p la c e m e n t of
body had been reconstructed osseointegrated im plants (Cour­
with a fibula free flap. Note tesy: Betsy Davis). Shape and cal­
how fibula has remodeled and cification pattern of scapula is less
now resem bles a mandible favorable.
(Courtesy: John Lorant).
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 165

Table 5-14. Implants In Fibula Flaps *

# Im plants # Im plants
Uncovered In F unction # B uried # Removed #Failed

54 46 2 2 I iSSPI

* Source: Roumanas E, Markowitz B, Lorant J, et al. Reconstructed mandible defects: fibula free flaps and
osseointegrated implants. Plastic and Reconst Surg. (In publication, 1996.)

Fig. 5-51 . a: Patient with lateral-anterior mandibular defect restored with fibula flap, b: Osseointegrated implants were placed
6 months later, c and d: An overlay, implant-supported prostheses was fitted to a milled bar. e: Final prosthesis in
position, f: Esthetic result-lip asymmetry secondary to resection of marginal mandibular nerve.

Fig. 5-52.
a: Radial forearm flap, planned for
reconstruction of subtotal tongue
defect. Note flap based on radial
artery, venae com itantes, and
cephalic vein, b: Flap elevated in
situ, c: Six-month follow-up. Note
contours of reconstructed tongue.
Swallowing was near normal and
speech was excellent.
166 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
be folded on itself to increase its thickness. It is not well suited
for osseointegrated implants.
The skin island is centered between the radial artery and
cephalic vein (when present), and, when necessary, with a volar
ulnar extension. If the cephalic vein is not available, the flap is
moved ulnarly and a superficial volar vein, as well as the venae
comitantes, are used for venous outflow. The cutaneous paddle
is nourished by perforators traversing the lateral intermuscular
septum. The fasciocutaneous component of the flap is thinner
distally, and the perforators are more numerous.
The radial forearm skin island is an ideal substitute for in­
traoral lining, and can also be used for external as well as com­
bined defects (Figure 5-53). The non-dominant upper extrem­
ity is the preferred site for flap harvest. The fasciocutaneous
flap, with a mandibular reconstruction plate, is preferred for the
reconstruction of composite posterolateral defects in patients
with advanced disease and finite life expectancies (Figure 5-
54). The composite flap is used (more sparingly) for straight
segmental bone defects that include buccal mucosa and/or the
floor of the mouth197. To reiterate, the major advantage and dis­
advantage of this donor site is the thinness of the tissue. It is an
excellent substitute for intraoral lining, but it does not have suf­
ficient volume for the more extensive composite resections, hi
addition, the bone is not of sufficient thickness for implants.
Fig. 5-53. a: Lower lip reconstructed with radial forearm flap.
b: Final result after flap revision. (Courtesy: John
Lorant).
Scapula The composite scapula, or parascapular flap, is nour­
ished by the circumflex scapular artery, through its terminal
deep branch, transverse and descending cutaneous branches,
and venae comitantes (Figure 5-55). Approximately 12-14 cm
of lateral scapula bone, 400 cm2 of the back skin, the latissimus
dorsi, and serratus anterior muscles may be included in the flap.
The thoracodorsal vessels must be included when the latissi­
mus or serratus muscles are used.
The lateral border of the scapula is dependent on the termi­
nal intramuscular (deep) branch of the circumflex scapular ar­
tery for its periosteal blood supply. The bone’s robust blood
supply allows for multiple osteotomies, but its dimensions limit
its use in extensive mandibular defects. Its contours, thin corti­
ces, and calcification pattern make it a poor recipient of
osseointegrated implants (Figure 5-55d). The cutaneous por­
tion of the flap may be directed in any plane, but is usually
planned horizontally or oblique. The axial transverse and de­
scending cutaneous branches run in the subcutaneous tissues to
supply their respective territories.
The vascular anatomy of this composite flap make it ex­
tremely versatile, as its component parts have a good degree of
3-dimensional independence. The skin island is particularly well
suited for composite defects involving large portions of the
tongue and through and through resections (Figure 5-56). Huge
craniofacial defects may be reconstructed w ith the
fasciocutaneous, or muscle, flap. Its major drawback is that flap
harvest must usually be performed after the resection is com­
pleted. This adds significant time to an already lengthy and ar­
duous procedure.
b
Fig. 5-54. Intraoral defect reconstructed with radial forearm
flap, b: Mandibular continuity in such patients is
often restored with reconstruction plate.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 167

Branches of the Circumflex Scapular Artery

Teres minor muscle

Circumflex scapular arteiy

Vessels to bone

Teres major muscle

CjroumBex scapular artery

Vessels to bone

F ig . 5-55. a: Diagrammatic representation of scapular flap-design of skin island, b: Illustration of dissection of osteocutaneous
flap, c: Flap retrieved and ready to be secured, d: Hemimandibulectomy-hemiglossectomy defect reconstructed
with scapula flap. Speech and swallowing were within normal limits.

F ig . 5-56.
Size, shape, and calcification pattern of scapula
make it a poor site for osseointegrated implants.
168 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Rectus abdominis The deep inferior epigastric vessels supply
the rectus abdominis myocutaneous flap. The skin island is usu­
ally centered around the periumbilical region, as the
myocutaneous perforators which supply the cutaneous portion
of the flap are most numerous there. The flap is commonly ori­
ented vertically, but horizontal and oblique extensions are fre­
quently added. The flap is usually used in conjunction with a
mandibular reconstruction plate for large composite through and
through defects.
Complications
Tongue release, for patients with base of the tongue resections,
offers minimal improvement to patients with discontinuity de­
fects, and is difficult to perform surgically.
Free epithelial grafts have been used as a means of pre­
venting relapse in mandibular vestibuloplasty by providing
immediate epithelial coverage of the deepened sulcus (Figure
5-57). Use of free grafts of palatal or buccal mucosa for vesti­
bular extension is less common, particularly in oncologic de­
fects, because the amount of graft material available may not be
sufficient to resurface the newly created vestibular surfaces.

Complications of these major reconstructive procedures are

divided into those related to the systemic manifestations of the
surgery and those which occur at the recipient and donor sites.
In this patient population, the cardiovascular, respiratory, and
cerebrovascular systems are at greatest risk. The problems seen
at the surgical sites are related to infection, bleeding, vessel
thrombosis, and wound healing. It is rather remarkable that these
long operative procedures, in radiated, orally contaminated en­
vironments, are so well tolerated.
In our series, the systemic complications that occurred most
commonly were atelectasis and pneumonia, affecting 30% of
all patients. Aggressive pulmonary toilet, respiratory support,
and systemic antibiotics are therapeutic. Cellulitis of the recipi­
ent site, usually due to pseudomonas, occurred in 25% of the a
patients, with 1 patient developing an orocutaneous fistula. The
infections were successfully treated with systemic antibiotics,
and the fistula closed spontaneously. Flap survival in most se­
ries exceeds 90%. In our series, flap survival has been 100%.
There was 1 late venous thrombosis without flap loss. Donor
site problems were most frequently due to delayed wound heal­
ing (15%), particularly when skin graft closure was necessary.

Vestibuloplasty and Tongue Release

Vestibuloplasty and tongue release are of value when man­

dibular continuity has been maintained or restored198. The cre­
ation of vestibules enables the patient to pool salivary secre­
tions more efficiently and allows for extension of denture flanges.
Creation of attached mucosa on the ridge surface, with either a
skin or palatal graft, enhances stability, support, and retention
of a prosthesis. Esthetics may also be improved, since a
prosthodontic restoration now can be molded to provide con­
tour and support for the lower lip and cheek. Improvement of
speech is less noticeable, except in the case of anterior soft tis­
sue defects (Figure 5-57). In these patients, usually the motor
and sensory innervations of the tongue are intact, and the tongue
dysfunctions are referable to tongue immobility.
Tongue release and vestibuloplasty may aid selected pa­
tients with unrestored mandibular discontinuity defects. The
primary benefit is improved control of salivary secretions.
Fig. 5-57. a: In this patient, one-half of the tongue was
resected because of epidermoid carcinoma. Man­
dibular continuity was maintained. A tongue re­
lease and vestibuloplasty, using split thickness
skin, enabled patient to control salivary secretions
more efficiently and permitted construction of
mandibular complete denture. Following proce­
dure, speech articulation improved only slightly,
b: Tongue release and vestibuloplasty with split
thickness skin graft gave this patient near normal
tongue function. Speech and control of saliva were
dramatically improved.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
Skin Graft Vestibuloplasty
The successful use of split-thickness skin grafts, as a free
epithelial graft over supraperiosteal dissections, has been well
documented in the literature. Schuchardt suggested that the pe­
riosteal surface but not the soft tissue bed be covered with skin199.
To achieve this, he sutured the free mucosal edge in the depth
of the newly created vestibule to the periosteum. The combina­
tion of vestibuloplasty with skin grafting, and concomitant low­
ering of the floor of the mouth, was described by Trauner200,
Rehrmann201, and Obwegeser202. The writings of Macintosh and
Obwegeser203, and Steinhauser204, on skin graft vestibuloplasty
have provided useful information regarding the success and dif­
ficulties with this method of vestibuloplasty.
The major advantage of skin-grafting is that the depth of
the sulcus does not regress following surgery. Tissue contrac­
tion is the major reason for regression of the sulcus, and there is
contraction of the wound when the margins are free to migrate,
or when granulation tissue forms205. The placement of a split-
thickness skin graft prevents the formation of granulation tis­
sue. If the margins of the incision are secured, contraction is
prevented as long as the surgery is technically correct. Healing
also progresses more rapidly.
Split-thickness skin grafting vestibuloplasty usually utilizes
skin from the patient’s thigh or buttocks area. The graft must be
thin to avoid including hair follicles located in the dermis. The
patient’s thigh is isolated, the skin lubricated with mineral oil
and, using a dermatome, a skin graft of 0.0125 to 0.015 inches
in thickness is taken. Attention is next directed towards the ves­
tibular extension procedure. A detailed description of the surgi- '
cal procedure is beyond the scope of this text, but can be found
in the excellent description by Davis206.
Following the dissection, an impression is made of the ex­
tended alveolar ridge and deepened vestibule using a previously
prepared stent and a temporary denture reliner. The readapted
stent is cleansed and painted with a tincture of benzoin that will
act as an adhesive for the skin graft. Dermatome cement may
also be used. After the adhesive has dried, the skin graft is placed
on the stent so that the raw side will be in contact with the peri­
osteum, and the skin graft is trimmed. The stent carrying the
graft is then carefully seated and secured with circumferential
sutures, encompassing the bone. Ten days later, the stent is re­
moved and the excess skin is trimmed with scissors. Healing is
generally free of complications.
Skin grafts will not take well on exposed cortical bone207.
Acceptance of a graft depends on rapid revascularization, and
bone denuded of periosteum presents a poorly vascularized
bed208. The periosteal surface of the vestibular extension must
remain intact or the success of the skin graft in this region will
be jeopardized204. Sequestrum of bone occurs in larger areas,
and the granulation tissue, which fills the defect, prevents the
acceptance of the graft. A technical mishap, such as tearing of
169
the periosteum during vestibuloplasty, is a very real possibility
for even the experienced surgeon. If a large tear that cannot be
resutured is created in the periosteum during a vestibuloplasty,
it may be advisable to decorticate the denuded site before plac­
ing the skin graft209.
The donor site usually heals in about 3 weeks without com­
plications. However, a scar will remain and, therefore, the do­
nor site should be in an inconspicuous area. Occasionally, when
the graft is too thick, skin appendages (hair follicles) will be­
come apparent after the graft has healed. The chances for the
presence of appendages increase with the thickness of the skin.
This possibility should be discussed preoperatively to avoid
problems with patient dissatisfaction.
Physiology of Oral Function Following Tongue,
Jaw, Neck Resection
The nature and extent of the disability is dependent upon
the location and size of the tumor, the impact of radiation and/
or chemotherapy, the structures and volume of tissue resected,
the design of the surgical resection, and the method of recon­
struction. In general, posterior lesions involving large portions
of the base of the tongue, tonsillar fossa, and soft palate, with
extension onto the posterior pharyngeal wall, mandible, or com­
binations of these structures, often result in the most significant
disabilities, hi these instances, loss of large portions of the tongue,
floor of mouth, and mandible, with subsequent loss of innerva­
tion from glossopharyngeal, hypoglossal, lingual, inferior al­
veolar, and marginal mandibular nerves, complicates oral func­
tion.
On the other hand, large portions of the anterior tongue
(50-60%) can be lost without significant functional deficits. The
sensory and mobility status of the remaining tongue and integ­
rity of the mandible are key factors in functional rehabilitation.
As larger volumes of tongue tissue are lost, compromises re­
garding oral function are usually encountered with the accom­
panying risk of aspiration. Currently, the total-glossectomy pa­
tient, without flap reconstruction, is infrequently encountered.
Although most of the flaps used to reconstruct the tongue are
non-sensate, and demonstrate varying degrees of mobility, if
bulk is carefully managed, they usually enhance functional re­
habilitation when accompanied by a physiologically-designed
palatal augmentation prosthesis (Figure 5-58). With the use of
this prosthesis, improvement of speech is most frequently ob­
served, followed by swallowing and, to a much lesser extent,
mastication.
Anterior lesions involving the tongue, floor of mouth, and
mandible usually result in less disabling functional outcomes
than posterior ones because of less compromise to structural,
sensory, or motor innervation. However, larger lesions that com­
promise the lips, preventing functional lip seal and salivary con­
trol, can be quite disabling. These patients often demonstrate
170 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
deficits in speech articulation, drooling, and slurred speech, sec­
ondary to pooling of saliva and inadequate lip seal. Incompe­
tent lip seal, whether sensory, motor, or structurally related, can
be a major disability affecting speech, mastication, and self es­
teem, and frequently challenge the prosthetic rehabilitation of
the patient.
For functional purposes, the mandible is considered to be
the mobile, stabilizing framework which supports tongue func­
tion. The evolution of sound oncological surgical principles of
preserving mandibular continuity whenever possible has done
much to enhance postsurgical tongue status and oral functions.
These procedures include median and lateral mandibulotomies
to gain access to tumors, and subsequent reapproximation of
the mandibular segments, along with plating them, to maintain
continuity. Inner table procedures and superior and inferior
shaves also maintain the integrity of the mandible. Surgeries so
designed and executed result in decreased volume of tissue loss,
more normal mandibular movements, improved relationship
with opposing structures in the maxillary arch, and an intact
stabilizing framework for the tongue and adjacent tissues.
When the size of tumor and resection allows for primary
closure, attention should be given to the tightness of wound
closure and the potential limitation of mobility and volume of
remaining tissue, as well as their effect on function. When re­
maining volume of tissue is reasonable, split thickness skin grafts
can be used to enhance mobility and restrict scar contracture.
When it is indicated, proponents of this approach report good
functional results198,210-2". Size and extent of resection may pre­
* Portions of the section on mastication contributed by Donald Curtis.
Fig. 5-58.
a: Total glossectomy, restored with
free flap and tongue at rest, b: Recon­
structed tongue valving with maxillary
anterior teeth during speech, c: Pros­
thesis inserted. Note position of recon­
structed tongue during production of
the “S” sound, d: Reconstructed
tongue elevated with prosthesis in po­
sition. e: Prosthesis in position with
tongue at rest. Speech was intelligible.
clude this approach. There are few instances where tongue flaps
should be used for surgical closure if functional rehabilitation
is planned for the patient. This flap has been used in the past
because it is convenient, reliable, and provides a viable tissue
for areas of exposed bone that are to be irradiated. These factors
are outweighed by the disabilities that tongue flaps are capable
of producing for speech, mastication, and swallowing.
With the development of regional myocutaneous flaps, it
was possible to restore the volume of lost tissue and provide
nonrigid stabilization to the mandibular segments. Although
these flaps invariably atrophy, their major problems are bulk,
limited mobility, and non-sensate status. These qualities may
lead to difficulty when used to reconstruct the pharyngeal wall
and base of tongue. If sufficient normal tissue remains adjacent
to the graft, many of the shortcomings can be overcome. If in­
sufficient adjacent normal tissue remains, significant deficits
may be encountered when finely coordinated function is re­
quired in such activities as mastication and swallowing.
Mastication*
Mastication is a learned, complex, neuromuscular activity
that is highly dependent upon the structural and neural integrity
of the mandible, tongue, muscles of mastication, dentition, hard
and soft palates, lips, cheeks, and adequate salivary flow. The
inability to accept food and liquids into the oral cavity, effi­
ciently masticate food substances, and develop the bolus into a
swallow-ready state can have a significant impact on dietary
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
selection, intake, nutrition, and quality of life. The physiologi­
cal function of mastication, and the oral and pharyngeal phases
of swallowing, are intimately related, requiring coordinated
neuromuscular activity and interaction to adequately accom­
plish these functions efficiently. The dysfunction seen in masti­
cation can be accompanied by the risk and fear of aspiration,
which can have a severe impact on fluid and dietary intake. The
degree of dysfunction encountered is dependent upon site and
stage of tumor, volume of resection, and method of reconstruc­
tion. In general, resections involving the tongue and mandible,
with loss of mandibular continuity, usually demonstrate the most
significant impairments in mastication.
All of the structures cited can be affected by treatment for
head and neck cancer. Surgical resection can result in loss of
teeth, portions of die mandible, tongue, soft palate, lips, and
cheeks, with accompanying structural, sensory, and mobility
alterations. Teeth may be lost as a result of preparation for ra­
diation therapy. Alterations in the quality and quantity of saliva
are well documented (See Chapter 4). Teeth that do remain may
lack an occluding mate, due to tooth loss or altered mandibular
position. If all the teeth are lost, a conventional resection pros­
thesis, retained on the remaining mandible or implant retained
prosthesis, is required. Both types of prostheses require the de­
velopment of adaptive mechanisms by the patient to affect effi­
cient mastication. Neither prosthesis can overcome significant
deficits in tongue function. If the altered tongue cannot ma­
nipulate or position the food substance between the oc­
cluding surfaces of the teeth, or form a bolus for swal­
lowing within a reasonable time, mastication will be im­
paired.
Logemann evaluated 100 patients who had been treated
for head and neck cancer, and reported tongue mobility to be
the most important factor for manipulation of the bolus and
efficient swallowing212. Marunick has studied masticatory func­
tion in patients treated for head and neck cancer, and found that
good tongue mobility and sensation were associated with more
efficient mastication—even in patients with loss of mandibular
continuity213. Kapur, studying normal, healthy subjects, dem­
onstrated that masticatory efficiency decreases with larger ar­
eas of anesthesia, due to regional nerve blocks214. His findings
support the observation that peripheral sensory impairment af­
fects masticatory efficiency, as demonstrated in many head and
neck cancer patients. The loss of sensation, caused by ablative
surgery and anesthesia in flap reconstruction, has been recog­
nized as causing impaired mastication, deglutition, and control
of saliva. Nerve grafting procedures, including the inferior al­
veolar nerve to the mental nerve, have been reported to decrease
drooling in patients with lower lip anesthesia, following a par­
tial mandibulectomy215,216. The use of microvascular sensate
cutaneous flaps has been shown to restore sensory feedback to
reconstructed areas of the oral cavity, including patients who
have had glossectomy-mandibulectomy defects217. These reports
171
are preliminary, and the functional benefit tojustify the increased
time of surgery has not been objectively substantiated. To ex­
pect a non-sensate or sensate flap, lacking proprioception with
non-multidirectional capability, to restore masticatory function
is not realistic. Sufficient normal sensate tongue tissue must
remain for meaningful masticatory function.
Loss and alterations of the muscles of mastication, com­
bined with a discontinuity defect and a unilateral functioning
condyle, frequently result in a decrease in force of closure.
Marunick has shown that, for edentulous patients tested with­
out dentures, anterior occlusal force can be decreased by 50-
60%, compared to pretreatment levels218. When these same sub­
jects were tested with their new dentures (post-cancer treatment),
a decrease of 15-52% was reported, compared to precancer treat­
ment levels with their old dentures. This decrease in occlusal
force may not be sufficiently great to inhibit the consumption
of a normal denture-wearer’s diet. However, major issues for a
good number of these patients are restricted diet, time to con­
sume reasonable portions of small, finely cut food, and appear­
ance while eating; which may be accompanied by an inability
to keep food and fluids confined to the oral cavity while masti­
cating.
A study, evaluating masticatory function, has shown that
the extent of mandibular resection and loss of continuity tend
to decrease masticatory function213. The time required to per­
form the test was increased, as were the number of strokes
required to achieve swallowing threshold. Conventional pros­
thetic rehabilitation can improve masticatory function for some
patients, but few, or none, are able to achieve pretreatment lev­
els of masticatory function. In general, when a mandibular re­
section prosthesis is stabilized with implants, a more signifi­
cant improvement in masticatory function tests is observed,
along with meaningful changes in consistency of food that is
consumed, on a routine basis, as determined by a dietary sur­
vey219. Definitive studies have not been reported regarding mas­
ticatory function in dentate patients who have lost mandibular
continuity.
Reconstruction that reestablishes continuity of the man­
dible provides the obvious benefit in esthetics, but also facili­
tates the potential for improved function. When continuity of
the mandible is reestablished, it is easier to create an occlusal
platform, and the patient has an easier time occluding to a re­
peatable position. The number of opposing tooth-to-tooth con­
tacts has been shown to be highly correlated with masticatory
efficiency220. The increase in occlusal contacts is probably the
reason patients with reestablished continuity of the mandible
report improved masticatory function. The improved symme­
try that follows reestablishing continuity of the mandible also
results in fewer patient reports of drooling.
Although numerous papers have been published, outlining
reconstructive techniques to establish continuity of the man­
dible, few have been related to the functional result of mastica­
172 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
tory performance. This shortcoming in the literature was high­
lighted by Schusterman, who stated: “...a shift in emphasis has
been slowly occurring in microvascular head and neck recon­
struction—from documentation of technical accomplishment
to evaluation of functional success.” Schusterman further stated:
“...the objective documentation of these efforts is in its in­
fancy”221.
Probably the most comprehensive study, evaluating masti­
catory function and mandibularreconstruction in cancer patients,
has been by Urken and coworkers216. The study evaluated pa­
tients who had microvascular surgery to reconstruct mandibu­
lar continuity, patients who did not have reconstruction, and
control patients. The objective measures of masticatory func­
tion included bite force, chewing cycle, a global measure of
masticatory performance (as defined by Manly and Braley222),
and a subjective questionnaire that asked patients to report per­
formance. Results indicate that patients with reconstructed man­
dibles had significantly improved bite force levels, improved
masticatory performance levels, and a more vertical mastica­
tory cycle. Urken’s study represents a major advance, yet prob­
lems exist with the measures of masticatory performance used.
For example, several investigators have shown that mea­
sures of bite force are poorly correlated with masticatory per­
formance and changes with age, gender, head posture, number
of teeth, and psychological state220,223,224. The statistically sig­
nificant difference Urken found between the reconstructed and
non-reconstructed groups, with regard to bite force, may or may
not be related to masticatory performance. Additionally, it would
be helpful to correlate objective measures of masticatory per­
formance with patient reports of masticatory performance to
more clearly discriminate which objective measures are clini­
cally significant. Findings of statistical differences between dif­
ferent tests are as important as establishing differences between
different patient populations. It is clear that both long-term pro­
spective studies and cross-sectional studies are needed in this
area to more clearly define the functional benefit of surgical
reconstruction of the mandible.
Tests to Evaluate Masticatory Performance in Oral
Cancer Patients
The terminology used to describe the process of grinding
and preparation of food for swallowing is often confusing.
Masticatory performance, chewing efficiency, masticatory func­
tion, and masticatory ability have often been used interchange­
ably. We will use masticatory performance to describe the pro­
cess of trituration and preparation of food for swallowing.
Most tests to evaluate masticatory performance were de­
veloped to help discriminate between the masticatory perfor­
mance of edentulous and dentate individuals. The goal has been
to develop tests that are reliable, so that different investigators
will achieve similar results from the same test, and valid, in that
the test will measure the phenomenon it is trying to measure.
Unfortunately, test foods and techniques have not been shown
to be either consistently reliable or valid. Investigators are just
beginning to adapt existing test protocols for evaluation of head
and neck cancer patients.
Global Measures of Masticatory Function
Marunick, Mathog, and others have completed both pilot
data and prospective data, evaluating masticatory performance
in patients without mandibular continuity213,225. Using com chips
as a test substrate, and having each participant act as his own
control, the authors found surgery does result in a measurable
impairment in mastication that cannot always be reversed by
prosthetic rehabilitation. Marunick found a test-retest reliabil­
ity of .59 for the measure of masticatory performance, and .84
for the swallowing threshold.
Measures of Tongue and Cheek Function
Global measures of masticatory performance have been
helpful to establish that there is a functional deficit following
cancer surgery, and that prosthodontic intervention often im­
proves masticatory performance. Also important are tests that
attempt to isolate factors accounting for poor measures of glo­
bal masticatory performance. Although many clinicians have
felt that compromises in tongue function account for much of
the reason for poor masticatory performance, this area has only
recently been studied. In a cross-sectional study, Curtis com­
pleted a series of objective measures of masticatory performance
and subjective patient responses in 9 hemimandibulectomy and
9 normal patients226. Objective measures included: (1) bite force
at the first molar and incisal edge, (2) an objective measure of
tongue and cheek function, and (3) a patient report of foods
they could eat. HM (hemimandibulectomy) patients were spe­
cifically defined as having lost continuity of their mandible,
having retained the majority of their remaining natural denti­
tion, and having been measured at least 1 year after surgery.
The questionnaire used was shown to be reliable and valid by
List, rating food from “difficult” (peanuts = 100) to “easy” (liq­
uids = 10) (Table 5-15)227. Tongue and cheek function was evalu­
ated using a technique developed by Kapur which involves re­
moving peanut particles from the buccal vestibule with 2 swipes
of the tongue (Table 5-16)228. Results indicate significantly lower
scores for tongue and cheek function in HM subjects (p<.001),
significantly lower scores for HM responses to normalcy of diet
(p<.002), and a significant correlation between patient reports
of normalcy of diet and objective measures of tongue and cheek
function (r=.903, pc.Ol). Normalcy of diet was poorly corre­
lated with molar clenching (r=.48, p>.05) and incisal edge
clenching (r=.07, p>.05). Ability to bite forcefully was only
weakly correlated with patient reports of ability to masticate.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 173

Table 5-15. Normalcy of Diet.

'100 W\§ ^ ^ ^ 0^ 000116^)^1

90 Peanuts^"
I ll 80 . All'Meat^'-
W im ^Sarrofs^.^elery
60 >Dfyj Bread ?andGraeke rs
50 Soft, Weyvablfe-'Foods (For.Example, Macaroni, Canned/Soft F ruity
"Gdoked Vegetable's,-Fish, Hamburger, Small Pieces of Meat) :
40 'SoftFood&Rfequinng No Chevying (For Example, Mashed POtatdes,
I App)6.SSuce^Rud6mg)
ijB J Pu^e^d^F'dbds (in BlendeO?; •/
20 : Warm Uquid'sv--

.;Non-'oral Feeding (Tube Fed)

Table 5-16. Hemimandibulectomy Patients.

First Molar Incisal Edge Normalcy Tongue and

Patient Clenching Clenching o f Diet Cheek Performance
1 132 ±45 48 ±11 40 .0289
- 2 ; 66 ± 3 46 ± 7 50 .543
3 152 ± 3 80 ± 4 40 .287
4 107 ± 3 36 ± 3 40 .076
5 N/A N/A 40 .082
6 84 ± 4 33 ± 4 50 .408
129 ±23 65 ± 3 60 .702
8 101 ± 1 2 32 ± 1 50 .432
9 64 ± 11 36 + 4 40 .288

Maximum bite force was-e6aluatedra t the mandibular first molar and mandibular incisaFedge (Newtons). “Normalcy of diet"- refers to ttie -foSds^he -
patient couldceat accordmg to the scale pre'sertted-in;Table 5-15V;" • -

Several HM patients were successfully treated with guidance Mandibular Movements

appliances, which established acceptable interdigitation of the
teeth with relatively high biting force, yet scored low on objec­
tive scores of tongue function and on reports of ability to mas­
ticate. The soft tissue factors of tongue and cheek function were
probably of equal importance to mandibularcontinuity and align­
ment of the dentition.
Many patients, following treatment for lesions involving
the tongue and the mandible, will demonstrate restrictions in
mandibular movements. These limitations are often accompa­
nied by uncoordinated efforts between the remaining tongue,
mandible, and accompanying flaps. These restrictions require
174 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
adaptive mechanisms by the patient to develop meaningful
movements and positioning to acquire reasonable masticatory
function. Limited opening and restrictions in lateral protrusive
and retrusive mandibular movements can limit the size of food
substances that can be placed in the mouth and between oc­
cluding surfaces. These restrictions can also limit the size and
position of die prostheses that can be accommodated in the oral
cavity.
The classic envelope of mandibular motion described by
Posselt has been developed for the lateral mandibulectomy pa­
tient133. Curtis demonstrated a more retruded and more lateral
functional range of motion for these patients. The phenomenon
of frontal plane of rotation for the classic mandibulectomy pa­
tient has also been described. For this rotation to occur, the as­
sumption is made that the natural teeth, or prosthesis on the
non-resected side, can occlude in a functional manner when
forceful closure is applied. When frontal plane rotation is en­
countered, a basis for decreased masticatory function can be
appreciated. With the advancement of mandibular preservation
procedures as well as reconstructive hard and soft tissue tech­
niques and flaps, frontal plane rotation is seen less frequently.
Maxillomandibular relationships are usually more appropriate,
and function generally better than most classic mandibulectomy
patients. Exceptions to these observations are encountered when
range of motion is significantly impaired, mandibular recon­
struction results in inappropriate anteroposterior and lateral
maxillomandibular relations, or lip seal and tongue status is sig­
nificantly altered. Sufficient inter-arch space must also be main­
tained for functional purposes and, if required, the placement of
a prosthesis.
Computer Modeling of Jaw Biomechanics in Oral
Cancer Patients*
The major problems in studying HM (hemimandibulec-
tomy) patients and patients having reconstructive surgery are
related to the small sample size and the heterogeneous nature of
this patient population. Tumor sizes vary, surgical approaches
differ by surgeon and region, and the resulting functional limi­
tations are specific to each patient. Often, the presurgical re­
cordings are influenced by the presence of the disease. Com­
puter modeling offers the opportunity to simulate an anatomic
deficit, make quantitative determinations about joint loading
and vectors of occlusal force, and make predictions about the
potential impact of prosthodontic intervention which are spe­
cific to each patient. Investigators have developed both mechani­
cal and mathematical models to help answer questions about
bite force, vectors of muscle force, and temporomandibularjoint
loading229,230. Models have ranged from a simple, 1-dimensional,
representing 2 muscles, to a 3-dimensional, with 9 muscles rep­
resented.
* Section on computer modeling of jaw biomechanics in oral cancer patients contributed by Donald Curtis.
** Section on normal deglutition and restoration of dysfunctional swallowing contributed by Richard Nelson.
The computer modeling program used to study HM pa­
tients (developed by Nelson and Hannam) was designed as a 3-
dimensional model, with 9 pairs of muscles represented229. Cal­
culations were completed on an existing data base, represent­
ing a normal patient having an intact mandible, to determine
the maximum clenching force at the first molar and incisal edge,
as well as the joint-force:tooth-force ratio. The computer mod­
eling program was then altered to simulate the anatomic deficit
characteristically seen in a HM patient, with the tests of clench­
ing force and joint-force:tooth-force measures duplicated.
Computer simulations of normal and HM patients predicted
that HM patients would have 35% less incisal clenching force,
45% less first molar clenching force, have an unfavorable joint-
force:tooth-force ratio, and have rotation of the mandible with
occlusal instability. Clinical trials show the computer simula­
tions provide slightly lower values for molar clenching and
higher values for the incisal clenching. The unfavorable joint-
force:tooth-force ratio prediction from computer modeling can­
not be validated clinically, but it makes sense that, without bi­
lateral articulation, the joint is heavily loaded. The rotation of
the mandible occurs because the masseter on the non-defect
side serves to rotate the mandible, and is not balanced unilater­
ally by the medial pterygoid.
Computer modeling of jaw biomechanics has potential
applications in many areas of preprosthetic surgery and man­
dibular reconstruction. For example, clinical experience has
shown that patients who have had unilateral resection and sub­
sequent reconstruction of the mandible, ramus, and condyle tend
not to havejoint pain associated with their reconstructed condyle.
Computer modeling simulation of the reconstructed patient pre­
dicts that joint loading of the reconstructed condyle would be
minimal, even when clenching maximally at the mandibular
incisors. The lack of symptoms observed clinically may be re­
lated to this minimal amount of joint loading. Other applica­
tions of computer modeling of jaw biomechanics include force
vector changes following differing surgical or reconstructive
procedures.
Normal Deglutition and Prosthetic Restoration of
Dysfunctional Swallowing**
Dysphagia (difficulty swallowing) frequently results from
ablative procedures for cancers of the upper aerodigestive tract.
The type and degree of dysfunction will depend upon the site
and stage of the primary neoplasm, the extent of resection, and
the reconstructive techniques employed. Dysphagia may result
from loss of skeletal support, or alteration in soft tissue bulk
and contour. Neurologic deficits may result in paresis or hyper­
esthesia. Additional dysfunction may result from a tethering of
remaining structures, which decreases their mobility and
strength. Epithelial changes secondary to flaps or grafts used in
 Acquired Defects ofthe Mandible: Etiology, Treatment, andRehabilitation
the reconstruction, or mucositis or xerostomia due to radiation
therapy, may further impede swallowing.
In addition to a general decrease in quality of life, dysph­
agia may lead to serious, life-threatening sequelae, including
dehydration, malnutrition, and aspiration. Restoration of swal­
lowing function, followinglargeresections, may require the use
of a prosthesis. A detailed understanding of normal deglutition
and the functional deficits which may result fromhead and neck
surgery is essential to the development of a suitable prosthesis,
and for optimal rehabilitation.
Normal Swallowing
Swallowing has been described as the most complex, ste­
reotypic behavior which can be elicited from peripheral stimu­
lation. Normal deglutition requires the fine coordination of 12
cranial and 6 cervical nerves, and some 60 muscles. Despite its
complexity, individual components of swallowingmay be iden­
tified and evaluated. Normal deglutition consists of 4 sequen­
tial phases: (1) oral preparatory, (2) oral transit, (3) pharyngeal,
and (4) esophageal (Figure 5-59). Dysphagia may result from
dysfunction during any phase. Dysphagia resulting from abla­
tive head and-neck surgical procedures primarily involves the
first 3 phases, and these will be the focus of the discussion.
Fig. 5-59. Swallowing sequence of a normal patient.
175
Oralpreparatoryphase The oral preparatory phase is the vo­
litional manipulation of the bolus into a swallow-ready state.
This phase begins with the introduction of a liquid or solid bo­
lus into the oral cavity. This material is then masticated, mixed
with saliva, and formed into a swallow-ready bolus. During the
oral preparatory phase, the lips approximate and form an ante­
rior sphincter, and the base of the tongue meets the soft palate
to create a posterior sphincter, thus containing the bolus within
the oral cavity. Adequate buccal tone further assists in confin­
ing the bolus. Skeletal elements, including the hardpalate, den­
tition, and mandible, provide the necessary rigidity and support
for this manipulation, and also act to contain the bolus. Lingual
sensation, coordination, and mobility are essential for control­
ling the bolus during mastication. The oral preparatory phase is
under voluntary control. The process is quite variable in dura­
tion and character, depending upon cultural norms, integrity of
the masticatory apparatus, and the nature of the bolus to be
swallowed. Once bolus preparation is completed, the bolus is
collected and positioned on the dorsal surface of the tongue.
Oral transitphase During the oral preparatory phase, the bo­
lus is modified into a swallow-ready state. Sensory information
regarding bolus volume, position, temperature, texture, viscos­
ity, and taste is transmitted centrally. This input is integrated,
176 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
and the upper aerodigestive tract is prepared for the orderly ini­
tiation of a swallow. The interpretation and integration of this
information is a learned function, though it typically takes place
without the individual being consciously aware of the process.
The swallow begins with the bolus confined to the dorsal
surface of the tongue. Lingual alveolar contacts on the anterior
and lateral maxillary arch maintain the bolus in a central posi­
tion. The tongue forms a deep, central groove to accommodate
the bolus volume. Early in the oral transit phase, lingual-velar
contact seals the pharyngeal introitus, prohibiting the prema­
ture egress of the bolus into the pharynx. The mandible is held
in near centric occlusion, supported by the masticatory muscu­
lature. The musculature of the floor of the mouth undergoes
contraction, supporting the tongue. The tongue then initiates a
stripping action, propelling the bolus toward the pharynx. This
transport is accomplished primarily by the progressively distal
lingual-palatal contact of the anterior tongue and the oblitera­
tion of the central groove containing the bolus.
Adequate lingual sensation, mobility, coordination, and
strength are required to successfully manipulate and transport
the bolus into the pharynx. The stripping action will vary some­
what, depending on the volume and viscosity of the bolus. With
thin liquids, the action may be abbreviated, as the fluid flows
readily under gravity into the pharynx. In this case, the bolus
may not be as well contained and may not make contact with
the hard palate. With a thicker, more adherent bolus, the gesture
may be exaggerated or repeated to deliver the material into the
pharynx. As the bolus passes the lingual base, the soft palate
elevates, opening the introitus to the pharynx. Up until this point,
the swallow has been under voluntary control and can be con­
sciously altered or aborted.
Pharyngeal phase The pharyngeal phase of swallowing be­
gins with the reflexive or non-volitional components of swal­
lowing. During this phase, the bolus is transported through the
pharynx and into the esophagus. This ends with die initiation of
esophageal peristalsis. The reflex is a stereotypic-patterned re­
sponse coordinating the complex movements of the tongue,
palate, larynx, andpharynx, whichis necessary for efficient bolus
transport. Pharyngeal deglutition involves 2 important processes
which, even though they occur simultaneously, are more easily
considered independently: (1) pharyngeal transport of the bolus
from the oral cavity into the esophagus and (2) laryngeal pro­
tective mechanisms which prevent bolus entry into the airway.
Pharyngeal transport As the bolus travels through the
introitus, from the oral cavity to the oropharynx, reflex swal­
lowing is initiated. The precise mechanism of reflex initiation
is unknown. It has been proposed that a “trigger” site exists in
the area of the facial arches, but this is unlikely. Reflex initia­
tion can be elicited from a variety of sites, and surgical removal
of these sites does not impede reflex deglutition. Swallowing
can be easily triggered volitionally, without a bolus or stimula­
tion of this region. However, repeated “dry” swallows are diffi­
cult. It is likely that the afferent information obtained during the
oral preparatory and transit phases is integrated with cortical
input at the brain-stem level and the pharynx is prepared for
reflex initiation. The reflex may be triggered by a number of
peripheral and central neural signals.
Early in the pharyngeal phase, the soft palate, which had
been in contact with the base of the tongue, elevates and con­
tacts the posterior and lateral pharyngeal walls. This contact
approximates the plane of the hard palate and occludes the na­
sopharynx, effectively separating the nasal and digestive tracts.
This closure is facilitated by medialization of the pharyngeal
walls. Simultaneous with velar elevation, the larynx is elevated
and the pharynx shortened. The bolus is propelled through the
facial isthmus and into the vallecula. The vallecula fills and, as
the epiglottis rotates posterior-inferiorly, the material progresses
into the hypopharynx. The bolus is directed into the pyriform
sinuses bilaterally by the epiglottis. This material then fills the
hypopharynx. The upper esophageal sphincter, which has a sig­
nificant basal tone, relaxes. Opening of the pharyngoesophageal
segment is facilitated by laryngeal elevation and anterior dis­
placement.
Bolus propulsion, provided primarily by the tongue, im­
pels the bolus through the hypopharynx into die esophagus. The
contraction wave of the pharyngeal constrictors begins rostrally
with palatal closure, progresses caudally the length of the phar­
ynx, and continues with the onset of esophageal peristalsis. The
pharyngeal contraction wave proceeds relatively slowly, when
compared to the bolus velocity, and follows the bolus through
the hypopharynx. Though it contributes to pharyngeal bolus
transport, the primary function of the pharyngeal contraction
wave is to clear the hypopharynx of residual material prior to
the restoration of respiration. Optimal pharyngeal deglutition
requires the ability to obliterate the entire oro- and
hypopharyngeal space as well as to complete transport of the
bolus into the esophagus. This is accomplishedprimarily by the
movement of the lingual base (from an anterior-superior to a
posterior-inferior position) during the swallow. Medial and an­
terior movement of the pharyngeal walls facilitates lingual con­
tact and pharyngeal clearance. The soft palate and larynx pre­
vent bolus egress into the nasopharynx or airway, respectively.
Laryngealprotection The primary physiologic function
of the larynx is to act as a sphincter, preventing entry of foreign
material into the airway. The airway and digestive tract share a
common space in the oro- and hypopharynx. During the pha­
ryngeal phase of deglutition, the bolus must pass around or over
the airway to gain access to die esophagus. In the rest position,
the larynx and airway occupy a dependent position, with the
laryngeal vestibule widely open to the pharynx. During a swal­
low, however, the larynx is elevated and drawn anteriorly by
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
the suprahyoid musculature. This elevation places the laiynx
firmly under the base of the tongue, which affords some protec­
tion, assists in opening of the pharyngoesophageal segment, and
moves the airway into a less dependent position.
The epiglottis forms a flap-like valve over the laryngeal
vestibule. During deglutition, the epiglottis rotates posterior-
inferiorly, occluding the airway. There are 2 components to this
rotation. The first is facilitated by laryngeal elevation, which
alters the relationship between the hyoid and thyroid cartilages,
the 2 principal attachments of the epiglottis. The second com­
ponent of rotation is accomplished by contraction of the supra-
glottic musculature, which results in a purse string like closure.
The endolarynx has 2 paired longitudinal soft tissue masses,
the vestibular and vocal folds (false and true vocal cords, re­
spectively), which meet in the midline and close off the airway.
This creates a 2-level sphincter mechanism within the larynx
and provides additional airway protection. With glottic (true
vocal cord) closure, a positive subglottic airway pressure can
be generated which further protects the airway and allows for a
cough, or throat clearing, following the swallow.
Esophagealphase With the entry of the bolus into the esopha­
gus, and completion of the pharyngeal contraction, esophageal
peristalsis is initiated. Esophageal peristalsis is much slower
and more uniform than pharyngeal transport. Esophageal tran­
sit times vary between 4 and 20 seconds, whereas pharyngeal
transit is typically less than 1 second.
Evaluation of Swallowing
Optimal restoration of swallowing function, following ab­
lative head and neck procedures, requires a clear determination
of residual and deficient function and the coordinated applica­
tion of the appropriate therapeutic measures designed to over­
come the dysfunction. Adequate pretreatment evaluation can
only be achieved by careful history and clinical examination
supported by appropriate laboratory or diagnostic studies.
Clinical evaluation Ideally, the initial swallowing evaluation
is obtained prior to any surgical or adjunctive therapy. This evalu­
ation assists the prosthodontist with detection of any preexist­
ing dysfunction, such as hypesthesia, paresis, or silent aspira­
tion, which may impact on posttreatment rehabilitation. Close
communication between the surgeon and the prosthodontist, with
discussion of osteotomy sites, margins of resection, and recon­
structive techniques, as well as anticipated skeletal, soft tissue,
and functional deficits, will greatly enhance posttreatment
prosthodontic and other rehabilitative activities. Additionally,
the specific prosthetic needs for each patient can be identified,
and the treatment plan can be outlined. A complete medical and
dental history, relative to the patients primary and associated
disease state, is essential.
177
A comprehensive review of swallowing function and ali­
mentation should be completed. The patient’s current diet, in­
cluding composition, route, adequacy, and restrictions, must be
documented. A history of weakness, weight loss, recurrent in­
fections, anemia, poor wound healing, food intolerance, or gas­
trointestinal complaints may indicate dietary inadequacy.
Chronic dehydration, orthostatic hypotension, urinary tract dis­
orders, or similar symptoms may result from insufficient fluid
intake. Complaints of coughing, choking, gagging, or regurgi­
tation may accompany aspiration during deglutition. Recurrent
pulmonary problems, especially pneumonia, a “wet” voice, or
increased sputum production may indicate chronic aspiration.
Foreign body sensation and oral or throat pain are frequent com­
plaints in patients with head and neck cancer. Inability to ma­
nipulate or control the bolus, delayed swallow reflex, nasal re­
gurgitation, or pharyngeal bolus retention is also common. Di­
etary adequacy and safety should be assured before implemen­
tation of prosthetic restorations.
The clinical examination begins with an evaluation of the
patient’s mental status. The incidence of head and neck cancer
increases with advancing age, and patients who develop these
neoplasms may suffer from age-associated mental dysfunction,
such as Alzheimer’s disease, or the consequences of chronic
malnutrition and alcohol abuse. The emotional impact of hav­
ing a cancer, and coping with the intensive treatments required,
may be overwhelming. Posttreatment pain, disfigurement, dys­
phagia, and communication impairments add to the burden.
Socioeconomic status, self-perception, education level, and cul­
tural identification all impact on the patient’s ability to under­
stand and actively participate in the rehabilitation process.
The physical examination requires a systematic evaluation
of skeletal and soft tissues and their function. Ostectomies and
resulting defects must be identified. Reconstructive measures,
including free and microvascular bone grafts, soft tissue flaps
and grafts, alloplastic implants and reconstruction plates, or simi­
lar devices, must be determined. Mandibular continuity and bone
shape, quantity, and quality are assessed. Mandibular move­
ment and strength as well as temporomandibular joint function
are evaluated. Skeletal defects of the cranium, orbit, nose and
paranasal sinuses, palate, and maxilla are carefully documented.
The dentition is evaluated. Salvageable teeth are identified, and
the necessary dental care outlined. The patient’s current den­
tures are evaluated for utility and fit, or for possible modifica­
tion for temporary or permanent prosthetic restoration of swal­
lowing.
The soft tissues of the face, oral cavity, and pharynx are
assessed. Lip control and closure are important for containing
the bolus. Buccal tone is evaluated. The gingival-labial and gin­
gival-lingual sulci are carefully evaluated, as they are often dis­
torted following oral resections. The tongue and anterior floor
of mouth are examined. Lingual volume, strength, range of
motion, sensation, and coordination must be assessed. Hyper-
178 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
csfca a. paresis, lingual tethering, and loss of soft tissue bulk
a r common following ablative procedures for oral malignan­
cies. Determination of residual function is key to successful
prosthetic restoration. The hard and soft palates are examined.
Itayngal-palatal resections often result in palatal insufficiency.
Soft palatal anatomy and function are evaluated, and the need
for palatal lift or obturation is determined. Patients with pha­
ryngeal resections, especially those reconstructed with muscu-
fcmaneous flaps, often have adynamic segments and decreased
ffcayngeal bolus transport. The larynx should be evaluated for
elevation during deglutition and glottic function. Cranial nerves
V , VH, IX, X, XI, and XII should be individually assessed. Spe­
cial attention should be directed to the quality of the epithelial
f a i e within the oral cavity and pharynx. Remaining mucosa
a n y be suboptimal secondary to tobaccoand alcohol use, poor
oral care, or malnutrition. Injuries sustained from ablative and
^constructive procedures, radiation, chemotherapy, or a com­
bination of these may be considerable and permanent Skin or
dermal flaps and grafts have a different quality than natural oral
Issues. They are typically drier and slower to heal, and may be
associated with significant scarring and atrophy. Salivary dys­
function and xerostomia, following radiation therapy, may fur-
f c r compromise oral hygiene and soft tissue quality. The abil­
ity o f the remaining tissues to retain a prosthesis must be con­
sidered.
Specialized testing The history and clinical examination pro­
vide insight into the nature and degree of the physical and func­
tional impairment following treatment of head and neck cancer.
However, this examination provides only limited information
Kganfing actual performance and adaptation relative to swal­
lowing function. The clinical assessment of deglutition is com­
pleted by die evaluation of appropriate imaging studies.
The video-fluoroscopic modified barium swallow is the
s ie ie most useful, widely available imaging study for the evalu­
ation of swallowing function. This technique is a radiographic
procedure in which the patient is examined fluoroscopically
■ H e swallowing a bolus of contrast material. The study con-
s b i s o f several swallows, demonstrating the patient’s functional
d d tie s and deficits. The fluoroscopic images are collected at
30 frames per second and stored on videotape, which can be
w iew ed following the test. The subjects are studied in both
feaerai aid A-P projections.
For each swallow, the subject is given a measured amount
o f contrast media. This material, which is radio-opaque, is readily
viTadiirri fluoroscopically. The contrast media may vary in
coBBsftency so that a complete study will test a variety of con-
« aFMrirs, including thin and thick liquids, paste, and solids (a
banana soaked cookie). The subject takes the material into his
o r her mouth and swallows when directed, while being exam­
ined fluoroscopically. The test is repeated as needed with dif-
faent projections, contrast media, or swallowing techniques until
clear documentation of the swallowing function is obtained.
The esophagus can also be studied with this technique. The vid­
eotapes can be reviewed anytime, and die capacity for review­
ing them in slow motion greatly facilitates the evaluation of the
swallows as well as the identification of subtle abnormalities.
Detailed analysis of mastication, oral motor function, pharyn­
geal reflex initiation, and oral and pharyngeal transport of the
bolus is possible. The presence and mechanism of bolus stasis,
premature egress, nasopharyngeal reflux, and aspiration can be
identified. The video-fluoroscopic modified barium swallow can
be repeated as needed, then compared to previous studies to
evaluate and document treatment efficacy and plan any addi­
tional interventions.
A technique of fiberoptic endoscopic evaluation of swal­
lowing (FEES) has been developed recently. With this tech­
nique, a small, flexible, fiberoptic nasopharyngoscope is passed
through a lightly anesthetized nasal cavity. Once the nasophar­
ynx is encountered, the patient is instructed to perform a variety
of maneuvers which demonstrate palatal and pharyngeal func­
tion. Once this assessment is completed, the scope is advanced,
and the base of tongue, larynx, and remainder of the pharynx
can be inspected. The subject may be asked to perform a vari­
ety of maneuvers which document pharyngeal and laryngeal
function. Then the patient is instructed to swallow a colored
bolus, and the swallow is viewed directly. Premature egress of
the bolus into the pharynx, reflex delay, bolus stasis, and aspi­
ration may be visualized directly. This test may be modified or
repeated as necessary. The study can be recorded by attaching a
video camera to the scope and viewing the study on a monitor,
while recording it on a VCR. This technique has the advantage
of simplicity, readily available equipment, and the avoidance of
additional radiation exposure to the patient Its limitations in­
clude the inability to visualize the oral cavity and the oblitera­
tion of the field of view during the pharyngeal phase.
The swallowing function can also be evaluated
scintigraphically. This technique uses a gamma-emitting radio­
isotope which is detected by a gamma camera to generate an
image. The patient is given a bolus mixed with a small quantity
of technicium 99 sulfur colloid. The patient is positioned be­
fore a gamma camera in the 80 degree right anterior oblique
projection. Markers are placed at the mandibular angle and cri­
coid cartilage to facilitate image analysis. The patient then swal­
lows the bolus, when instructed, and scintigraphic images are
collected at 16 frames per second. Following the swallow, a
static scintigram is obtained in the A-P projection. Two types of
scintigraphic data are generated. By reviewing the scintigraphic
images, the progress of bolus transport from the oral cavity,
through the pharynx and esophagus, and into the stomach, can
be determined. Using a computer-graphic representation of bo­
lus, flow and transit times can be readily obtained. The static
image obtained following the study has particular utility in the
detection and quantification of aspiration. Scintigraphy is the
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
most sensitive and only objectively quantitative technique for
the evaluation of aspiration. This technique is limited by the
inability to visualize the anatomic structures and movements
during die swallow. It is not widely available.
A variety of other diagnostic procedures are available for
the assessment of swallowing. Ultrasound can be used to visu­
alize die oral cavity during swallowing. This technique has the
advantages of avoiding ionizing radiation and poses no risk to
the patient or examiner. It is limited by image quality and the
inability to visualize the pharynx, larynx, or esophagus. Other
forms of endoscopy (direct laryngoscopy, bronchoscopy,
esophagoscopy) are important diagnostic measures, but they
have marginal utility for evaluating swallowing function. Pha­
ryngeal electromyography and manometry are helpful in select
cases, but they are rarely used and not widely available.
Dysphagia in Head and Neck Cancer Patients
Patients treated successfully for head and neck cancers of­
ten experience significant posttreatment dysphagia. This dys­
function may involve any phase of swallowing (Figure 5-60).
Effective rehabilitation requires a clear understanding of the
clinical priorities and available resources. Defects in the oral
cavity may result in dysfunction involving the preparation or
transportation of the bolus. Bolus preparation is accomplished
by masticating the material into a swallow-ready state, and col­
lecting the bolus on the dorsal surface of the tongue prior to the
initiation of oral transport. Efficient manipulation of the bolus
within die oral cavity requires adequate lingual, palatal, and
mandibular function.
Lingual resections vary from small marginal resections with
primary closure to a total glossectomy. Limited resections, par­
ticularly those which preserve normal sensation and movement,
are well tolerated and result in minimal dysfunction. Physiologic
function of the anterior tongue is primarily determined by lin­
gual mobility.
Fig. 5-60.
Anterior third of tongue
reconstructed with sca­
pula free flap (a). Recon­
structed tongue does not
elevate effectively, and
patient must swallow with
a modification of the “jug
a lug” technique (b).
179
Relatively modest anterior tongue and floor of the mouth
resections may result in significant impairment if the tongue is
primarily used to close the defect. This results in tethering of
the tongue and decreased mobility, although hypoglossal inner­
vation may be normal. A similar resection closed with a skin
graft would permit greater lingual mobility and lessen the dys­
function. Oral resections with closures that obliterate the ante­
rior sulci, or result in malposition of the tongue, may result in
significant dysfunction, and prohibit the use of a mandibular
prosthesis. Secondary procedures, such as a vestibuloplasty, may
facilitate rehabilitation efforts. With laiger anterior lingual re­
sections, the loss of soft tissue bulk becomes a consideration.
The reconstructive surgeon must consider the relative advan­
tages of flap closure versus the introduction of insensate tissue
and distortion of remaining structures. In general, prosthetic or
therapeutic restoration of function is facilitated by preserving
sensation and movement of the anterior tongue. Volume loss
can be accommodated by the fabrication of a palatal augmenta­
tion prosthesis.
Posterior-lateral lingual resections often result in signifi­
cant dysphagia. Two patterns of dysfunction are common. Re­
section of the base of the tongue may result in the inability to
contain the bolus within the oral cavity. During the oral phases,
the bolus may pass prematurely into the pharynx and an unpro­
tected airway. The second pattern of dysfunction results from
diminished lingual propulsion of the bolus. This may be exac­
erbated by resection of adjacent pharyngeal tissues, which of­
ten accompanies these procedures. With both patterns, the level
of the dysfunction increases with the volume of tongue resected.
These lingual-pharyngeal defects are often closed with muscu­
locutaneous flaps or free flaps. The introduction of this insen­
sate and adynamic tissue may add to the dysfunction. Deglutoiy
function of the base of the tongue appears to be better preserved
when sensation is maintained-even at the expense of volume
loss and malposition. Closures which result from a base of tongue
elevation, a smaller introitus, and decreased pharyngeal vol­
ume are well tolerated.
180 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Total glossectomy, or large resections involving both the
anterior and posterior tongue, results in significant dysfunction.
The surgical defects are typically closed with a myocutaneous
flap or free flap. Although these flaps help restore soft tissue
bulk, volume deficits generally persist following healing and
flap atrophy. In general, these flaps are insensate and adynamic.
The inability to feel the bolus or other oral structures coupled
with flap immobility result in severe impairment of oral motor
control. Prosthetic restoration of lingual palatal contact may sig-
nificantly improve deglutition.
Swallowing is generally better with the maintenance of
mandibular continuity. An alveolar or marginal resection may
have little functional impact, although loss of bony height or
obliteration of sulci may limit the use of a prosthesis.
Monocortical resections maintain mandibular continuity and are
well tolerated. The loss of bone may result in segmental weak­
ness or limit the use of osseous integrated implants. A
mandibulotomy may be used to gain surgical access and expo­
sure. These osteotomies are reduced during closure with the 2
segments supported by internal fixation. Following an adequate
healing period, normal mandibular strength is restored and con­
tinuity is maintained.
Segmental resections generally result in significant oral
dysphagia. Limited distal resections, such as a condylectomy,
are well tolerated. As the resections increase in length, involv­
ing more of the mandible, the dysfunction increases significandy.
Bony restoration of mandibular continuity is preferred in order
to minimize the need for adaptive mechanisms.
The optimal rehabilitation of dysfunctional swallowing
depends upon the recognition of the clinical priorities. These
priorities include: (1) define the PROBLEM, (2) determine
SAFETY, (3) establishADEQUACY, (4) improve FUNCTION,
(5) achieve OPTIMUM. The correction of deglutition disor­
ders requires a diagnosis. The first task of the clinician is to
define the problem; that is, to determine the specific functional
deficits and their etiology. This evaluation will include an as­
sessment evaluation of all phases of swallowing, establishing
the type and degree of dysfunction. Prior to formulating and
instituting a treatment plan, 2 additional considerations are re­
quired. The patient’s safety must be assured. The primary safety
concern is recurrent aspiration. Aspiration is common in this
patient population, and clinical determination of adequate air­
way protection and pulmonary toilet is required. If aspiration is
documented, appropriate corrective measures must be instituted.
This may require maintaining the patient with tube feedings.
The third priority is the establishment of the adequacy of the
patient’s hydration and nutrition. Head and neck cancer patients
are frequently malnourished. Their metabolic requirements are
often high, and adequate intake may be limited by their dys­
function. Pain, fatigue, dietary restrictions, and dysphagia may
all act to impede alimentation. Dietary modification and supple­
mentation, tube feedings, or parenteral nutrition may be neces­
sary to establish nutritional adequacy.
Once the diagnosis is established and the patient’s safety
and dietary needs are assured, attention is directed to the im­
provement of swallowing function. A treatment plan is devel­
oped based upon the diagnosis and realistic therapeutic goals.
This plan may include the participation of multiple health care
providers in addition to the prosthodontist. The prosthetic ob­
jectives are prioritized according to the specific needs of the
patient These may include esthetic, masticatory, and speech
considerations in addition to swallowing function. The initial
therapeutic objective is to restore or improve function. Once
this has been achieved attention is directed to optimizing func­
tion. In many rehabilitation settings, optimal function is achieved
only after multiple incremental improvements. A modified max­
illary denture may function as a temporary prosthesis to rees­
tablish functional swallowing; however, optimal restorationmay
be achieved following fabrication of a new prosthesis.
Speech
Production of intelligible speech is dependent upon the
controlled movement of air from the lungs through the larynx,
hypopharynx, and oral cavity. The production of various pho­
nemes and silibants is highly dependent upon the shape of the
structures as the air passes through the various chambers. In the
oral cavity, the tongue, soft palate, hard palate, dental alveolar
complex, buccinator muscle, and lips play an important role in
the control of the shape and volume of the oral cavity in the
production of speech.
The tongue shapes the oral and pharyngeal cavities for
vowel production. It restricts air flow in the oral cavity to pro­
duce consonants linguovelar, linguopalatal “K”, 1inguoalveolar
“G”, linguodental “T” “D” and “S” “Z”. The tongue is the ma­
jor articulator during the production of all phonemes, with the
exception of the bilabial and labiodental sounds. Compromise
to the tongue secondary to surgical resection, resulting in al­
tered volume, and limited andrestricted movement of the tongue,
tongue segments, or flaps, can have an adverse affect upon the
quality of speech.
As previously mentioned, mandibulectomy patients are
likely to exhibit errors in articulation of speech sounds231,232’233.
Articulation is accomplished by discreet and precise positional
changes of the tongue, lips, and cheeks in relation to the palate,
teeth, and other oral structures.
The tongue is the principle structure responsible for these
articulations. Basic tongue movements are controlled by its at­
tached extrinsic musculature and, to a certain extent, mandibu­
lar movements. The intrinsic musculature creates changes in
the form and shape of the tongue, such as elevation, or depres­
sion of the blade or tip. The intrinsic musculature has the poten­
tial to make discreet changes in the shape and position of the
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
tongue, independent of either mandibular movements, or con­
traction of the extrinsic musculature234. The tongue is richly
endowed with both motor and sensory innervation. The lips
(especially the lower lip) and cheek are also intimately involved
in the articulation of speech.
Consequently, following resection of lesions located close
to the mandible, articulation is adversely affected. As discussed
previously, this group of patients is not homogenous. Lesions
vary in their size and location and, therefore, the surgical and
radiological treatment will vary; as will the impact upon oral
structure and function. In general, following mandibular resec­
tions, the oral cavity is reduced in size and a portion of the tongue
often is excised and/or used for closure of the wound. The sen-
soiy and motor innervation of the tongue can be compromised,
especially following resection of posterior tongue lesions. In­
nervation of the lower lip and cheek are compromised by the
primary mandibular resection and the radical neck dissection.
Varying amounts of the mandible and numbers of teeth are re­
moved. Mandibular movements are significantly altered. If the
patient required radiation therapy, changes in the volume and
consistency of saliva will make prolonged discourse difficult.
All of these factors, either alone or in combination, predispose
to misarticulation of speech sounds.
In general, the speech exhibited by most mandibulectomy
patients will be understandable. The degree of impairment is
related primarily to the status of tongue function. With exten­
sive resections of the tongue and floor of the mouth, the re­
maining portion of the tongue may exhibit limited and impre­
cise movements. Sensory loss compromises proprioceptive
mechanisms of the residual tongue, requiring that contiguous
structures, with unimpaired sensory innervation, serve to moni­
tor tongue position. Consequently, placement of maxillary and
mandibular prosthesis may cover structures, serving as alter­
nate sensory pathways for monitoring the position of the tongue,
and may interfere with established adaptive and compensatory
mechanisms. It is therefore not surprising that placement of pros­
theses may compromise articulation in some patients with man­
dibular defects.
Unfortunately, few controlled studies have been performed
concerning the effects of mandibulectomy surgery upon articu­
lation, and the results are somewhat conflicting. For example,
Duguay described 2 patients following total glossectomy who
produced intelligible speech without a tongue235. He reported
that substitutions for tongue motion were made by the buccina­
tor muscles and the muscles of the floor of the mouth. Conso­
nant substitutes were used to produce acceptable speech. A doc­
toral dissertation by-Kalfuss reported on the speech of 22 pa­
tients following mandibulectomy and glossectomy surgery231.
The patients were divided into 4 groups, based upon the degree
of tongue resection. There was a direct correlation between the
amount of lingual tissue that was resected and the impairment
of articulation. Heberman reported that speech for
181
mandibulectomy patients improved through a regimen of regu­
lar muscle stretching, resistive exercises, and massage236. Skelly
studied and provided speech therapy for 14 total glossectomy
and 11 partial glossectomy patients233. Studying this patient
population with cineradiography, they reported different com­
pensation patterns between patient groups. Partial glossectomy
patients made use of the residual tongue to perform adaptive
movements approximating normal movements, whereas the total
glossectomy patients developed truly compensatory patterns of
speech. Both patient groups benefited from speech therapy when
dysphagia was not a problem. Describing a patient with a total
glossectomy, Bloomer reported that, although it had a “Donald
Duck” quality, speech was understandable237. Rentschler stud­
ied 20 patients, 2 with total glossectomies and 18 with partial
glossectomies238. The majority of these patients also had partial
mandibulectomies. He found that the rate of speech for most of
these patients was slower than normal. Speech and oral dis­
crimination were more severely impaired in patients who had
more extensive surgical excisions.
Palatal Speech and Swallowing Aids
An approach to the improvement of the articulation for
mandibulectomy patients has been suggested by Cantor239. They
noted that consonant sounds, such as “K” and “G”, required
valving by using the posterior part of the tongue in concert with
the posterior part of the hard palate and the anterior portion of
the soft palate, and these consonant sounds were particularly
difficult for mandibulectomy patients to make properly.
Heberman also noted distortion of these phonemes236. Cantor
reasoned that, if the palatal vault were lowered prosthetically
into the space of Donders to accommodate for restricted tongue
movements, speech improvement might be noted (Figure 5-
61)239. To test this hypothesis, 10 patients were selected, all with
restricted tongue movements. Five patients had extreme restric­
tion of movement of the tongue, and 5 had moderate restriction.
sum of reconstructed tongue to valve against the
prosthetic palate.
182 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Extreme restriction was defined as inability to contact either
the palate or the maxillary teeth with the residual tongue. Mod­
erate restriction was defined as partial or frequent tongue con­
tact with the teeth or the palate during speech. The palate was
lowered by means of a retainer for dentulous patients, and by a
palatal acrylic resin extension onto the maxillary denture for
the edentulous patients. A functional impression of the dorsal
surface of the tongue was molded during attempts at speech
production, and a hollow palatal speech prosthesis was con­
structed. Speech samples were recorded before placement of
the prosthesis, then recorded again after a 2-week period. The
test sample contained 10 words with “K” and “G” sounds. No
speech therapy was utilized during the test period. The speech
samples were randomized and rated by 5 trained speech pa­
thologists in a double blind evaluation. The results showed a
significant improvement for those patients with severely re­
stricted tongue movements, but the prosthesis slightly hampered
speech for those patients with moderate movement. While
Chierici and Lawson question the value of these prostheses for
sustained speech240, this study does demonstrate that, in patients
with severely restricted tongue movements, specific sounds can
be improved by a palatal speech aid.
In recent years, the palatal prosthesis has been evaluated
for its effects on speech and swallowing. Wheeler241, Davis242,
and Robbins243objectively evaluated the effects of a palatal pros­
thesis on speech and deglutition in 10, 1, and 10 patients, re­
spectively, who had partial or total glossectomies with or with­
out mandibular involvement. The prosthesis was designed to
accommodate the required range of motion of the residual
tongue. Voice recordings were used to evaluate speech and video
fluoroscopy techniques were used to study deglutition. (It is
important to note that all patients were evaluated and received
speech and swallowing therapy prior to the insertion of the pros­
thesis.) The authors reported improvement in speech and de­
glutition following the placement of the prosthesis.
In the Robbins study, the patients also received follow-up
speech and swallowing therapy after the insertion of the defini­
tive prosthesis. With the exception of Robbins, these authors
reported compromises in the design of the prosthesis to accom­
modate both speech and swallowing. Robbins did not find any
impairment of speech in patients with limited residual tongue
mobility, contrary to the findings by Cantor.
Leonard and Gillis evaluated the differential effects of a
speech prosthesis in 5 glossectomy patients244. Three patients,
who had 50% or more remaining tongue with good mobility,
were treated with a palatal prosthesis. One patient was treated
with a mandibular prosthesis, and 1 patient had both a palatal
and a mandibular prosthesis. Hie mandibular prosthesis was
used if litde or no residual tongue remained. Recordings with
and without the prosthesis were evaluated by a practicing speech
pathologist All subjects demonstrated varying degrees of im­
provement in the speech measures evaluated (intelligibility,
number of consonants in error, and the acoustic measures range
of vowels). The effects of these prostheses on swallowing was
not studied, nor was it determined if the same results could have
been achieved with a palatal prosthesis in the 2 patients who
had a mandibular prosthesis.
Speech Therapy
Speech therapy is probably the most effective means of
improving articulation in these patients. Scott investigated the
potential benefit of intensive speech therapy for mandibulectomy
patients232. Twenty patients were selected for study; 10 wore
palatal speech aids and 10 did not The patients were divided
into 4 groups. Two groups of 5 patients (5 with and 5 without
prostheses) received 6 weeks of intensive speech therapy, and
the control groups received no speech therapy. Although the
groups were small, the study did offer 2 valid conclusions: (a)
placement of a palatal speech aid, although improving the qual­
ity of specific sounds, may not improve discourse, and (b) in­
tensive speech therapy improved speech significantly for pa­
tients both with and without prostheses.
Speech-Deglutition Prosthesis Fabrication
The determination of whether a speech or deglutition aid
prosthesis should be placed in the maxillary or mandibular arch
has been based primarily on volume and mobility of residual
tongue or reconstructed flaps. Other factors to consider are pres­
ence and condition of teeth to help stabilize the prosthesis, man­
dibular range of motion, Up and cheek mobility, tongue sensa­
tion and position, and commissure width. The patient’s chief
complaint regarding speech or swallowing, or both, and expec­
tations for improvement, may influence the treatment options
along with patient motivation. As mentioned previously, a thor­
ough examination, with appropriate tests and radiographic stud­
ies, should be completed prior to initiating treatment
A mandibular-based tongue prosthesis, following surgery,
has improved the quality of speech, and also assisted in degluti­
tion (Figure 5-62)245,246,247. Residual movement of the mandible
and contiguous tissues were utilized to approximate the pros­
thesis with palatal and dental structures. Although there are ad­
vocates for the mandibular prosthesis for total glossectomy pa­
tients, the support for this intervention has been based on case
reports involving a small number of patients who have been
evaluated in a research setting (see Chapter 12).
Palatal speech and swallowing aids are easily made. After
obtaining a cast a temporary acrylic resin template is made that
can be modified with modeling plastic, elastomeric impression
materials, waxes, or tissue conditioning materials. These modi­
fications must be made to accommodate residual tongue and
mandibular movements during speech or swallowing, or both,
depending upon the planned function of the prosthesis. Because
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 183

of its ease of handling and adjustment, and patient acceptance
for interim use, the authors prefer the tissue conditioners mixed
to a thick, moldable consistency. When the final contour has
been determined, it is converted to a hollow acrylic resin pala­
tal prosthesis (Figure 5-63). Patients are seen for follow-up ap­
pointments to make any adjustments to accommodate specific
adaptations, including increased mobility or hypertrophy of the
articulating tissues. This approach does require multiple appoint­
ments with trial-and-error modifications guided by input from
the patient, family members, and the speech pathologist. Re­
cent developments with computerized analysis and simulation
techniques may prove to be helpful in patient selection for pros­
thetic intervention, design, and location of speech and degluti­
tion prosthesis. Clinical fine-tuning will usually be required248.
Surgical Reconstruction of the Tongue
With the development of myocutaneous flaps and free flaps,
there has been an increased frequency of surgical attempts to
rehabilitate the total glossectomy patient with and without man­
dibular involvement (Figures 5-56 and 5-58)249,250. As with pros­
thetic intervention, the degree of success has varied, and there
are far fewer objective controlled studies that assess the quality
of function of the surgically reconstructed tongue. The major
problems with these flaps are bulk, lack of voluntary control
with limited or no sensation, and, usually, single directional
movement. Nevertheless, some patients do develop adaptive
movements and do reasonably well. When these flaps are used,
consideration should be given to limiting bulk, allowing room

Fig. 5-62.
a: Total glossectomy defect, b:
Mandibularly based tongue pros­
thesis. Speech was intelligible
with prosthesis in position. Pros­
thesis was made of acrylic resin.

Fig. 5-63. a: P atient with hem iglossectom y defe ct repaired w ith

myocutaneous flap, b: Thick mix of temporary denture reline
material was added to palatal vault area, and patient was asked
to speak and swallow. Note contours, c: Prosthesis inserted, d:
Compare contour of speech aid to that of reconstructed tongue.
184 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
for future prosthodontic rehabilitation in the mandibular arch to
restore mastication and deglutition. An awareness and use of
the palatal speech and swallowing prosthesis should be stressed
to the surgeons to assure them that excessive bulk may actually
hinder future rehabilitation.
Mandibular Guidance Therapy
Loss of continuity of the mandible destroys the balance
and symmetry of mandibular function, leading to altered man­
dibular movements and deviation of the residual fragment to­
wards the surgical side. The disparities of the postsuigical en­
velope of motion and the severity of deviation are dependent
upon many complex and interrelated factors. In general, those
patients suffering extensive soft tissue loss resulting in tight
wound closure, those patients receiving full course radiation
therapy, and those patients requiring a classical radical neck
dissection suffer the most severe mandibular deviation and dys­
function. Patients with discontinuity defects precipitated by car­
cinomas arising from the base of the tongue are particularly
affected. The poorly to moderately differentiated squamous cell
carcinomas occurring in this region often require pie- or post­
operative radiation therapy and a radical neck dissection. If pri­
mary closure is employed because of the lack of local tissue
following the resection, the surgical closure is exceedingly tight.
In selected cases, the surgeon will purposely deviate the man­
dible towards the surgical side with the surgical dressing in or­
der to relieve tension on the suture line, thereby reducing the
risk of wound breakdown and fistula formation. Conversely,
mandibular resections resulting in little soft tissue loss and not
requiring a radical neck dissection, such as in removal of odon­
togenic tumors of the mandible, or those who have the soft tis­
sues resected or replaced with a myocutaneous flap or a free
flap, precipitate much less mandibular deviation and dysfunc­
tion.
In general, the use of myocutaneous flaps reduce the se­
verity of mandibular deviation, and usually facilitate guidance
therapy. These observations are based on initiating an exercise
program immediately following surgery and prior to, during,
and following radiation therapy. When a functioning condyle
and portion of ascending ramus have been maintained on the
resected side, and free osseous tissue grafts of appropriate vol­
ume are used to restore mandibular continuity, guidance therapy
is not indicated. When the condyle is lost on the resected side,
and free osseous grafts of appropriate volume and contour are
used, guidance therapy may be required to achieve normal align­
ment and function. No matter how aggressive the guidance in­
tervention may be, all function will be based on the side with
the intact TMJ apparatus. When osseous grafts with excessive
volume and improper contour are used, mandibular deviation
may be minimal, but mandibular range of motion may be se­
verely impaired, with resultant altered maxillomandibular rela­
tionships and oral function. These conditions cannot be improved
with guidance therapy.
There are a number of methods which will reduce or elimi­
nate mandibular deviation, including intermaxillary fixation, use
of mandibularly-based guidance restorations, and palatally-based
guidance restorations. For best results, these methods and res­
torations should be combined with a well-organized mandibu­
lar exercise regimen. The method of choice depends on numer­
ous factors.
Intermaxillary Fixation
An approach used in the past to reduce the deviation asso­
ciated with resection of the mandible, but is currently not in
favor, was to place the patient into intermaxillary fixation im­
mediately, using arch bars and elastics. Intermaxillary fixation
is maintained for 5 to 7 weeks following surgeiy. Although no
controlled studies have been performed to evaluate the efficacy
of this approach, some clinicians feel that it is distinctly benefi­
cial in reducing postsurgical mandibular deviation. Aramany
and Myers reported the findings in 12 patients treated with in­
termaxillary fixation immediately following surgical resection
of the mandible251. Five patients were partially edentulous and
7 were totally edentulous. Intermaxillary fixation was achieved
with arch bars and elastics or wire in dentuious patients, and
gunning splints in edentulous patients. Following removal of
fixation, only 2 of the 7 edentulous patients demonstrated suffi­
cient deviation to require construction of a palatal guidance res­
toration. In the remaining 5 patients, normal occlusal relation­
ships were maintained and no guidance therapy was necessary.
Only 1 of the 5 partially dentuious patients required mandibu­
lar guidance therapy following removal of fixation. At first
glance, this study appears to substantiate the value of intermax­
illary fixation in preventing mandibular deviation. However,
the lack of a control patient population, and the absence of data
regarding type of resection employed, site of the tumor, extent
of soft tissue resection, or the use of radiation therapy, prevent
all encompassing conclusions. Indeed, some experienced sur­
geons feel that intermaxillary fixation has no place in the com­
posite resection of the mandible252.
We feel intermaxillary fixation provides little benefit to
these patients. It is feasible only in patients with resections con­
fined to the mandible, and with little associated soft tissue loss.
In these patients, scar contracture is minimal and, since ample
soft tissue is available for closure, mandibular deviation is actu­
ally secondary to muscle imbalances and compromised prop­
rioception. Using intermaxillary fixation in these patients main­
tains the proprioceptive sense of occlusion and enables most
patients to readily assume appropriate intercuspal positions fol­
lowing removal of fixation. However, even without intermaxil­
lary fixation, these patients soon regain appropriate
maxillomandibular relationships and redevelop a propriocep­
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
tive sense of occlusion. It is not feasible or appropriate if the
patient required composite resection with a classical radical neck
dissection and/or radiation therapy, the oral wound is closed
primarily, mandibular deviation is worsened, and the resulting
scar contracture is more profound and unyielding. In these pa­
tients, scar contracture and tight wound closure contribute more
to deviation than do muscle imbalances and/or loss of the prop­
rioceptive sense of occlusion. Experience has indicated inter­
maxillary fixation to be of little use in this group of patients,
and it may actually lead to additional discomfort and morbidity,
such as fistula formation and dental disease.
Resection Guidance Restorations
Mandibular guidance therapy begins when the immediate
postsurgical sequelae have subsided, usually at about 2 weeks
after surgery. Initially, the patient should be placed on an exer­
cise program. Following maximum opening, the mandible is
manipulated by grasping the chin and moving the mandible away
from the surgical side. These movements tend to loosen scar
contracture, reduce trismus, and improve maxillomandibular
relationships. Exercise should be carefully demonstrated to die
patient and notes made periodically, describing the progress
made by the patient.
The earlier mandibular guidance therapy is initiated, the
more successful the result If the patient has undergone an ex­
tensive resection, including a classical radical neck dissection,
and received radiation therapy, and if a considerable period of
time has elapsed since the surgical procedure, guidance proce­
dures are much more difficult, and a compromised occlusal re­
lationship may result Unfortunately, those patients suffering
the most severe deviations of the mandible, due to extensive
soft tissue loss, tight wound closure, radiation therapy, and clas­
sical radical neck dissection, are most susceptible to the com­
plication of fistula formation, flap necrosis, and other postsur­
gical morbidities which delay the beginning of mandibular guid­
ance therapy. Because of these necessary delays, some patients
may never be able to achieve normal maxillomandibular rela­
tionships.
In the absence of primary wound complications, placement
of a resection guidance restoration can be considered. There are
several approaches which can be utilized to guide the mandible
to an improved intercuspal relationship. Unfortunately, if teeth
a e not present, guidance is not effective. The excessive lateral
forces generated during guidance of the mandible will only serve
to dislodge complete dentures. If only mandibular teeth are
present then guidance is possible, but not as effective as when
teeth are present in both arches. The guidance prosthesis may
be constructed for either the mandible or the maxilla. All guid­
ance prostheses are utilized on an interim basis until acceptable
occlusal relationships and proper proprioception are reestab­
lished. Once an acceptable occlusal relationship is established,
185
the guidance prosthesis may be discarded or used occasionally
to reinforce the proprioceptive mechanism.
If the mandible can be manipulated into an acceptable
maxillomandibular relationship but the patient lacks the motor
control to bring die mandible into occlusion, a cast mandibular
resection restoration, as described by Robinson and Rubright,
is appropriate253. This mandibular guidance prosthesis consists
of a removable partial denture framework, with a metal flange
extending 7 to 10 mm laterally and superiorly on the buccal
aspect of the bicuspids, and molars on the non-defect side. This
flange engages the maxillary teeth during mandibular closure,
thereby directing the mandible into an appropriate intercuspal
position (Figure 5-64). The partial denture framework must be
suitably stable and retained to counteract the lateral forces gen­
erated upon the prosthesis during closure. The guidance flange
may be constructed of cast chrome cobalt metal or acrylic resin.
The material of choice will depend upon the existing occlusal
relationship of the patient and the need for adjustability. If the
mandible can be manipulated comfortably into an acceptable
occlusal position, then a cast metal guidance ramp will be ap­
propriate. If some resistance is encountered in positioning the
mandible, then a guidance ramp of acrylic resin is suggested, as
this material can be periodically adjusted as an improved rela­
tionship is obtained. (A cast metal guidance flange allows for
only minimal adjustment.)
Fabrication begins with retrieval of suitable mandibular and
maxillary casts. A wax interocclusal record, obtained by the cli­
nician to guide the mandible into the best possible interocclusal
relationship, is used to mount the diagnostic casts on a suitable
articulator. With the use of this mounting, occlusal relationships
should be examined carefully. Often, selected occlusal equili­
bration can be performed that will aid the patient in achieving
an improved occlusal relationship. If a considerable period of
time has elapsed since surgery, the patient may exhibit some
extrusion of teeth, due to the lack of occlusal contact and modi­
fication of tooth contours may permit closure into a more fa­
vorable position. The diagnostic cast of the mandible is sur­
veyed and the design of the partial denture framework is out­
lined. To prevent movement of individual teeth, framework
designs should positively engage most of the remaining denti­
tion (Figure 5-64 a,b). The guidance ramp is usually designed
to extend from a continuous clasp along the buccal surfaces of
the bicuspids and molars. Because of the angular pathway of
mandibular closure, this extension must extend superiorly in a
diagonal manner, and it must allow for the normal horizontal
and vertical overlap of the maxillary teeth. If autopolymerizing
resin is to be used to form the guidance ramp, a retentive mesh
is extended from the continuous buccal clasp on the non-defect
side, and the ramp is formed in the mouth by the patient. In
most instances, it is necessary to construct a maxillary frame­
work with a buccal plate incorporated within die design, so that
as the patient closes, the guidance ramp attached to the man­
186 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

dibular prosthesis does not traumatize maxillary teeth and gin­
giva. The maxillary framework also serves to resist the forces
of arch contracture and maintain the maxillary teeth on the de­
fect side in proper alignment until an appropriate intercuspal
position is achieved.
The exact angulation of the guidance ramp is difficult to
fabricate with a conventional articulator. A second wax record,
obtained with the posterior teeth separated approximately 3 mm
and the mandible maximally deflected towards the unresected
side, will give the prosthodontist an approximation of the cor­
rect angulation of the mandibular guidance ramp. The partial
denture framework is fabricated following customary
prosthodontic guidelines. The wax pattern of the framework
should be reviewed by the clinician prior to casting. Many den­
tal laboratories are not acquainted with the principles of man­
dibular guidance and, often, either the cast guidance ramp or
retention for the ramp is placed incorrectly. The partial denture
framework is verified in the mouth and adjusted using rouge
and chloroform, disclosing wax, or other similar mediums.
If the completed guidance ramp is to be formulated in
acrylic resin, the retention provided for the addition of the resin
should not touch or interfere with the maxillary teeth during a
guided closure. Autopolymerizing acrylic resin is added to the
retention and the prosthesis is seated in the mouth. As the resin
reaches the doughy stage, the mandible is manipulated into the
desired interocclusal relationship. This movement should be
repeated several times. The resin should be manipulated to ex­
tend 7 to 10 mm superiorly. The prosthesis is removed from the
mouth and the resin is allowed to polymerize. Sharp projec­
tions formed by the maxillary teeth are rounded and all borders
are smoothed. The prosthesis is replaced in the mouth to verify
the guidance established by the addition of the resin. Some pa­
tients will experience initial difficulty engaging the ramp with
the buccal surfaces of the maxillary teeth, and manual manipu­
lation of the mandible may be necessary in order for the patient
to “sense” this position. If this position cannot be assumed by
the patient by manual manipulation of the mandible, it may be
necessary to remove the resin and reestablish the ramp, allow­
ing for a more medial position of the mandible at closure.

Fig. 5-64.
a and b: Mandible from tooth #31, up to and including the condyle, was resected. Cast
partial denture frameworks were fabricated for both maxilla and mandible. Frame­
works engage residual dentition to prevent movement of individual teeth during man­
dibular closure. Following resection, remnants of the masseter muscle were reattached
to the residual mandible, c and d: Consequently, no frontal plant rotation is observed
during closure. Note angular path of closure. (Courtesy: Frank J. Kratochvil.)
d
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 187

Acrylic ramps are advantageous because periodic revisions

and adjustments of the ramp are possible, and the final desired
position does not have to be achieved with the initial applica­
tion of acrylic resin. After the patient has adjusted to the initial
position, the ramp may be reformed in resin and the mandible
may be guided further laterally into an improved occlusal rela­
tionship.
A second design confines the guidance ramp and index to
a maxillary prosthesis. This form of guidance is indicated in
most patients with mandibular deviation. Maxillary guidance
ramps are more adjustable than mandibular guidance ramps,
and are preferred for the patient with severe mandibular devia­
tion. These maxillary prostheses are usually constructed of a
acrylic resin with either cast- or wrought-wire retainers, since
they serve only on an interim basis until an acceptable occlu­
sion can be established. The full palatal coverage prosthesis is
constructed, following conventional prosthodontic guidelines,
and then fitted and adjusted in the mouth. The mandible is ma­
nipulated laterally toward the desired position, and the occlusal
contact with the palatal prosthesis is noted. The prosthesis is
removed, a mix of autopolymerizing acrylic resin is prepared,
and the resin is added to the palatal prosthesis, along the lateral
and anterior borders on the non-defect side. The prosthesis is
replaced in the mouth and the mandible is manipulated to the
desired position, thus establishing an index in the palate. At the
first appointment, this index is usually lingual to the maxillary
teeth (Figure 5-65 a,b).
The movement is repeated several times until the resin be­
gins to polymerize. The prosthesis is then removed to allow for
completion of polymerization of the acrylic resin. After adjust­
ment and smoothing, the prosthesis is reinserted. The patient
should be able to close into the index, using appropriate manual
manipulation of the mandible. The prosthesis is polished, and
the patient is instructed to wear the prosthesis continuously. The
index should not extend below the level of the maxillary teeth
because, if it does, it may interfere with speech, deglutition, and
other oral functions requiring tongue manipulations. In selected
patients with limited tongue motion, this observance may not
be necessary. The objectives of the prosthesis are explained to
the patient and the exercise instructions are outlined.
When the patient returns, the mandible will usually exhibit
more freedom of movement laterally towards the nonsurgical
side, requiring adjustment of the palatal ramp enabling the man­
dible to assume a more desired maxillomandibular relationship
(Figure 5-65c). As the index approaches the maxillary teeth, it Fig. 5-65. a: Severity of mandibular deviation did not permit
may be necessary to equilibrate selected teeth to eliminate cuspal establishment of appropriate maxillomandibular
interference. When an acceptable intercuspal position is relationships with guidance ramp, b: When pala­
achieved, occlusal equilibration is generally necessary to main­ tal prosthesis was formulated and delivered, man­
tain the mandibular position. dibular teeth still occluded lingual to desired po­
The success of mandibular guidance therapy varies and sition. c: As scar contracture loosened, occlusal
depends upon the nature of the surgical defect, early initiation index was adjusted so patient achieved adequate
of guidance therapy, patient cooperation, and other factors. Pa- interocclusal relationship.
188 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

tients with extensive posterior base of tongue lesions, resulting
in significant soft tissue resection and requiring radiation therapy,
are frequently unable to achieve useful intercuspal relationships.
Mandibular guidance therapy is most successful in patients in
whom the resection involves only bony structures, with mini­
mal sacrifice of tongue, floor of the mouth, and adjacent soft
tissues. The absence of a radical neck dissection also improves
the prognosis for mandibular guidance therapy. Those patients
who have not been irradiated likewise have a better chance of
obtaining a useful interocclusal position with mandibular guid­
ance therapy.
If guidance therapy is successful and the patient is able to
achieve a useful intercuspal position, efficient mastication may
still not be possible in patients with compromised tongue mo­
bility and control. In most patients, reestablishment of reason­
able masticatory efficiency is dependent on good tongue func­
tion.
Occlusal Equilibration
Occlusal equilibration is often necessary after mandibular
guidance therapy has been completed. In most patients, the
mandible assumes a different postural position at closure from
what it had assumed prior to surgery. Occlusal equilibration is
challenging because of the imprecise nature of mandibular
movements and the non-reproducibility of centric relation
records. Centric occlusion records are made and transferred to
a suitable articulator. The occlusal relationships are carefully
examined and prematurities identified and noted. Reductions
are made on the teeth of the mounted casts and the sequence of
the reductions is recorded. The sequence is repeated on the pa­
tient and, upon completion, new impressions and interocclusal
records are made. The casts are mounted and studied as before,
and the entire sequence is repeated. Two to 3 sessions may be
required before a stable occlusion is obtained (Figure 5-66).
Often, selective crown placement may be required to achieve
appropriate interocclusal relationships. The patient should be
informed that, as mandibular deviation is reduced, the facial
disfigurement on the defect side will be accentuated, for the
deviation of the mandible towards the surgical side will tend to
camouflage the defect.
The ultimate occlusal relationships established will depend
on the reduction of mandibular deviation, the amount of frontal
plane rotation, and the limitations imposed by the status of the
remaining structures (i.e., tongue, lips, cheeks, floor of mouth,
soft palate, and flaps). The reestablished occlusal stops must
not interfere with speech or deglutition, and must provide free­
dom for the patient to masticate food and position the bolus in a

Fig. 5-66. a: Patient at beginning of mandibular guidance therapy. Palata. s ie r.

\sn4s n s atvd <n^naii. PaSten&te ab\e to achieve this position on a re:
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
manner that is consistent with.the existing adaptive limitations.
Patient motivation should not be discounted when attempting
to rehabilitate these patients. Many can overcome difficult ob­
stacles and, if given a stable occlusion, many learn to masticate
in a reasonably functional fashion.
Prosthetic Rehabilitation
The prosthetic prognosis of removable prostheses is quite
variable for patients with resections of the tongue and man­
dible. In some patients, only esthetics can be improved, whereas,
in others, improved mastication is a reasonable objective. In
this segment, we will attempt to delineate those factors and clini­
cal procedures that are important in achieving the best possible
results with removable prostheses.
Partially Edentulous Patients
The delay from surgery until the definitive prosthesis is
constructed will vary considerably for the mandibulectomy pa­
tient, as compared to postsurgical maxillary patients. Follow­
ing resections of the maxilla, the progression of healing is the
primary determinant regarding when the definitive prosthesis
can be constructed. With patients who have undergone resec­
tions of the mandible, healing is important, but other factors
must be considered. With most mandibulectomy patients, the
primary determinant usually is related to occlusion. In these
patients, definitive partial denture restorations are deferred un­
til acceptable maxillomandibular relationships are obtained, or
an endpoint in mandibular guidance therapy has been reached.
In patients with mandibular defects, the urgency for place­
ment of the definitive prosthesis is not as great, and the progno­
sis for these prostheses is not as favorable, as it is for patients
with maxillary defects. Many mandibulectomy patients are not
dependent on their prosthesis for oral functions. If anterior teeth
are not involved in the resection, some mandibulectomy pa­
tients will prefer not to wear a removable prosthesis. Radiation
caries may be a major consideration. Since partial dentures can
complicate oral hygiene, they may be contraindicated for re­
placement of a few teeth if esthetics and mastication are not
major considerations. Since time is not a major factor, the pros­
thodontist should insure that all conventional restorative proce­
dures have been completed and that the occlusion is acceptable.
After mandibular guidance therapy is completed and the occlu­
sion is acceptable, the definitive prosthesis is begun.
Lateral Discontinuity Defects
Partial denture design* Included in this category are patients
with lateral resections, where anterior teeth are still present The
usual principles of partial denture design and fabrication apply
to lateral discontinuity defects. Major connectors should be rigid,
* Section on partial denture design contributed by Frank J. Kratchovil
189
occlusal rests must direct occlusal forces along the long axis of
teeth, guiding planes should be employed to enhance stability
and bracing, retention must be within the limits of physiologi­
cal tolerance of the periodontal ligament, and maximum sup­
port should be gained from the adjacent soft tissues. Retainers,
minor connectors, and proximal plates should be designed so
that they do not express excessive lateral forces on the remain­
ing teeth during function. Designs also should consider the needs
of cleansibility, the compromised oral hygiene, and predisposi­
tion to plaque accumulation exhibited by patients treated for
head and neck cancers. Designs also must take into consider­
ation retention and, because of the increased lateral forces gen­
erated during the chewing cycle, the need for horizontal brac­
ing.
In patients with lateral discontinuity defects, it may not be
possible to design a framework whose retainers disengage dur­
ing function because of the altered patterns of force generation.
As explained previously, the arc of closure of the mandible is
quite different from that in nonsurgical patients. Mewed from
the frontal plane, closure is angular rather than vertical, produc­
ing forces of occlusion that are entirely unilateral and confined
exclusively to the non-resected side. Rotation of the mandible
in the frontal plane causes the resected side to drop down out of
occlusion as the force of contracture on the unresected side is
increased. Hence, the location of the fulcrum line is not as eas­
ily determined, making it more difficult to predict movement
patterns of the prosthesis during function. Typical lateral
mandibulectomy defects with suggested designs are shown in
Figure 5-67. The forces of occlusion are unilateral and, conse­
quently, the axis of rotation (fulcrum line) of the partial denture
deviates from the norm. By placing the occlusal rest on the cin-
gulum or on the mesial aspect, it is possible to place retainers
that disengage during expression of a posterior occlusal load on
the distal abutment of the resected side. However, a retainer
that will disengage during occlusal function cannot be posi­
tioned on the opposite terminal abutment Consequently, this
retainer must either be placed on the height of contour, or must
possess adequate flexibility, so that an occlusal load will not
unduly expose the cuspid to pathologic stresses. After the par­
tial denture casting has been fabricated, it is important to physi­
ologically relieve it. The combination of rouge and chloroform
is an effective medium, and special attention should be paid to
proximal plates and minor connectors (Figure 5-68).
Altered cast impressions After the partial denture casting has
been fabricated, verified, and adjusted, an altered cast impres­
sion is obtained of the edentulous areas. Particular attention
should be paid to the lingual extension on the unresected side,
especially the polished surfaces. This extension, when suitably
developed, provides additional retention and stability for the
prosthesis (Figure 5-69). An accurate impression of the pol­
ished surfaces of the denture flange on the normal side will
190 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Occlusal Load
Occlusal rests

Occlusal load A x is of rotation

anterior posterior
Proximal plate

Fulcrum line

Height of
BUCCAL VIEW

Fig. 5-67. a and b: Suggested partial denture design for a lateral discontinuity defect. Note fulcrum line, c and d: RPD frame­
works for 2 patients. Note position of rests and retainers. Lingual plate was used for both patients.

Fig. 5-68. Rouge and chloroform used to physiologically Fig. 5-69. Note the lingual extension on the unresected side
adjust casting. {arrow). Accurate impression of the polished sur­
face will improve stability and retention during
function.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
enhance stability. Maximum soft tissue coverage is always at­
tempted. Coverage of the buccal shelf on the unresected side
will maximize support. Attempts should be made to extend the
impression into soft tissue areas on the resected side. If the par­
tial denture is extended beyond the bony resection, teeth may
be placed on the resected side, thus improving esthetics and
enabling bilateral occlusal contacts in some patients. Rarely,
however, will this extension on the resected side provide cheek
support or alleviate the facial concavity secondary to loss of
bone and soft tissue. This tissue bed is quite unyielding and is
not easily displaced. In molding this segment of the prosthesis,
the clinician should manipulate the cheek and direct the patient
to protrude and move the tongue from side to side in order not
to impinge upon tongue and cheek function. The extension be­
yond the bony resection has been termed an outrigger—an apt
description. Often, a slight space will exist under this outrigger
when the tissues are at rest, but, during function, the tissues will
be in contact with these surfaces. After the altered cast impres­
sion is obtained, the master cast is segmented, and the impres­
sion is boxed and poured in the usual way.
An alternative cast preparation technique is suggested if
the patient has 3 or less contiguous teeth on the non-defect side,
especially if long edentulous spans border this remaining tooth
segment. It is difficult to maintain the proper orientation of this
small tooth segment to the edentulous areas recorded with the
altered cast impressions after the original cast is segmented.
The manipulation necessary to bead, box, and pour the altered
cast may compromise this orientation, and subtle changes are
difficult to detect after the impression is poured. Therefore, a
pickup impression is suggested. After the altered cast impres­
sion of the edentulous segments is completed in light body rub­
ber base impression material, the framework is removed, and
any wash material in inappropriate areas is carefully removed
from around the framework, retainer assemblies, or edentulous
areas. The framework is then repositioned in the mouth and a
pickup impression is made with irreversible hydrocolloid im­
pression material in a rigid stock tray. Only a limited amount of
alginate material should be loaded into the tray in areas corre­
sponding to the edentulous segments, and this impression and
the framework must be removed as a unit. The possibility of
distortion exists if the framework is repositioned in the impres­
sion after removal of the impression in the stock tray. If the
irreversible hydrocolloid impression material flows beyond the
peripheries, as established by the altered cast impression, it may
be removed with a sharp scalpel. If this cut is made at right
angles to the edentulous span, a land area in the cast can be
created. If the framework is unusually retentive, consideration
should be given to adjusting the retainers, slightly prior to mak­
ing the pickup impression, to ensure the framework’s removal
in the alginate impression.
191
Remaining clinical procedures The master cast is retrieved,
wax rims are constructed on the record bases, and a centric oc­
clusionjaw relation record is obtained. In patients with impaired
tongue mobility or insufficient tongue bulk, centric occlusion
should be established at a closed vertical dimension of occlu­
sion. This closed vertical dimension will enable the tongue to
interact more effectively with palatal structures. The
maxillomandibular relationship may have been established pre­
viously with mandibular guidance therapy, and refined with
occlusal equilibration and selected crown placement. The wax
is softened and the mandible is gently guided to this predeter­
mined position. We prefer to obtain maxillomandibular records
with a soft wax and a minimum of occlusal pressure. As has
been previously noted, when the force of contracture on the
unresected side increases, mandibularrotation in the frontal plane
results in the resected side moving downward out of occlusion.
This phenomena is impossible to correct in the dentulous pa­
tient requiring a partial denture. Since this movement does not
result in deflective occlusal contact, and since mastication is
performed on the non-resected side, we expect and accept this
movement, and have no suggestions regarding how this prob­
lem can be corrected.
The occlusion should be designed so that the patient can
identify proprioceptively the appropriate intercuspal position at
centric occlusion. Selection of denture teeth is dependent upon
the configuration of the opposing dentition. In most instances,
acrylic resin teeth are suggested with cusps approximating the
angulation displayed by the opposing dentition. When less than
ideal occlusal relationships must be accepted, it may be neces­
sary to establish an occlusal ramp lingual to the maxillary teeth
on the unresected side (Figures 5-70 and 5-71). If the patient
requires a maxillary partial denture, provision for this ramp must
be included in the design of the partial denture framework (Fig­
ure 5-72). The ramp is established grossly on the articulator in
wax. After the jaw relationships are verified at the try-in, the
ramp is functionally generated by the mandibular teeth. The
ramp can also be established in autopolymerizing acrylic resin
after delivery of the prosthesis. A more detailed discussion of
the design and fabrication of functionally-generated occlusal
ramps is explained in the section dealing with complete den­
tures.
The partial denture prostheses are delivered and adjusted
in the usual way. At delivery, attention should be paid to oc­
clusal relationships. The soft tissue extensions on the defect side
should be carefully verified because these tissues may have little
sensory innervation. The remaining denture flanges must be
checked for overextension, and dislodging forces should be
eliminated. The patient is scheduled for sequential recall visits
and placed on a recall system that allows for quarterly follow-
up examinations during the first year.
192 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

9 h
Fig. 5-70. a and b: Patient with lateral tongue and mandibular discontinuity defect, c: Maxillary removable partial denture with
palatal index, d: Mandibular overlay partial denture, e: Mandibular prosthesis in position, f: Maxillary removable
partial denture in position, g and h: Open and closed positions. Note angular path of closure.

Defects with Mandibular Continuity Maintained or
Reestablished
Anterior Defects Included in this category are patients with
anterior inner table resections and patients with anterior com­
posite resections in whom mandibular continuity has been re­
established with reconstructive surgery. Both types of patients
have posterior teeth and an extensive edentulous area anteri­
orly, creating the need for a Kennedy Class IV partial denture.
The length of the edentulous area depends-upon the extent of
the surgery and the number and location of posterior teeth. Fol­
lowing these resections, the occlusion of the posterior teeth is
rarely altered, and the pattern of mandibular movements is usu­
ally normal. Patients with surgically restored anterior disconti­
nuity defects may display occlusal abnormalities because of graft
contracture, or inaccurate positioning of the residual mandibu­
lar fragments at the time of surgical reconstruction. Once bony
continuity is reestablished, the occlusion cannot be changed,
except with occlusal equilibration or placement of coronal res­
torations.
The anterior edentulous segment will usually display un­
usual soft tissue configurations and compromised bony support
for both types of patients (Figure 5-73). There is considerable
variation in size and length of the span of these defects. In large
defects, the lack of attached mucosa and the obliteration of ves­
tibules may require a vestibuloplasty and skin graft. Frequently,
bands of scar tissue cross the residual anterior alveolar ridge
between the lip and tongue. Unless a vestibuloplasty is per­
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 193

d e f

Fig. 5-71. a: Patient with a lateral mandibular discontinuity defect. Note deviation, b: Palatal guidance prosthesis, c:
Maxillomandibular relation after mandibular guidance therapy, d: Maxillary removable partial denture was fabri­
cated following equilibration. Note palatal ramp and index on maxillary removable partial denture, e: Prosthesis in
mouth, f: Occlusal relationship. Index increases length of occlusal table, improving mastication effectiveness for this
patient.

formed, and denture bearing surfaces are created that are lined
with attached tissue upon movement of either the lip or tongue,
these tissue bands are frequently displaced preventing the effi­
cient engagement of this bearing surface by the prosthesis. These
tissue bands are easily irritated by the prosthesis.
Conventional removable partial dentures for these patients
enhance esthetics, provide support for the lower lip and cheek,
frequently lead to improved articulation of speech, and enhance
the control of saliva. In small defects (Figure 5-74), when a
cuspid has been retained, mastication is effectively restored. In
larger defects (Figure 5-75), the primary benefit of the prosthe­
sis is to provide lip support for the patient. Masticatory effi­
ciency is compromised because of the length and movement of
the anterior edentulous section of the partial denture due, in
turn, to compromised mucosal support and length of the eden­
tulous section. The placement of implants in the symphyseal
region will provide the necessary support and should be con­
sidered for these defects.

a b c

Fig. 5-72. a: Patient presented with a lateral discontinuity defect, b and c: Because of mandibular deviation, a palatal ramp
was incorporated into maxillary complete denture.
194 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Fig. 5-73. Anterior defects present with a number of different configurations, a: Continuity of mandible has been restored with
a free bone graft, b: Marginal mandibular resection. Continuity was retained and wound closed primarily, c: Marginal
resection. Skin graft used to resurface exposed mandible.

Fig. 5-74. a: Anterior mandibular defect following local alveolar ridge resection, b
and c: Removable partial denture framework, d: Completed prosthesis.
Mastication was effectively restored because of the presence of the left
cuspid.

Conventional removable partial dentures Partial denture
designs must consider the movement of the anterior segment of
the prosthesis. A suggested design is presented in Figure 5-76.
Note the axis of rotation. With a distal rest, the retainers will
disengage during a forceful closure. The long mesial rests on
the second molars provide indirect retention. Particular care
should be taken to relieve the proximal plates and the distal
aspect of the minor connectors to allow for the expected move­
ment of the framework during occlusion.
The edentulous areas are recorded with an altered cast im­
pression. Thermoplastic waxes are especially suited for the an­
terior edentulous segment because they record movable tissue
beds more accurately than do elastic impression materials. At
try-in, esthetics, occlusion, and speech should be verified, with
particular attention paid to establishing the contour of the lower
lip. These prostheses are processed, polished, delivered, and
adjusted following conventional prosthodontic guidelines, and
the patient is placed on a recall system for periodic monitoring.
Implant-retainedprostheses Prostheses retained and sup­
ported by osseointegrated implants placed in the anterior re­
gion of the mandible, in combination with the remaining poste­
rior teeth, enable most anterior resection patients to masticate
effectively. Most of these patients possess good tongue func­
tion, but the lack of support anteriorly impairs effective inci­
sion and mastication of the food bolus. Osseointegrated implants
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
provide this support. In patients who have undergone a mar­
ginal resection of the mandible, at least 10 mm of vertical bone
is advisable before implants are considered. A similar bulk of
bone is required for grafted mandibles.
In the marginal resection patient, the viability and density
of the residual bone in the anterior mandible lead to success
rates in excess of 95%. The bone-implant interface levels ap­
Fulcrum line
Fig. 5-76. a, b, and c: Suggested partial denture
design for anterior defect. Retainers will
disengage when occlusal load is ap­
plied.
c
195
Fig. 5-75.
a: Anterior mandibular discontinuity de­
fect restored with a fibula free flap, b:
Partial denture framework, c: Completed
prosthesis. Note contours o f anterior ex­
tension. d: Prosthesis inserted, e and f:
Pre- and post-insertion contours.
proach 75% to 85% and, therefore, these implants are capable
of supporting significant occlusal loads. Implants placed in free
grafts used to reconstruct this region have a similar high suc­
cess rate177. Free bone grafts demonstrate a homogenous calci­
fication pattern which results in an excellent bone implant in­
terface (Figure 5-77, left side)186. Bone grafts associated with
free flaps, particularly the fibula, present with prominent corti-
Occlusal Load
anterior
Proximal plate
Axis of
BUCCAL VIEW
196 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
Free Graft Fibula
Fig. 5-77. Free grafts derived from compacted cancellous
bone have a more homogenous calcification pat­
tern and therefore form an excellent bone implant
interface. Bone from fibula flap has thick cortices
but little calcified structure in the marrow. Anchor­
age of implants is dependent on engaging the 2
cortical layers.
Fig. 5-78. Periimplantitis. Thinning overlying tissues and
attaching the tissues to periosteum will help pre­
vent this problem.
Fig. 5-79. Surgical template, made from a trial denture setup,
is used to ensure implants are positioned prop­
erly.
cal plates which, when properly engaged, provide excellent sta­
bilization for the implants; the preliminary reports are favor­
able (Figure 5-77, right side)196.
The major challenge encountered when placing implants
into the anterior mandibular resection patient is to create thin,
attached, keratinized tissues around the implant. Following
marginal mandibular resection there is a significant soft tissue
deficit in the area because the original wound is usually closed
primarily. These sites almost always require vestibuloplasty, with
the proximating soft tissues supplemented with a skin or palatal
graft. The objective is to create thin, keratinized soft tissues
which are attached to the periosteum of the residual mandible.
When implants penetrate attached keratinized tissues, oral hy­
giene measures are easier for the patient, and the risk of
periimplantitis is reduced.
In contrast, defects restored with free bone grafts generally
present with an excess of soft tissue overlying the graft. In most
patients, a myocutaneous flap is used to replace the soft tissues
removed during the tumor extirpation. The free autogenous bone
graft is usually placed at a later date, and is positioned within
the tissues of the myocutaneous flap. Implants are placed into
the bone graft 6 to 9 months later. Sometimes, the soft tissues
covering the implants can be 10-15 mm in thickness. These
tissues must be thinned, and attached tissues around the im­
plant must be created, if periimplantitis is to be avoided. Like­
wise, the bulky soft tissues overlying the bone of free flaps must
be carefully thinned and attached to periosteum. Ideally, the
thickness of the tissues adjacent to the implants should not ex­
ceed 3 or 4 mm. If the tissues are not thinned sufficiently, deep
periimplant pockets will result, predisposing to infection, granu­
lation tissue formation, and hypertrophy. These soft tissue in­
fections can spread to bone, leading to loss of bone and, ulti­
mately, implant failure (Figure 5-78).
Removable overlay prostheses are preferred for restoring
these defects. Support for mastication is provided by the im­
plants anteriorly and by the residual dentition posteriorly. Den­
ture flanges can be contoured to reposition and support the lower
Up. In addition, access for oral hygiene is easier for the patient.
When bone sites are sufficient for long implants (13 mm or
greater in length), only 2 implants are required to restore most
defects. If shorter implants are required (10 mm or shorter in
length) or the posterior dentition is compromised, 4 or more
implants may be needed. A surgical template should be used to
ensure that the implants are inserted into the proper locations
(Figure 5-79).
If an implant-supported prosthesis is preferred, and if the
edentulous space extends into the molar region, a minimum of
4 or 5 implants must be placed. In this instance, the proper ar­
rangement of the implants is critical. The arc of curvature of the
arrangement must result in at least a 1 cm anterior-posterior (A-
P) spread (Figure 5-80). This arrangement will enable the im­
plants and the prosthesis to effectively withstand the forces of
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
Fig. 5-80. a and b: An implant supported restoration is
planned. Five implants were placed. Note the
anterior-posterior (AP) spread.
197
mastication. Fixed restorations with lessA-P spread have a higher
rate of implant failure and an increased number of complica­
tions associated with the prosthesis, such as screw or implant
fracture.
If a fixed restoration is planned, implants should be placed
in the sites to be occupied by the teeth as opposed to interproxi-
mal areas. The buccal-lingual position and angulation are also
important Implants should be positioned so that the screw ac­
cess channels exit through the cingulum area of anterior teeth
and central fossa of the posterior teeth. If a removable overlay
prosthesis is planned, only the buccal-lingual or labial-lingual
position and angulation are of concern. Implants should be placed
so that the abutments and retentive apparatus fit within the con­
fines of the prosthesis, allowing for proper placement of den­
ture teeth.
Impressions are made in the usual manner, using impres­
sion copings. We prefer the cylindrical-type impression coping
because it is easier to use and requires less chair time. The inac­
curacies associated with these impression copings are accounted
for by the use of a solder relation record, made at the time of
metal try-in. If an overlay prosthesis is planned, the impression
tray must be border molded. A detailed description of implant
impression techniques is beyond the scope of this discussion so
the reader is referred to Beumer and Lewis254.
Maxillomandibular records are made and the casts are trans­
ferred to an appropriate articulator. A trial prosthesis is prepared,
and a template is fabricated from this prosthesis (Figure 5-81).
This template can be used to design any type of metal frame­
work, whether the metal framework is for a porcelain-fused-to-
metal restoration or for a framework intended to be a retention
bar for an overlay denture. To insure a passive fit of the metal
framework, we recommend that it be divided into segments.
Individual segments are secured to each implant and a solder
Fig. 5-81.
This template (a and b) is
designed to be mounted on
the articulator (c) to aid in
design and preparation of the
implant prosthesis (d).
 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

j k

. 5-82. a and b: Patient presents with large squamous carcinoma of alveolar ridge and floor of the mouth, c: Patient recon­
structed immediately with fibula flap, d and e: Implants placed 6 months later. Healing after second stage implant
surgery was delayed, so porcelain fused to metal healing abutments were custom made to facilitate healing of the
soft tissues, f, g, and h: Master cast, full contour waxup, and completed restoration, i and j: Completed restoration
in position, k: Thirty-month follow-up radiograph. I: Facial view.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 199

relation record is obtained. A soldering index is made o f im­

proved dental stone and used later to verify the accuracy of the
soldering procedure. The prosthesis is then completed, using
conventional prosthodontic guidelines (Figure 5-82). Hygiene
instruction is provided and the patient placed on 3-month re­
call.

Lateral defects

Conventional removablepartial dentures Lateral defects,

in which posterior dentition remains on only one side of the
arch, are particularly difficult partial dentures to design (Figure
5-83). The extremely long lever arms and compromised eden­
tulous bearing surfaces contribute to excessive movement of
the prosthesis during function. A proposed partial denture de­
sign is presented in Figure 5-84. The fulcrum line is dynamic in
Fulcrum
line Fulcrum line
Posterior load on
defect side
a
Fig. 5-83. Patient has a lateral defect. Mandible was
intact, but only 5 teeth remained.
that it changes depending on the position of force application
on the extension base. Patients tend to confine the bolus to the
dentate side during the chewing cycle, but they may generate
considerable load when incising a bolus of food and incisal forces
are applied. The fulcrum line runs through the most anterior
rest in a manner shown in Figure 5-84. The anterior and poste­
rior proximal plates move freely during function. The labial
retainer on the cuspid is placed in a retentive area. It will disen­
gage when a bolus is incised. The posterior retainer and lingual
plating aid retention and bracing in the horizontal plane. Maxi­
mum coverage of the edentulous bearing area is suggested. The
occlusion should be refined so as to achieve contact in centric
occlusion only, and the patient should be instructed to masti­
cate on the non-defect side with the residual mandibular denti­
tion (Figure 5-85).

Fulcrum
line Fulcrum line

Fig. 5-85.
a: Completed res­
toration. The rib­
bon rest serves to
co n tro l o cclusal
forces, b: Occlu­
sio n on d e fe c t
Posterior load on
defect side s id e s h o u ld be
limited to centric
b occlusion contact
Fig. 5-84. Suggested partial denture designs for a lateral only.
mandibular continuity defect, a: Design for patient
with a favorable edentulous extension area, b:
Design for patient with an unfavorable edentulous
extension area.
200 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

a c

Fig. 5-86. a and b: Lateral mandibular defect reconstructed with fibula free flap, c: Partial denture framework. Note position of
occlusal rests, proximal plates and retainers, d: Altered cast impression, e: Completed restoration, f, g, and h:
Prosthesis in position.

Implant-retained prostheses The patient in Figure 5-86
has a lateral mandibular defect reconstructed with a fibula free
flap. The mesial rest on the second premolar controls the axis of
rotation when a force is applied to the distal extension on the
unresected side. The cingulum rest on the cuspid controls the
axis of rotation when an occlusal load is applied on the resected
side. Therefore, the casting is physiologically adjusted to ac­
count for multiple axes of rotation.
In these large defects, osseointegrated implants significantly
improve the retention, stability, and support for removable par­
tial dentures. If the bone volume permits, and the anterior man­
dible is edentulous, 2 or more implants should be placed in this
region. These implants improve retention and stability of the
prosthesis, but the primary benefit is support. With anterior
implant support, the patient can incise much more effectively
with the prosthesis. The purpose of the portion of the prosthesis
that extends into the defect is to support the lip and cheek, and
to prevent hypereruption of opposing dentition. These objec­
tives are easily met with a mucosally-supported distal exten­
sion prosthesis.
Many dentulous patients with oral tongue and/or lateral
floor of mouth carcinomas require resection of the mandibular
body distal to the cuspid tooth. In the past, few of these patients
had continuity of the mandible restored with a bone graft for a
variety of reasons. With the introduction of the myocutaneous
flap and, more recently, the microvascular free flap, reconstruc­
tion of most mandibular discontinuity defects can be accom­
plished with a high degree of predictability. The refinement of
these surgical reconstruction techniques has coincided with the
development of osseointegrated implants, and recent data indi­
cates that implants can be placed into either free grafts177,186or
free flaps196,215 with a high degree of success. The question is
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
whether the placement of implants into the bone grafts used to
restore lateral mandible defects of dentuious patients improves
mastication.
The factors determining whether implants should be placed
into these grafts is the status of the motor and sensory innerva­
tion on the defect side. The Ungual and hypoglossal nerves are
frequently sacrificed during composite resection of tongue and/
or lateral floor of mouth tumors. These neurologic deficits pre­
vent the patient from detecting or manipulating the bolus on the
defect side, regardless of how effectively the bone and soft tis­
sue defects have been surgically reconstructed. So-called “sen-
sate flaps” have not improved this phenomenon because the
nature of the sensory feedback is not sufficient for the patient to
detect or control the food bolus. Therefore, the objective of pros­
thesis extension into this region is for Up support, esthetics, pre­
vention of eruption of opposing dentition, speech, and so forth.
These objectives can be met with a conventional removable
partial denture, providing the residual dentition is in reasonable
condition (Figures 5-86 and 5-87). Compromised dentitions can
be supplemented with implants. If motor and sensory innerva­
tion on the defect side is intact, the use for implants is justified
and will enable efficient mastication (Figure 5-88).
Fig. 5-87. a: Hemiglossectomy-hemimandibulectomy defect
restored with scapula flap. Speech and swallow­
ing were restored to near normal, b: Dentition re­
stored with removable partial denture. Mastica­
tion conducted on the non-defect side because
food bolus cannot be detected or controlled on
resected side.
201
Prosthodontic Rehabilitation of Edentulous Patients
Lateral Discontinuity Defects—
Conventional Complete Dentures
Few edentulous patients with lateral discontinuity defects
of the mandible have the capabiUty of achieving presurgical
levels of masticatory efficiency. While the number of patients
with lateral, non-reconstructed, discontinuity defects is decreas­
ing yearly, some of the patients stiU remain, and they will re­
quire prosthodontic rehabilitation. This discontinuity defect
group includes mainly patients with a guarded prognosis for
tumor control, or with major health problems, precluding ma­
jor reconstruction efforts. Resection complete dentures for these
patients are primarily for esthetics. They improve lip and cheek
contour and replace missing teeth. In selected patients, these
prostheses improve the articulation of particular speech sounds.
Only with implant retained and supported overlay dentures does
the patient have the hope of efficient mastication. A number of
factors compromise the patient’s abiUty to masticate with re­
section complete dentures:
• With only one-half or two-thirds of the mandible remain­
ing, stability, support, and retention of the mandibular den­
ture are compromised.
• Since many patients will have received radiation therapy
either prior to or after surgery, the oral mucosa is atrophic
and fragile, predisposing to soft tissue irritation and ulcer­
ation. Chronic alcohol abuse and poor nutrition may fur­
ther compromise the health of oral mucous membranes.
• The reduction of saliva output, and the thick mucinous
nature of the saUva that remains after therapeutic levels of
radiation, impairs retention and compromises lubrication
of the denture-mucosal interface (see Chapter 4).
• The angular pathway of mandibular closure induces lat­
eral forces upon the dentures, which tend to dislodge them.
• The deviation of the mandible creates abnormal jaw rela­
tionships. The abnormal profile and position of the man­
dible in relation to the maxiUa may prevent ideal place­
ment of the denture teeth over their supporting structures.
• The impairment of motor and/or sensory control of the
tongue, lip, and cheek impairs the ability of the patient to
control the prostheses during function. The integrated neu­
romuscular balance between tongue, Ups, and cheeks that
serves to stabilize complete mandibular dentures in nor­
mal patients is compromised in patients with mandibular
discontinuity defects.
202 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

f g h

Fig. 5-88. Lateral mandibular discontinuity defect restored with a free graft, a: Four implants have been placed, b, c, and d:
Milled bar enables fabrication of an overlay implant-supported prosthesis, e: Tissue side of prosthesis. Note recep­
tacle sites for Hacfer-style clips, f: Panorex radiograph of implants and completed bar. g and h: Prosthesis in posi­
tion. Hypoglossal and lingual nerves were intact; therefore, patient was able to masticate on defect side.

Factors determining theprostheticprognosisfor conventional
complete dentures The prosthodontic prognosis is dependent
upon a number of complex factors. The extent of the bony and
soft tissue resection has significant impact If the bony resec­
tion does not involve significant amounts of adjacent soft tis­
sues, such as in the case of resection of a benign tumor or an
epidermoid carcinoma confined to the alveolar ridge, the prog­
nosis is quite favorable (Figure 5-89a). However, if the resec­
tion results in significant soft tissue loss, such as with resection
of portions of the tongue, floor of the mouth, and buccal mu­
cosa, the prosthetic prognosis is quite guarded (Figure 5-89b).
These patients demonstrate more mandibular deviation and tris­
mus, as well as significant tongue and lip disability.
The location of the bony resection is also a good prognos-
ticator. Mandibular resections extending to the midline have a
poor prosthetic prognosis and, in our experience, very few com­
plete dentures have been used successfully by patients with this
type of resection (Figure 5-90a)255. In almost all patients, place­
ment of osseointegrated implants in the residual anterior man­
dible or reconstruction of the mandible with a bone graft, or
both, will enable function with dentures. If the resection is lim­
ited to the cuspid region anteriorly, the prosthetic prognosis is
more favorable (Figure 5-90b). An even more favorable prog­
nosis for complete dentures exists when the resection is con­
fined to the molar region. In some of these patients, remnants of
the masseter and medial pterygoid muscles may remain attached
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
to the mandible, enabling the prosthodontist to obtain a bilater­
ally-balanced occlusion. These patients demonstrate nearly ver­
tical envelopes of motion (when viewed in the frontal plane)
and near normal alveolar ridge relationships, allowing for a more
favorable distribution of forces during mastication and swal­
lowing. Balanced occlusion is impossible to achieve in man­
dibular resections extending more anteriorly.
The status of the remaining tongue is the most important
prosthodontic prognostic indicator (Figure 5-91). If the motor
and/or sensory control of the tongue has been significantly com­
promised by the resection, the prosthetic prognosis becomes
extremely guarded. The mobility and bulk of the tongue is also
b b
Fig. 5-89. a: Patient underwent composite resection for epi­
dermoid carcinoma of posterior alveolar ridge; §f
mandible. Since most of tongue remains, and
motor and sensory innervation is intact, progno­
sis for complete dentures use is favorable, even
though alveolar ridge has been resorbed, b: Al­
though bony resection in this patient was identi­
cal to that in the previous patient, extensive loss
of tongue and adjacent soft tissues, plus resec­
tion of the lingual and hypoglossal nerves, make
prosthetic prognosis poor.
203
important. If the patient is capable of moving his tongue in a
number of directions he probably will be successful in stabiliz­
ing the mandibular denture during function. If possible, resected
tongue tissue should be restored preferably with a free flap (Fig­
ure 5-92). Free flaps are preferred over myocutaneous flaps
because the reconstructed tissues of the free flap are more flex­
ible. A small amount of residual tongue can move a large bulk
of free flap if motor innervation is intact. Obviously, patients
who have lost significant amounts of tongue in combination
with resection of one of the hypoglossal nerves, accompanied
by considerable local paresthesia, have a less favorable pros­
thetic prognosis. Ironically, immobility of the tongue creates a
Fig. 5-90. a: Resection of mandible extended to midline. An
outrigger extension is available, but prosthetic
prognosis is poor unless implants are placed an­
teriorly or mandible is reconstructed with a bone
graft, b: Resection was limited anteriorly to cus­
pid region. Prosthetic prognosis improves as more
mandible is retained.
204 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Fig. 5-91. a, b, and c: Tongue movement patterns for patient I. d, e, and f: Tongue movements for patient II. Note difference in
tongue control and mobility. Prosthetic prognosis is much more favorable for patient I, even though height and
contour of alveolar ridge for Patient II is far superior.

minor anatomical advantage in that it often enables a more ag­
gressive extension of the lingual flange on the nonsurgical side,
thus facilitating stability and retention.
As with normal patients, the position of the tongue is an
important prosthodontic prognosticator. Resection of base of
tongue lesions often results in a retruded tongue position, mak­
ing it difficult to obtain a peripheral seal. However, with most
lateral and anterior resections of the mandible and tongue, the
tongue is fixed in a more favorable position anteriorly.
Mandibular deviation and the character of mandibular
movements are important indicators of the prosthetic progno­
sis. Those patients with severe deviation of the mandible and
angular paths of closure will have more difficulty wearing den­
tures because of instability and increased mucosal irritation (Fig­
ure 5-93). Retention of the mandibular denture is further com­
promised because these patients can apply occlusal forces only
to the unresected side. In patients with inadequate palatal mor­
phology, this phenomenon may result in a loss of the peripheral
seal of the maxillary denture. Denture adhesives enhance reten­
tion of the maxillary denture in selected patients. The severity
of mandibular rotation in the frontal plane, as viewed at rest and
during a forceful closure, is also an important indicator. Ad­
equate stability generally cannot be obtained in a patient with
excessive frontal plane rotation (Figure 5-94).
Postsurgical lip posture and control, although less impor­
tant diagnostically than tongue function, does have important
prosthodontic implications (Figure 5-95). As previously men­
tioned, most composite resections compromise the motor con­
trol and sensory innervation of the comer of the mouth, cheek,
and the lower lip on the resected side because of resection of
marginal mandibular and inferior alveolar nerves. This predis­
poses to cheek biting and poor control of salivary secretions. In
some patients, the lip may be retracted posteriorly, significantly
compromising the extent of the labial and buccal flanges, and
necessitating a more lingual placement of the denture teeth.
If the patient has received full course radiation therapy,
tolerance of complete dentures is further compromised (see
Chapter 4). The increased complement of lateral forces, in com­
bination with the compromised mucosal bearing surface, sec­
ondary to the radiation therapy and reduction in salivary flow,
increases the risk of mucosal irritation and ulceration from com­
plete dentures. The reduction in volume and the change in con­
sistency of the saliva further compromise the peripheral seal,
especially in the maxillary denture. Therapeutic levels of radia­
tion may also make mandibular deviation more severe. This
results in a more angular path of mandibular closure during
function, thereby applying lateral forces of greater magnitude
to the resection denture. Radiation therapy also may increase
trismus and precipitate lymphedema.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 205

Fig. 5-92. Patients are shown with various tongue configurations, a: Patient with hemiglossectomy and hemimandibulectomy
defect restored with a free bone graft. Tongue is malpositioned, its bulk is reduced, and mobility is poor; therefore,
prosthetic prognosis is poor, b: Hemiglossectomy. Residual tongue has been reshaped and vestibuloplasty per­
formed. Tongue mobility is poor and tongue bulk is reduced; therefore, prosthetic prognosis is poor, c: Hemiglossec­
tomy and hemimandibulectomy defect. Resected tongue tissue restored with myocutaneous flap. Mandibular con­
tinuity has not been restored. Mobility of reconstructed tongue is poor, but restored bulk and ideal positioning
improve prosthetic prognosis, d: Hemiglossectomy defect restored with radial forearm free flap. Tongue is properly
positioned, has adequate bulk, and has excellent mobility. Prosthetic prognosis is good, e: Subtotal glossectomy
defect. Only 20% of oral tongue remained, but it was innervated with hypoglossal nerve. Patient was able to accom­
plish extensive movement of reconstructed tongue with residual tongue element. Speech was excellent, but pros­
thetic prognosis, with respect to mastication, is guarded because of lack of innervation in reconstructed portion of
tongue, f: Total glossectomy defect. No oral tongue remained, and it was not reconstructed. Prosthetic prognosis is
very poor.

Fig. 5-93. Patient presented with severe mandibular
deviation and angular path o f closure.
Patients with such closure patterns gen­
erate more lateral forces during function,
thus predisposing to dislodgment of den­
tures.
Fig. 5-94. Patient presented with frontal plane ro­
tation at vertical dimension of rest, which
was accentuated during a forceful clo­
sure. If frontal plane rotation is exces­
sive during function, complete dentures
become unstable.
206 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Prior to therapy, the prosthodontist must consider all these

factors and inform the patient of the prognosis for the complete
dentures. This is an important discussion that must be handled
in a delicate and supportive manner. As with all phases of pros-
thodontics, those problems affecting the prognosis, which are
discussed with the patient prior to fabrication, are usually ac­
cepted.

Impressions Maximum extension and tissue coverage should

be recorded with the preliminary impression. Irreversible hy­
drocolloid is used in combination with an altered stock tray.
Wax or modeling plastic may be useful to extend the stock tray
in areas of difficult access. This is especially true for the lingual
flange on the unresected side. Often, the tongue closely approxi­
mates the alveolus, and placement of impression material into
the lingual sulcus on the non-defect side is difficult. Special
attention should also be paid to recording the soft tissue areas
posterior to the resection. A disposable syringe is often used to
inject impression material into areas of difficult access prior to
seating the stock tray with impression material into position
(Figure 5-96).
Master impression trays are fabricated in the customary
manner. The objectives of the master impressions are the same
as in conventional prosthodontics (i.e., to establish retention,
provide support and stability, and create the appropriate esthetic
support for the lips and cheeks). Since experience and training
will vary, we suggest that the clinician employs the techniques
that he or she prefers for making the master impression. We
advocate conventional border molding with dental modeling
plastic to establish peripheral extensions. We also suggest that
the peripheral extensions be refined with an elastic impression
material or a thermoplastic wax.

d
Fig. 5-95. a: Note contour of lower lip, particularly on
resected side (arrow), b and c: Patient has diffi­
culty obtaining lip seal on both resected and non­
resected sides, d: Prosthesis in place. Upon open- Fig. 5-96. Disposable syringe used to inject irreversible hy­
ing, lip on resected side is displaced posteriorly, drocolloid into lingual vestibule prior to seating
tending to dislodge denture. tray.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 207

Fig. 5-97. a: Completed mandibular impression. Note development of lingual flange on the unresected side, b: Both polished
and tissue bearing surfaces have been recorded. In this patient, it was possible to extend the impression past the
bony resection on resected side, thus enhancing stability and support, c: Impression is boxed in usual fashion. Note
that more of the polished surface of the lingual flange on non-defect side is maintained than is customary.

Retention in the mandible is achieved by obtaining close
adaptation of the prosthesis with the bearing surface, and by
extending the lingual periphery on the unresected side to the
maximal extent compatible with functional and anatomical limi­
tations. Surprisingly, the degree of peripheral seal effected may
be greater than expected. An accurate recording of the contour
of the polished surfaces of the denture is also an important con­
sideration, especially for the lingual flanges on the resected and
unresected sides. If these polished surfaces are accurately re­
corded, the tongue will retain the mandibular denture in posi­
tion more efficiently during function (Figure 5-91)756. Support
for the mandibular prosthesis can be obtained from the buccal
shelf, the crest of the ridge, the retromolar pad, and, when pos­
sible, the soft tissue bed posterior to the bony resection (Figure
5-97). Because of the lingual inclination and rotation of the
mandible, the buccal shelf on the unresected side becomes a
prime support area. The stability of the definitive prosthesis is
facilitated if the clinician appropriately develops the contours
of the lingual flange on the unresected side. The surface of the
tongue that functions with or against this flange resists the lat­
eral dislodging forces developed during closure. Careful con­
touring of the lingual flange on the resected side and the outrigger
extension region will also help to resist the lateral forces ex­
erted upon the prosthesis during mastication. As previously
mentioned, the lower lip on the resected side is often retracted
posteriorly, predisposing to cheek and lip biting. If the lower lip
can be repositioned labially with a denture flange, this frustrat­
ing and disconcerting side effect can be negated. Proper sup­
port for the lower lip will also enhance control of salivary se­
cretions. If the lip and cheek on the resected side are heavily
scarred and unyielding, this extension can create a dislodging
force upon the prosthesis. Consequently, this flange must be
carefully molded to obtain appropriate lip support without com­
promising retention. We prefer to develop this flange, some­
times referred to as a lip plumper, after delivery of the denture,
when a more accurate assessment can be made of the affect of
the lip plummer on the stability of the denture.
Some clinicians advocate making a functional impression
of the polished surfaces of the mandibular prosthesis257,258,259.
This concept has special application for mandibulectomy pa­
tients, and clinically enhances the stability and retention of the
prosthesis256. The clinician can record the polished surfaces when
molding the master impression, during try-in or at delivery. If
these surfaces are recorded at the impression stage, care should
be taken to box the impression in order to maintain the imprint
of the polished surfaces.
Peripheral seal of the maxillary denture may be difficult to
achieve in some patients. Because of deviation of the mandible,
the anterior border of the ramus and the coronoid process may
be in close apposition to the maxillary tuberosity on the non-
resected side (Figure 5-98 a, b, and c). Consequently, when the
maxillary impression is molded, the extension of the denture
around the tuberosity is often compromised. If a proximal man­
dibular fragment remains on the resected side, a similar prob­
lem results. This fragment is pulled medially and superiorly by
the lateral pterygoid and the temporalis muscles, bringing it into
close approximation to the maxillary tuberosity (Figure 5-98d).
In other patients, the pedicle flaps or free flaps used to recon­
struct local soft tissues may compromise denture extension
around the maxillary tuberosity (Figure 5-98e). If denture ex­
tensions are compromised, consideration should be given to
placement of implants into the anterior maxilla in order to ef­
fectively retain and stabilize the maxillary complete denture.
Centric registrations Record bases are constructed in the usual
way with the following exceptions. In the maxilla, the wax rim
used to record the centric occlusion registration record is wid­
ened on the unresected side towards the palatal side in order to
account for deviation of the mandible. The labial and buccal
contours of the maxillary wax rim are normal, with the excep­
tion that support for the upper lip may need to be reduced. Be­
208 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Fig. 5-98. a: Lateral mandible has been resected in this patient, b and c: Mouth mirror is used to determine if proper denture
extensions can be made around maxillary tuberosity on both resected and non-resected sides, d: In this patient, a
residual coronoid process has obliterated buccal pouch area around maxillary tuberosity, e: Forehead flap used to
reconstruct a soft tissue defect obliterated vestibule around tuberosity.

cause of the deviation and retrusion of the mandible, normal
support for the upper lip will tend to accentuate the altered
maxillomandibular discrepancy.
Hie vertical dimension of occlusion is difficult to deter­
mine. Altered proprioceptive mechanisms, trismus, mandibu­
lar deviation, impaired motor and sensory function, and muscle
imbalances make it difficult to obtain accurate and repeatable
registrations. Consequently, many of the traditional methods
successfully employed in normal patients are not applicable to
patients with discontinuity defects of the mandible. If the pa­
tient has near normal tongue bulk, mobility, and control, evalu­
ation with phonetics and the closest speaking space are best
suited for the determination of vertical dimension of rest and
vertical dimension of occlusion. Some clinicians feel that swal­
lowing is also a beneficial adjunct Methods in which pressure
and neuromuscular determinations are used to record the verti­
cal dimension of rest are not applicable because of the instabil­
ity of the record bases, the unilateral forces of occlusion, and
the altered pathway of closure. For the same reasons, intra- and
extraoral tracing devices cannot be used successfully.
The vertical dimension of occlusion should be closed as
much as possible in patients that exhibit reduced tongue bulk,
compromised tongue mobility, and, particularly, poor elevation.
Restoring the original vertical dimension of occlusion in these
patients will prevent the tongue from effectively interacting with
the palatal structures during speech and swallowing. If the tongue
is very restricted, consideration should be given to functional
augmentation of the palatal surface of the maxillary complete
denture with a palatal speech aid (Figure 5-63).
Centric Occlusion registrations may be obtained with wax,
plaster, or other similar recording media. The clinician should
manipulate the mandible and place it in the most advantageous
position that is within reach of the patient (Figure 5-99). Some
patients may demonstrate significant trismus. In these patients,
the vertical dimension of occlusion may need to be reduced in
order to facilitate insertion of the bolus between the teeth. The
more favorable the maxillomandibular relationship obtained
with the centric occlusion registration record, the more favor­
able the prosthodontic prognosis. Clinical judgment is the most
important factor in identifying a usable occlusal position. For
optimum function, a fimctionally-generated palatal ramp may
need to be formulated256,260. Mandibulectomy patients will usu­
ally function in a variety of positions during a functional clo­
sure. In addition, as scar contracture lessens, and as the patient
gains control over the movements and position of his mandible,
the deviation becomes less severe.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
Occlusal schemes and lateral registrations The abnormal jaw
relationships, in addition to the angular path of closure, favor
the use of nonanatomic posterior teeth260,261. The lack of a de­
finitive end point of closure, the loss of proprioception, and the
increased lateral stresses exerted on the denture bases during
function are additional factors that favor the use of nonanatomic
teeth. The arrangement of denture teeth requires some variation
from conventional prosthodontic guidelines. The degree of
modification is determined by the effect the surgical resection
has on the position and resiliency of residual soft tissues, the
tonus and control of bordering musculature, and the severity of
mandibular deviation. Positioning of mandibular teeth is facili­
tated by identification of what is known as the neutral zone.
This zone usually is nicely delineated by obtaining an impres­
sion of the polished surfaces during molding of the master im­
pression. Wax rims are fabricated accordingly.
Fig. 5-99. a: Occlusal registration obtained with wax and zinc
oxide paste. Note mandibular deviation repre­
sented by this record, b: Record transferred to an
articulator.
209
Special attention should be paid to developing appropriate
contours of the rim which contacts with the inside of the upper
and lower lip. If the residual tongue rests on the edentulous
ridge, it usually does so in the cuspid region on the non-defect
side, and the wax must be adjusted accordingly. After the wax
rims have been altered and registrations obtained, the maxillary
and mandibular casts are mounted on a suitable articulator. This
maxillomandibular relationship and the contoured wax rims will
serve as a starting point for the arrangement of the denture teeth.
The maxillary and mandibular anterior teeth are positioned
initially according to the wax rims. Because of the deviation
and retrusion of the mandible, it is usually advisable to place
the maxillary anterior teeth lingual to, and the mandibular ante­
rior teeth labial to, their accustomed position (Figure 5-100).
Lip-tooth relationships can be improved if the vertical overlap
is increased so that the amount of tooth displayed and the smile
line are consistent with a more labial or normal position of the
maxillary teeth. Most patients with lateral resections of the
mandible cannot make protrusive movement; therefore incisal
guidance is not a factor and excessive vertical overlap does not
result in a deflective incisal contact
The mandibular posterior teeth are arranged according to
the contours of the wax rims. Generally, in the mandible, the
posterior teeth on the unresected side will be buccal to the crest
of the edentulous alveolus, especially in the bicuspid region
(Figure 5-101). With the lingual inclination of the residual man­
dible, and with elevation of the buccal shelf, placement of pos­
terior teeth to the buccal of the residual alveolar ridge centers
the forces of occlusion more favorably over the supporting struc­
tures, thus considerably enhancing stability of the prosthesis
(Figure 5-102). Buccal positioning of posterior teeth on the
unresected side also is more compatible with existing tongue
positions.
Labial
Set to
Occlusal plane
Fig. 5-100. Sagittal view of anterior tooth position. Note
maxillary central incisor is positioned slightly lin­
gual, and mandibular central incisor placed
slightly labial, from normal positions.
210 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

Fig. 5-101. Arrangement of posterior denture teeth, a and b: Note that, on unresected side, posterior maxillary teeth are
positioned towards the lingual, with corresponding mandibular teeth towards the buccal. Reverse is seen on
resected side, c: Note ridge relationship and frontal plane rotation on resected side, d: Note ridge relationship and
closed vertical dimension of occlusion on unresected side.

The posterior mandibular teeth on the surgical side are usu­

ally placed lingual to the crest of the edentulous ridge. In most
Un resected side
patients, the lip and cheek bordering the defect are pulled medi­
ally, are heavily scarred, and are quite unyielding. If the clini­
cian attempts to displace the lip and cheek with the teeth, the Occlusal plane
lower denture will surely be dislodged. Contour and support
for the comer of the mouth and the lip on the resected side is
best accomplished by thickening the denture flange below the
crest of the ridge. Lingual placement of these teeth also serves Buccal s h e l f ^ ^ ^ ^
to facilitate the occlusal relationship with the maxilla. Because
of the deviation of the mandible, occlusal contacts on the resected
side at touch closure can be achieved only if the maxillary teeth Fig. 5-102. Because of lingual inclination of remaining man­
are extended buccally from their accustomed position. Lingual dible, buccal shelf on unresected side is elevated
placement of mandibular posterior teeth also serves this pur­ and likely to be at right angle to occlusal forces.
pose. Thus, buccal shelf becomes prime support area.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 211

Unresected Resected

Fig. 5-103. Note lingual inclination of man­

dible and distance between al
veolus and mandibular poste­
rior teeth on resected side.

The profile established by the mandibular denture, when After tooth arrangements have been finalized, the occlusal
viewed in the frontal plane, will be abnormal in that the poste­ contact of the mandibular teeth is checked with the maxillary
rior teeth on the non-resected side will be close to the alveolar ramps. The patient should be able to establish contact with the
ridge, whereas the posterior teeth on the surgical side may be ramps without guidance. With slight guidance from the clini­
quite far from the alveolar ridge (Figure 5-103). There are sev­ cian, m ost patients w ill slide into a m ore norm al
eral reasons for this abnormal profile. First, in most patients, maxillomandibular relationship. Tracing wax is added to the
postsurgical trismus requires a modest reduction in the vertical maxillary ramps and the patient is instructed to carry out a full
dimension of occlusion. This results in the placement of the range of mandibular movements (Figure 5-104). During the trac­
denture teeth on the nonsurgical side closer to the alveolar ridge. ing, modest occlusal forces should be generated in order to par-
However, because of the lingual inclination of the mandible
(frontal plane rotation) away from the surgical side, the poste­
rior denture teeth must be elevated on the surgical side of the
mandible to achieve bilateral occlusal contact (Figure 5-103).
If the occlusal plane is lowered excessively to compensate for
this altered mandibular posture, the esthetics of the maxillary
prosthesis are compromised by the inappropriate display of teeth
on the resected side. Mastication is confined exclusively to the
non-defect side, and these bilateral occlusal contacts serve more
as a rescue or stabilizing force. It should be reiterated that, be­
cause the muscles of mastication are no longer attached to the Fig. 5-104.
mandible on the surgical side, bilateral balance of complete a and b: Maxillary
dentures during function, in the classical sense, is not possible. ramp on unresec­
After all the mandibular teeth and the maxillary anterior ted side ( arroii) is
teeth have been arranged, ramps are developed for the maxil­ developed function­
lary prosthesis in baseplate wax. These ramps should be ap­ ally, and it should
proximately 5 to 10 mm wide and should provide 3 to 4 mm of be extended to al­
horizontal overlap with the mandibular posterior teeth. Depend­ low 3-4 mm of hori­
ing upon the severity of mandibular deviation, the ramp on the zontal overlap with
nonsurgical side usually extends considerably lingual to the the opposing man­
maxillary alveolar ridge, and the ramp on the defect side ex­ dibular teeth.
tends buccal to the alveolar ridge. If desired, posterior maxil­
lary teeth can be positioned at this time. In order to obtain more
favorable occlusal relationships, the maxillary posterior teeth
should be placed to the lingual on the unresected side and to the
buccal on the resected side. During trial insertion, if the man­
dibular prosthesis seems to lack stability, the contour of the la­
bial extension and placement of anterior teeth should be checked
for excessive lip displacement.
212 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

tially compensate for frontal plane rotation of the mandible. In

some patients, the clinician may be required to stabilize the bases
during the tracing. Other patients will require some guidance
during these manipulations. The lingual extension of the maxil­
lary ramp on the unresected side will vary, depending upon the
severity of mandibular deviation and the status of tongue func­
tion. In patients with good mobility and control of the tongue,
the lingual extension of this ramp should be minimal in order
not to interfere with normal palatal valving (Figure 5-105)

Processing, deliveryandfollow-up After the trial prostheses

have been perfected, they are processed following customary
procedures (Figure 5-106). If the maxillary posterior teeth were
not positioned with the ramps, a buccal facing of autopolymeri-
zing tooth-colored resin is added. The prostheses are delivered
remounted and adjusted following conventional prosthodontic
guidelines. Disclosing wax is useful in identifying areas of ex­
cessive tissue displacement (Figure 5-107). We recommend that
tissues displaced excessively by the mandibular resection den­
ture be identified using a functional method. Disclosing wax is
placed into a disposable syringe and heated in a water bath. The
heated wax is applied to the underside surface of the denture,
and the patient is instructed to close and function with the op-
Fig. 5-105. Finished tracing is processed into methyl meth­
acrylate. Note that ramp widens occlusal table
primarily in the bicuspid region.
posing maxillary denture. The forces generated during function
will tend to deflect the denture laterally, towards the defect side.
Therefore, the lingual mucosa of the mandible on the defect
side is most susceptible to excessive tissue displacement. When
these areas are relieved, the wax will not be displaced. Patients

Fig. 5-106. a, b, c, and d: Completed resection dentures. Note variation in contours.

 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation
Fig. 5-107. a: Disclosing wax indicates that lingual surface
of denture on the resected side is causing tis­
sue displacement, b: Wax pattern following re­
lief of denture.
should be monitored closely during the post-insertion period,
particularly if the patient has received radiation therapy. In ad­
dition, many patients require continual support and encourage­
ment. The use of the prosthesis for mastication should be de­
ferred for at least a week. As the patient uses the prostheses,
some adjustment of the ramps is usually necessary. This can be
accomplished by remounting the dentures with records obtained
from a variety of occlusal positions. In most patients, the lower
lip on the defect side will be flaccid and retracted posteriorly,
and additional labial support may be required from the man­
dibular denture to produce normal contour and eliminate lip
biting. Proper contours are developed with a soft disclosing wax,
making sure that the extension does not displace the denture.
We prefer to process these lip plumpers with clear
autopolymerizing acrylic resin (Figure 5-108).
Lateral Discontinuity Defects—
Implant Retained and Supported Overlay Dentures
As previously discussed, complete dentures for edentulous
patients with discontinuity defects are primarily for esthetics.
213
Mastication is difficult because of compromised denture bear­
ing surfaces, deviation of the mandible, angular pathway of clo­
sure and abnormal jaw relationships, impaired motor and sen­
sory innervation of remaining tissues, and, most importantly,
compromised tongue function. These patients would be required
to stabilize and retain their resection complete dentures with
the tongue while using the tongue to manipulate the bolus, which
is beyond the capability of almost all patients. Osseointegrated
implants enable the fabrication of well-retained and stable over­
lay prostheses. The support derived from the residual denture
bearing surfaces, and the retention and stability provided by the
implants, is more than sufficient to allow effective mastication.
Patients with reasonable tongue bulk and mobility, and with
motor and sensory innervation intact on at least one side, will
benefit the most from implant-retained overlay prostheses. The
tongue is .no longer required to control the denture, so it can
now be used solely for control and manipulation of the bolus
during mastication and swallowing. Therefore, the key to reha­
bilitation is the status of tongue function following tumor re­
section. When portions of the tongue are resected because of
tumor, all reasonable effort should be made to restore its bulk
and avoid tethering it laterally or inferiorly. Free flaps are pre­
ferred over myocutaneous flaps because the flexibility of the
tissues result in improved mobility of the residual and recon­
structed portions of the tongue. The tongue should never be
used as the primary means of wound closure unless other op­
tions are not available.
Whereas edentulous, lateral mandible resection patients
with reasonable tongue function stand to realize significant
improvement in function with implant retained and stabilized
prostheses, patients with poor tongue function have little to gain.
One measure of tongue function available to the clinician is
speech articulation. If the patient’s speech is intelligible, the
prognosis for effective manipulation of the bolus with an im-
Fig. 5-108. Lip plumper added with resection denture in po­
sition.
214 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS

plant retained prosthesis may be considered reasonable. With
poor speech intelligibility, the prognosis for effective mastica­
tion is less predictable. Amore objective measurement of tongue
function and coordination would be a modified barium swal­
low. If the results of this study reveal prolonged oral transit
times, with considerable retention of the contrast medium in
the oral cavity, the prognosis for improved mastication would
be guarded. These findings would not necessarily preclude the
use of implants in such patients because there are other benefits
to be gained from a well retained prosthesis, such as esthetics,
restoration of oral competence, and so forth. However, neither
the clinician nor the patient should anticipate reasonable masti­
catory efficiency unless there is good tongue function.
In mandibular resection patients, if implants are to be placed
into the mandible to retain and support an overlay prosthesis,
consideration should be given to placing implants in the oppos­
ing maxilla. The unilateral occlusal loads, and the increased
lateral forces generated during the chewing cycle, tend to dis­
lodge the upper denture. Xerostomia secondary to radiotherapy
may further compromise peripheral seal. Therefore, implants
should be considered if retention and stability of a conventional
maxillary denture is marginal. Two implants, placed in the cus­
pid positions, will provide the necessary retention and stability.
Treatment procedures Implant retained overlay prostheses
are preferred for obvious reasons. First, as previously discussed,
deviation of the mandible may require that the teeth be posi­
tioned either buccal or lingual to the ridge. This is difficult when
designing a fixed, implant-retained restoration. Second, den­
ture flanges are necessary to provide support for the reposi­
tioned lower lip. Third, a sufficient number of implant sites may
not be available to provide the number and arrangement of im­
plants necessary to support a fixed restoration. In addition, the
hygiene of implant surfaces and retention bars are more easily
accomplished as compared to the oral hygiene necessary for
fixed restorations-an important factor because most resection
patients are elderly and may have impaired vision and/or poor
manual dexterity.
In most patients, the only implant sites available in the eden­
tulous resected mandible are located in the symphyseal region.
A minimum of 2 implants should be placed; however, more are
desirable if space allows, not so much for retention or support,
but for stability. As previously discussed, resection patients dem­
onstrate a unilateral envelope of motion confined mainly to the
defect side, and their mastication is limited to the non-resected
side. Thus, this occlusal pattern will tend to compromise the
stability of the overlay prosthesis.
We recommend for most patients fabrication of trial den­
tures, from which a surgical template is made to ensure that the
implants are properly positioned. Implants should not be placed
close to the border of the resected mandible because the bone in
this region may be necrotic or poorly vascularized, secondary
to the pervious surgical procedure. If only 2 implants are to be
placed, they should be at least 15 mm apart in order to accom­
modate the retention bar apparatus. Implants should be placed
perpendicular to the occlusal plane and, if possible, within the
zone of the residual attached gingiva. Care must be taken to
avoid lingual inclinations, for this may result in the implants
exiting through the mobile tissues of the floor of the mouth.
The prognosis for lingually inclined implants is poor and usu­
ally requires burying them beneath the mucosa.
For many resection patients, there will usually be 2 im­
plant sites on the normal side and 1 site on the resected side. We
favor the bar clip designs shown in Figure 5-109. If only 2 im-

Occlusal load Fulcrum line

Fig. 5-109. a: If only 2 implant sites are available, they should be positioned
as shown. When splinted with a bar, the axis of rotation is favor­
able, distributing occlusal forces more equitably between implants
and along their long axis, b and c: Patient with lateral mandibular
defect. Note bar configuration.
 Acquired Defects o f the Mandible: Etiology, Treatment, and Rehabilitation 215

, "O" ring attachment

Fig. 5-110. If 3 implants can be placed, we recommend configuration shown. Occlusal rest controls axis of rotation, ERA
attachment posteriorly provides retention, and bar provides stability

plants have been placed, we prefer to splint the implants to­ When the periimplant tissues are well healed, border molded
gether with a Hader-type bar. The bar should be designed so impressions are made, centric relation records obtained (usu­
that it is parallel to the axis of rotation of the prosthesis when an ally at a reduced vertical dimension of occlusion), and the teeth
occlusal force is applied on the normal side. With this design, positioned as described earlier. The trial dentures are inserted,
the prosthesis will rotate freely around the bar, minimizing the records verified, and the esthetics refined as necessary. A tem­
torquing forces delivered to the implants. If a third implant is plate is made and used to fabricate the retention bar apparatus.
available, an ERA* attachment can be added (Figure 5-110). In The bar is cast with a type V gold and verified orally, and the
this design, as an occlusal force is applied, the prosthesis will prosthesis is completed using conventional laboratory meth­
rotate around the bar. The ERA attachment allows for this rota­ ods254. The prosthesis is delivered as described earlier. Patients
tion so that torquing forces are minimized and the retention and with implants should be followed every 3 months to ensure com­
stability of the restoration is improved. If space permits, an “0 ” pliance with prescribed oral hygiene measures.
ring-type attachment can be secured to the implant on the de­
fect side through the bar. We recommend that implants be placed Anterior Border Defects
in the maxilla to improve the support and retention of the max­
illary denture (Figure 5-111). Patients in this category have either undergone anterior body
Implant surgery is performed in the usual way; sites are inner table resections, retaining mandibular continuity, or have
prepared to avoid overheating the bone and the implants must had successful reconstruction, following a through and through
be firmly anchored. During the 3 to 4 month healing period,
care should be taken to avoid exposing the implants to occlusal
loading through the mucosa because, during this early stage,
the bone-implant interface is not prepared to accept significant
loading. If the implants become mobile, they will eventually
become encapsulated by fibrous connective tissue and will need
to be removed.
During the second-stage surgery when the implants are
uncovered, care must be taken to thin the mucosa around the
implants. An ideal result is the presence of attached keratinized
tissue, circumscribing the implants, that does not exceed 3 mm
in thickness. Healing abutments are inserted and, in about 1
month, fabrication of the definitive prosthesis may begin. Soft
tissue complications in the immediate period following stage II
surgery are rare. They consist mainly of gingival hypertrophy
and granulation tissue formation, and these are resolved with Fig. 5-111. Implants have been placed in the maxilla to
improved oral hygiene. Occasionally, surgical excision of the counteract unilateral forces of closure. Note fron­
hypertrophied tissue is required. tal plane rotation.

* Stemgold, Attleboro, MA.

216 MAXILLOFACIAL REHABILITATION: SURGICAL AND PROSTHODONTIC CONSIDERATIONS
Fig. 5-112. Implant-supported prosthesis, a: Man­
dible reconstructed with fibula free
flap. Four implants have been placed,
b: Implant splinted with Hader-type
bar. Note ERA attachments and re­
constructed tongue, c: Opposing re­
movable partial denture, d: Wide rib­
bon rest restores occlusal contours
and improves occlusion, e: Occlusion.
resection of the anterior body of the mandible. The prosthetic
prognosis is usually favorable for these patients, especially if a
vestibuloplasty has been completed. The prosthetic prognosis
is enhanced because mandibular movements and maxillo­
mandibular relationships are usually within normal limits and
the tongue retains its motor and sensory innervation bilaterally.
Because of these factors, prosthetic treatment is more likely to
follow conventional guidelines. Since the anterior tongue and
the lower lip are the soft tissue structures which may have been
altered during the resection and reconstruction, careful place­
ment of the mandibular anterior teeth and careful development
of flange contour in this area are suggested.
The placement of implants improves the prosthetic prog­
nosis dramatically. If the opposing maxilla is edentulous, 2 im­
plants are sufficient. If the opposing arch is dentuious, 4 or more
implants are recommended (Figure 5-112).
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223 Carlsson GE: Bite force and chewing efficiency. Front Oral
Physiol. 1:265; 1974.
224 Hagberg C: Assessments of bite force: A review. J Cranioman
Disorders: Fac Oral Pain. 1: 162; 1987.
225 Marunick MT, Mathog RH: Mastication in patients treated
for head and neck cancer: A pilot study. J Prosthet Dent.
63:566;1990.
226 Curtis D, Sharma A, Finzen F, et al.: Tongue and cheek function
in the hemimandibulectomy patient. J Dent Rest. 73:187;1994.
227 List MA, Ritter-Sterr C, Lansky SB: A performance status
scale for head and neck cancer patients. Cancer. 66:564; 1990.
228 Kapur K, Garrett N, Hamada M: A new approach for assessing
tongue and cheek function. J Dent Res. 70:#207; 1991.
229 Nelson GJ, Hannam AG: A biomechanical stimulation of the
craniomandibular apparatus during tooth clenching. J Dent
Res (Abstract). 61:813;1982.
230 Hatcher DC, Faulkner MG, Hay A: Development of
m echanical and m athem atical m odels to study
tem porom andibular joint loading. / Prosthet Dent.
55:337; 1986.
231 Kalfuss AH: Analysis of the speech of the glossectomy patient.
Ph.D. dissertation. Wayne State University; 1968.
232 Scott L: Speech rehabilitation for oral cancer patients—a pilot
investigation. Master of Arts Thesis. University of California,
Santa Barbara; 1970.
233 Skelly M, Spector DJ, Donaldson RC, Bordeur A, Faletta FX:
Compensatory physiologic phonetics for the glossectomy
patient. J Speech Hear Disord. 36:101; 1971.
 Acquired D efects o f the M andible: Etiology, Treatment, and Rehabilitation 223

234 Bradley DD: Muscular functions of the dentofacial milieu; the second international symposium. Sisson GA, Tandy ME,
speech. ASHAReports No. 5, p. 76. Speech and the dentofacial eds. New York, 1977; Grune & Stratton, Inc.
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235 Duguay MS: Speech after glossectomy. New York State Med. 253 Robinson J, Rubright W: Use of a guide plane for maintaining
64:1836; 1964. the residual fragment in a partial or hemimandibulectomy. J
236 Heberman M: R ehabilitation o f patients follow ing Prosthet Dent. 14:992;1964.
glossectomy. Arch Otolaryngol. 67:182; 1958. 254 Beumer J, Lewis S: The Branemark Implant System: Clinical
237 Bloomer HH, Hawk AM: Speech considerations: speech and Laboratory Procedures. St. Louis, Mo., 1989; Ishiyaku
disorders associated with ablative surgery of the face, mouth, EuroAmerica, Inc.
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No. 8, p. 42. Orofacial Anomalies: clinical and research mandibulectomy patients. Part III: Clinical evaluation. J
implications; 1973. Prosthet Dent. 25:670; 1971.
238 Rentschler G J, Mann MB: The effects of glossectomy on 256 Cantor R, Curtis T: Prosthetic management of edentulous
intelligibility of speech and oral perceptual discrimination. J mandibulectomy patients. Part II: Clinical procedures. J
Oral Surg. 38:348; 1980. Prosthet Dent. 25:546;1971.
239 Cantor R, Curtis TA, Shipp L, Beumer J, Vogel B: Maxillary 257 Fish EW: Principles of Full Denture Prosthesis, ed. 6.
speech prostheses for mandibular surgical defects. J Prosthet Springfield, 111., 1966; Charles C. Thomas, publisher.
Dent. 22:253;1969. 258 Lott F, Levin B: Flange technique: an anatomic and
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pathologist. J Prosthet Dent. 29:29; 1973. 16:394; 1966.
241 Wheeler R, Logemann J, Rosen M: Maxillary reshaping 259 Beresin YE, Scheisser FJ: The neutral zone in complete
prostheses; Effectiveness in improving speech and swallowing dentures. St. Louis, 1978; The C.V. Mosby Co.
of postsurgical oral cancer patients. J Prosthet Dent. 260 Swoope C: Prosthetic management of resected edentulous
43:313;1980. mandibles. J Prosthet Dent. 21:197;1969.
242 Davis J, Lazarus M, Logeman J, Hurst P: Effect of maxillary 261 Jones P: The monoplane occlusion for complete dentures. J
glossectomy prosthesis on articulation and swallowing. / Amer Dent Assoc. 85:94; 1972.
Prosthet Dent. 57:715; 1987.
243 Robbins K, Bowman J, Jacob R: Post-glossectomy deglutitory
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113:1214;1987.
244 Leonard R, Gillis R: Differential effects of speech prostheses
in glossectoimized patients. J Prosthet Dent. 64:701; 1990.
245 Moore DJ: Glossectomy rehabilitation by mandibular tongue
prosthesis. J Prosthet Dent. 28:429; 1972.
246 Lauciello FR, Vergo T, Schaaf NG, Zimmerman R:
Prosthodontic and speech rehabilitation after partial and
complete glossectomy. J Prosthet Dent. 43:204; 1980.
247 Aramany MA, Downs JA, Beery QC, Aslan Y: Prosthodontic
rehabilitation for glossectomy patients. J Prosthet Dent.
48:78;1982.
248 Leonard RJ: Computerized design of speech prostheses. J
Prosthet Dent. 66:224;1991.
249 Krespi YP, Sisson GA: Reconstruction after total or subtotal
glossectomy. Amer J Surg. 146:509; 1983.
250 Salibian AH, Allison GR, Rappaport I, Krugman ME, et al.:
Total and subtotal glossectomy: Function after microvascular
reconstruction. Plast Reconstr Surg. 85:513;1990.
251 Aramany M, Myers E: Dental occlusion and arch relationship
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reconstructive surgery of the face and neck; proceedings of
Chapter 6
Restoration of Acquired Hard Palate
Defects
Etiology, Disability, and Rehabilitation
Thomas A. Curtis and John Beumer III
Introduction
A rewarding area of prosthodontics is the rehabilitation of
patients with acquired maxillary defects. Here, the dentist con­
tributes to all facets of patient care from diagnosis and treat­
ment to rehabilitation. In most circumstances, the prosthetic
prognosis is favorable, and patients are pleased and grateful
upon completion of rehabilitation.
Two famous individuals have been rehabilitated with max­
illary prostheses, their case histories revealing some interesting
contrasts1. Dr. Sigmund Freud and President Grover Cleveland
both developed oral tumors that required surgical resection of
the hard palate and contiguous structures and subsequent
prosthodontic rehabilitation. Their experiences with treatment
and rehabilitation differed markedly, illustrating the variation
which may exist between patients with the same type of defect.
At age 67, Freud developed a squamous cell carcinoma of
the right maxilla. During his remaining 16 years, he underwent
33 major and minor surgical procedures, plus several sequences
of radiation therapy. The eventual defect included the right
maxilla, most of the soft palate and the anterior border of the
ascending ramus of the right mandible. Extreme trismus com­
plicated the construction and use of the many prostheses fabri­
cated for Freud. Because of this protracted struggle with his
prosthesis, Freud nicknamed it “the monster.” In the end, he
expired from recurrent disease that ultimately proved inoper­
able.
In contrast, the prosthodontic rehabilitation of Cleveland
was quite successful. Cleveland was inaugurated President of
the United States during of the “Silver Panic” of 1893. During
this financial crisis, over 400 banks failed. The Nation, a lead­
ing publication of the day, commented, “only President Cleve­
land stood between the country and financial disaster.” In May
1893, Cleveland became aware of a small ulcer on the left side
of his maxilla. Although the histologic diagnosis has been ques­
tioned, a subsequent biopsy proved to be malignant Because of
the political-economic crisis, the illness and surgery were not
revealed to the public until 1917, when one of the assistant sur­
geons involved described the event The surgery was performed
on a yacht while sailing up the East River. The transoral surgi­
cal resection included the left maxilla distal from the cuspid
and the anterior portion of the left soft palate. The surgical and
definitive prostheses (constructed of vulcanite rubber) were so
successful from a functional and cosmetic standpoint that Presi­
dent Cleveland appeared before Congress and spoke in public
within 2 months after surgery. Cleveland lived 15 years after
the surgery with no recurrence reported.
The histories of these individuals illustrate 2 primary fac­
tors that the prosthodontist should keep in mind: (1) the degree
of malignancy and the propensity for recurrence of tumors in
this region will vary as will (2) the acceptance and effective­
ness of a prosthesis.
Maxillary Versus Mandibular Defects
Differences may be noted between patients with maxillary
surgical defects and those with mandibular surgical deficits re­
garding method of rehabilitation, quality of life postsurgically,
level of psychosocial function, and other factors. Differences
may also be noted between patients with congenital and ac­
quired defects of the maxillae.
Quality of Rehabilitation
Most patients with acquired maxillary surgical defects can
be restored to close to normal function and appearance. Friends
and acquaintances are usually unable to detect a functional or
cosmetic deformity. Consequently, the patient truly feels reha-
226 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
bilitated. In contrast, many patients with composite surgical re­
sections of the mandible, tongue, and adjacent soft tissues dem­
onstrate lingering functional disabilities and cosmetic disfig­
urement. Often, the oral functions of speech, mastication, de­
glutition, and salivary control are not easily restored to
presurgical levels. Consequently, these posttreatment sequelae
may profoundly diminish the quality of life.
Patients with acquired maxillary defects differ from pa­
tients with congenital maxillary defects because of the abrupt
alteration in physiologic processes associated with surgical re­
section of the maxillae2. However, definitive prosthodontic treat­
ment will restore the patient to a normal or near normal level of
function. In contrast, the treatment of congenital malformations
of the maxillae, such as cleft lip and palate, is prolonged, often
extending from infancy into early adulthood. Even with appro­
priate multi-disciplinary treatment, lingering cosmetic and
speech deficits may remain.
Mode of rehabilitation
Restoration of acquired maxillary defects is usually affected
prosthodontically. Rehabilitation is immediate and relatively
simple; further, patients can identify an end point in therapy
which, when achieved, leads to fairly predictable results. In
contrast, restoration of mandibular defects is primarily a .surgi­
cal responsibility and follows a long, less predictable course
requiring the combined effort of surgeons, prosthodontists,
speech therapists, and other allied specialists. The benefits to
the patient are less predictable.
Effectiveness of rehabilitation
Postsurgical maxillary defects predispose the patient to
hypemasal speech, fluid leakage into the nasal cavity, impaired
masticatory function, and, in some patients, various degrees of
cosmetic deformity. The oral disabilities are minimized or elimi­
nated almost immediately with obturation, thereby lessening
the sequelae of tumor surgery. The maxillary resection prosthe­
sis also reduces the cosmetic deformity by supplying the miss­
ing teeth and by properly supporting the upper lip and cheek.
Also, radiation therapy has less impact upon maxillary struc­
tures. The immediacy and effectiveness of rehabilitation enables
the patient to mobilize his or her resources to cope with the dis­
ease itself. Therefore, it is not surprising that, following maxil­
lary surgery, most patients lead relatively normal lives. In con­
trast, patients with mandibular defects rarely achieve normal physi­
cal and psychosocial function. Many must cope with the enor­
mity of their disease process and their protracted disability.
Section on etiology and treatment of palatal and paranasal sinus defects contributed by Horst Konrad.
Reconstructive surgery
Prosthetic rehabilitation of maxillary surgical defects is so
effective that reconstructive surgery is not indicated in most
instances. Also, surgical reconstruction may preclude examina­
tion of the surgical site and may delay discovery of recurrent
disease. Conversely, the improvement in appearance and func­
tion for patients with mandibular surgical defects is often de­
pendent upon the efficiency of surgical reconstruction. Recon­
struction, if indicated, may be done immediately, at the time of
the initial cancer resection, or delayed, after approximately a
year for healing, tumor monitoring, and possibly postsurgical
radiation therapy.
Private practice
Prosthodontic rehabilitation of acquired and congenital
maxillary defects can be managed quite effectively in a private
practice environment. However, the rehabilitation of mandibu­
lar discontinuity defects requires a multi-disciplinary team ap­
proach to patient management. Although the prosthodontist is
capable of providing prosthetic care in a private practice set­
ting, the inexperienced clinician should be aware of the multi­
faceted and lingering problems exhibited by many
mandibulectomy patients.
Psychosocial profiles
Patients with maxillary surgical defects are generally
younger and have dentitions in better condition than those with
mandibular defects (Table 6-1). In addition, patients with max­
illary defects demonstrate higher socioeconomic levels (Table
6-2), with less tobacco and alcohol abuse (Table 6-3) as com­
pared to patients with mandibular defects3. Continued alcohol­
ism can compromise rehabilitation, oral health compliance
measures, reduce the effectiveness of radiation therapy, and
potentiate the possibility of recurrent disease.
Etiology of Palatal and Paranasal Sinus Defects*
Almost all acquired palatal defects are precipitated by re­
section of neoplasms of the palate and paranasal sinuses. The
extent of the resection is dependent upon the size, location, and
potential behavior of the tumor. In general, malignant tumors
require aggressive resections, whereas benign neoplasms de­
mand less extensive surgery. Most of these tumors, whether
benign or malignant, are quite late to metastasize and, hence,
radical neck dissections are employed only when palpable nodal
disease in the neck is detectable clinically or by computer to-
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 227

Table 6-1. Oral Condition at Diagnosis*.

Patient’s Teeth and P rosthesis. M axillary M andibular C ontrol

C ondition
M ost teeth: average co n d itio n 9 .11 :
O ne-half o f teeth present : .8 1Q
E dentulous J | j j =8 Hi z*H
D isposition o f teeth
Full m outh extra ctio n s necessary J jiP Ip S P -•/i p
Some extra ctio n s necessary '3
No ex tra c tio n s necessary jjjl | '4'-, - • 12^.
P rostheses
Num ber o f prostheses co n stru cte d 59 44 , 31
No p ro sth e tic treatm ent desired ; 0 lljjjl

Table 6.2. Socioeconomic levels at time of diagnosis*.

Variables M axillary M andibular C ontrol

Patient’s occupation
Professional 4 3 jjl|
W hite co lla r 4 | 4 4
Skilled labor 6 5 6
Laborer 3 6 7
U nem ployed o r retired B 3 1
H ousewife 7 6 4
M onthly incom e o f fa m ily wage earner (in 1967 $)
<300 fPSjf 8 9 ■
<450, > 3 0 0 5
< 600, > 450 4 6
>600 6
S pouse as principal earner 7 4 6

Table 6-3. Use of alcohol and tobacco at time of diagnosis*.

M axillary M andibular C ontrol

A m ount of alcohol No. Heavy sm oker No. Heavy sm oker No. Heavy sm oker
None 4 0 '1 * 0 10 1
O ccasional 15 6 te S 2 10 > 4
M oderate to heavy 5 3 9 !S 9 v:S 4 \ 2

♦Source: Curtis TA. Treatment planning for intraoral maxillofacial prosthetics for cancer patients. J Prosthet Dent. 18:70;1967.
228 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
mography (CT). The pathogenesis and behavior of these tu­
mors is best understood with appropriate knowledge and ap­
preciation of the anatomy of the palate and paranasal sinuses.
Anatomy
The palate is composed of the maxillary and palatine bony
plates. Anteriorly, the median nasal process (premaxilla) car­
ries the incisor teeth, while laterally the maxillary alveolar pro­
cesses can be observed with the remaining maxillary teeth. A
longitudinal suture divides the maxillary and palatine processes
at the midline, and a transverse suture separates the palatine
P^latirie.proces^
-iSfmaxilla.
Horizontal plate
cf pa|atlne bone •
Fig. 6-1. Diagram of a bony anatomy of palate.
nodes
Superior constrictor muscle
Lowe?jugular nodes
i- Internal Jugular vein
Vagus nerve
Fig. 6-3. Diagram of a lymphatic drainage from palate.
bones from the maxillary processes of the palate (Figure 6-1).
Blood vessels, nerves, and lymphatics traverse the palatine fo­
ramina and are located laterally and posteriorly. The soft palate
attaches to the posterior rim of the hard palate and has a median
posterior extension, the uvula. Laterally, the velum fuses with
the anterior and posterior tonsillar pillars. The soft palate con­
tains a series of muscles which aid in the closure of the
velopharyngeal complex during deglutition and speech, and aid
in the opening of the eustachian tubes. The mucosa of the soft
and hard palate is lined with stratified squamous epithelium
and contains numerous minor salivary glands and some lym­
phatic tissue.
Orbital floor
Maxillary sinus
M id d l# u fa ria te i
Nasal septum
Fig. 6-2. Diagram of a palate and nearby spaces and structures.
Posterior nasal septal artery
Greater palatine artery;
Lesser palatine artery
Ascending palatine artery
Fig. 6-4. Diagram of a blood supply to palate.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 229

Except for the anterior portion (premaxilla), the palate arises external and deep facial veins to the external and internal jugu­
from lateral palatine processes which fuse in the midline. Be­ lar veins.
cause of this embryologic feature, vascular, lymphatic, and neu­
ral elements are divided at the midline. This phenomenon ex­ Himors of the Region
plains why unilateral palatal and paranasal sinus tumors rarely
demonstrate contralateral lymphatic spread. The midline also Most tumors occurring in the palatal and paranasal sinus
serves as an effective anatomic barrier for resistance of local region are epidermoid carcinomas. Other types include adeno­
tumor extension and often serves as the medial surgical margin carcinomas, adenoid cystic carcinomas, mucoepidermoid car­
in resection of palatal and paranasal sinus tumors. Superior to cinomas, pleomorphic adenomas, lymphoepitheliomas, and lym­
the palate is the nasal cavity medially and the maxillary sinuses phosarcomas (Tables 6-4 and 6-5). Tbmors of the paranasal si­
laterally (Figure 6-2). Posterolaterally, the pterygoid plates and nuses are quite rare and make up only 1% of all head and neck
the pteiygomaxillary spaces may be found. The pterygomaxil- tumors6. Other lesions, such as midline granuloma and
laiy spaces contain muscles, nerves, blood vessels, and lym­ Wegener's granulomatosis, may also cause palatal defects.
phatics which approximate the base of the skull.
Lymphatics of the anterior maxillary alveolar ridge and
anterior palate drain to the submaxillary lymph nodes. The re­
maining bony palate drains to the superior deep cervical and Table 6-4. Distribution of Palate Tumors by Histologic Origin*
subparotid nodes. The soft palate drains posteriorly and later­
ally to the retropharyngeal, subparotid cervical nodes, or possi­ Type No.
bly directly to the deep cervical nodes. The nasopharyngeal as­
Epidermoid 326
pect of the soft palate, posterior nasal cavities, paranasal sinuses,
Salivery gland 231
and nasopharynx drain initially to the retropharyngeal nodes
Other 85
and later may extend to the deep cervical nodes or possibly
directly to the deep cervical nodes. The lymphoid tissue com­ Total 642
prising Waldeyer’s ring drains to the superior deep cervical
nodes4 (Figure 6-3). ♦Data sources:
Whereas foramina, lymphatics, blood vessels, nerves, and Martin H. Tumors of the palate. Arch Surg. 44:
bone marrow spaces facilitate the spread of tumor, periosteum, 599;1942.
bone, and fascia can act as restrictive barriers. Once a tumor Boyle WF, Cole TB. Tumors of the palate.
spreads into a space, it tends to expand to fill it. For example, Laryngoscope. 178:1140;1968.
extension of tumor along the palatine nerves can lead to tumor Hjertman L, Eneroth CM. Tumors of the
invading through the pterygopalatine canal and into the ptery­ palate. Acta Otolaryngol, 263:179;1970.
gopalatine fossa. From here, the tumor may extend to the base
of the brain via one of the foramina of the base of the skull or to
the inferior orbital fissure5. Perineural invasion is especially
prominent in adenoid cystic carcinoma. Table 6-5. Distribution of Palate Tumors by Histologic Origin*.
Vascular supply is of particular importance with regard to
control of bleeding, wound healing, wound closure, and recon­ No.
struction. The hard palate is supplied anteriorly by the posterior
Epidermoid • |jj
septal nasal artery, which enters via the incisive foramen in the
SaliValry gland
midline, and the greater and lesser palatine arteries, which enter
malignant 21
via the greater, and lesser palatine foramen posterolaterally. The
benign SP
greaterpalatine artery supplies most of the hard palate. The lesser
Mesenchymal
palatine artery supplies the junction of the soft and hard palates,
malignant 5
whereas the ascending palatine artery supplies the soft palate.
benign 5
These vessels have rich anastomoses in the palate and deliver
Metastatic origin ; 3
blood from a variety of sources, most often the internal and
external maxillary arteries and the ascending pharyngeal artery Total 146
(Figure 6-4). However, there are few anastomoses across the
midline of the hard palate. In general, venous drainage parallels ♦Source: Data collected at UCLA Medical Center (1955-
the arterial supply in the palate and finally drains through the 1975).
230 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Epidermoid carcinomas

While most of these tumors arise in the maxillary sinuses,

their frequency of oral signs and symptoms makes them sig­
nificant. Although oral extension of tumor is rare, dental pain
or loosening of teeth may be an early sign. Most patients present
with swelling around the eye and cheek (Figure 6-5) accompa­
nied by nasal congestion, infection, and bleeding. Oral symp­
toms occur from 26% to 36% of the time7 and, in one study8,
were the initial sign in 15% of the cases. Roentgenographic
studies will reveal cloudiness of the sinus, with advanced cases
demonstrating erosion of the bony walls of the antrum. Treat­
ment is by surgical removal, although preoperative or postop­
erative radiation therapy is used as an adjunct in many centers.
Eneroth and Moberger9 have proposed a method for grading
epidermoid tumors in this region. The rating was determined
by the histologic structure, differentiation, nuclear pleomor-
phism, mitoses, signs of invasion, and the lack of an inflamma­
tory cell infiltrate. A high correlation was found between this
method and the subsequent behavior of the tumor. In general,
poorly differentiated tumors recur early, usually within 1 year,
whereas well-differentiated epidermoid carcinomas recur less
often and more slowly.

Salivary gland tumors

Pleomorphic adenoma Pleomorphic adenoma, a benign neo­

plasm, occasionally arises from the palatal mucosa (Figure 6-
6). These tumors are characterized by slow, intermittent growth
which may last 20-50 years. Malignant transformation occurs Fig. 6-5. a: Patient had nasal congestion and bleeding, as
infrom 3 %‘°to 15 %" of the cases. Clinical signs of malignant well as a swelling in the mid-facial region. Biopsy
transformation include sudden growth, irregular surface, and of contents of maxillary antrum revealed epider­
pain. The histopathology of pleomorphic adenomas is charac­ moid carcinoma, b: Another patient demonstrating
terized by a broad range of histologic patterns of glandular epi­ swelling due to malignant tumor of right maxillary
thelium and connective tissue. Treatment consists of local exci­ sinus.
sion. Since nests of cells often extend beyond the connective
tissue capsule, resections should be performed with adequate
margins.

Other salivary gland tumors Other tumors of the region in­

clude adenoid cystic carcinomas, mucoepidermoid carcinomas,
and adenocarcinomas. They are most often seen in the paranasal
sinuses. Signs and symptoms are similar to those described in
epidermoid carcinomas, although the growth rates for some of
these tumors may be slower. The treatment is surgical excision.
Radical neck dissections are generally performed when there is
detectable adjunctive disease in the neck. Radiation therapy is
employed pre- or postoperatively, or used postoperatively in
patients with tumors incompletely removed or in palliation of
large unresectable tumors.
Fig. 6-6. Pleomorphic adenoma appeared as a symptomatic
mid-palatal swelling.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 231

Mesenchymal Tumors

Malignant mesenchymal tumors of the palate include lym­

phosarcom as, rhabdom yosarcom as, chondrosarcom as,
neurofibrosarcomas, angiosarcomas, and osteosarcomas. Be­
nign mesenchymal tumors include fibromas, hemangiomas,
angioleiomyomas, angioblastomas, fibrolipomas, and myxomas.
Tumors of dental origin can also occur in the palate. The distri­
bution of these tumors at the UCLA Medical Center is given in
Table 6-5. a

Other Phenomenon

Midline granuloma and Wegener’s granulomatosis cause

defects of the hard palate. These are rare lesions consisting of
vasculitis and round cell infiltration, with eventual necrosis,
usually of mucosa and bone of the mid-palatal area. The use of
cyclophosphamide (Cytoxan), methotrexate, azathiopine
(Imuran), methotrexate, steroids, and radiation therapy have
resulted in many long-term remissions in this previously rap­
idly fatal disease, making these patients candidates for rehabili­
tation of their palatal defect.
Mucormycosis and aspergillosis fungal infections can oc­ Fig. 6-7. Defect secondary to mucormycosis, a: Immediately
cur in patients with diabetes mellitus, patients with major im­ after resection, b: Following healing.
mune deficiencies, and/or those using immunosuppressive medi­
cations. The infection usually involves the nasal cavity, the
maxilla, paranasal sinuses, and orbits. The organisms cause as­
cending venous thrombosis, resulting in necrosis of the involved
structures. Treatment may require extensive resection of palate,
maxilla, and facial tissues in order to remove the full extent of
the necrosis. If the patient survives, the resulting defects often
require prosthetic rehabilitation (Figure 6-7).

Tumor Behavior

The treatment, resulting defect, and prognosis for recur­

rence can often be predicted from the location, size, extension,
and histology of the lesion. Benign tumors expand locally into
available spaces. Although many of the benign salivary gland
and mesenchymal tumors appear well encapsulated, careful
examination will often show invasion of soft tissue and even
bone. In addition to local invasion (Figure 6-8), malignant le­
sions extend along cranial nerves and marrow spaces, metasta­
size along regional lymphatics, and extend to distant sites. The
size of palatal malignant tumors affects the prognosis signifi­
cantly; larger lesions have a poorer prognosis. The extension of
palatal tumors to the tongue, nasal cavity, paranasal sinuses,
nasopharynx, pterygoid plates, or cranial foramina affects the
prognosis adversely12. Squamous cell carcinomas spread not b
only locally, but along the regional lymphatics as well. Involve­ Fig. 6-8. a: Osteosarcoma of the floor of the nose, with
ment of the superior nodes is common (one third of the cases). extension into the hard palate, b: CT scan showing
The parapharyngeal lymph nodes can also be involved. When extent of the tumor.
232 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
tumors cross the midline of the palate, bilateral nodal involve­
ment can occur. Lesions with bilateral, contralateral, or fixed
nodal metastases have an extremely poor prognosis.
Adenoid cystic carcinomas are so slow growing that in the
past they were considered benign lesions. With longer follow-
up, it is apparent that the extended prognosis for these lesions is
poor. Metastatic spread along cranial nerves is common. Mar­
row spaces can be invaded and pulmonary metastases occur
frequently, making adenoid cystic carcinomas the palatal tu­
mor with the poorest long-term prognosis.
Diagnosis
The behavior and appearance of palatal tumors are helpful
clues in diagnosis. Benign tumors tend to grow slowly, cause
minimal induration at the margins, and usually do not penetrate
the mucosa. Malignant tumors tend to grow more rapidly, erode
bone, and make teeth mobile. The mucosa may break down,
resulting in an ulcer or fungating lesion (Figure 6-9). There are
many exceptions, so diagnosis should be based upon biopsy.
Fig. 6-9. Epidermoid carcinoma of the palate.
Methods of Resection
Resection of benign lesions requires removal of the tumor
along with a margin of normal tissue. Since benign tumors some­
times invade periosteum and bone, the margins must be checked
carefully with histological sections. For benign salivary gland
tumors, the periosteum approximating the tumor should be
resected, since these tumors frequendy extend beyond the ob­
vious capsule. The frozen section diagnosis of benign salivary
gland tumors is often changed to a malignant diagnosis upon
review of the permanent sections. Thus, unless these lesions are
treated somewhat aggressively, a second and more radical re­
section would be required at a later date.
Palatectomy
The mucosal incisions are outlined to give 5 to 10 mm
margin around the tumor, depending on the histopathology ob­
served in the biopsy. These incisions are made through the peri­
osteum. The periosteum is elevated to expose sufficient bone to
permit cutting with a power saw or osteotome. If the soft palate
is also invaded, then either a generous margin of the soft palate,
or the entire soft palate, is resected. After all soft tissue cuts are
completed, bone is resected using a power saw or osteotome. If
the nasal septum or the medial wall of the maxillary sinus is
involved, these structures can be included in the resection. If
the lesion approaches the greater palatine foramen, then the
posterior alveolar ridge and the pterygoid plates should be in­
cluded in the resection. After the resection is completed, the
bony edges are smoothed and contoured, then covered with the
periosteum and the mucosa, which had previously been elevated
away from the margin of resection. The raw tissues in the surgi­
cal defect are covered with split thickness skin grafts. Packing
is placed in the defect, and an immediate surgical obturator is
inserted and wired to the teeth or alveolar ridge.
Maxillectomy
A maxillectomy is required if the tumor is very malignant
histologically, or if it either invades or involves the nasal cavity
or paranasal sinuses. If the lesion is located primarily anteri­
orly, this procedure can sometimes be accomplished without
splitting the lip, thus reducing external scars. If there is any
difficulty with exposure, or if the lesion is located laterally or
posteriorly, it is vital to change the approach to allow better
access to the tumor. More complete exposure of the maxilla is
obtained by splitting the lip and extending the incisions around
the nose up to the orbit and along the eyelid (Weber-Fergusson
incision) (Figure 6-10). The cosmetic aspects of the resection
are secondary to the need of adequate surgical exposure. The
incision permits the soft tissues over the maxilla to be reflected
laterally, ensuring access to the underlying bony structures.
The mucosal cuts on the palate are made first and are simi­
lar to those described for the palate resection. The periosteum is
elevated and bony cuts are made with an osteotome, power saw,
or Gigli wire saw (Figure 6-11). The orbital rim is spared if the
orbital contents have not been invaded. The pterygoid plates
and the soft tissues of the pterygomaxillary space are resected
at the base of the skull using a curved osteotome. A split thick­
ness skin graft is placed under the soft tissue flap to line the
surgically-produced cavity. The wound is packed, the immedi­
ate surgical obturator is placed, and the Weber-Fergusson inci­
sion is closed. Should the orbit or lateral wall of the nose be
involved, the orbital contents and ethmoid sinuses can easily be
resected in continuity with the maxillary resection. Extension
to the cheek, mandible, and tongue with neck metastases re­
 Restoration o f Acquired H ard Palate Defects: Etiology, Disability, and Rehabilitation
quire a more extensive resection. For a detailed description of
maxillectomy procedures, the reader is referred to Montgom­
ery13.
Fig. 6-10. Skin incisions for maxillectomy {Weber-Fergusson
incisions and exposure). Since orbital contents
were invaded with the tumor, incision extends onto
the upper lid.
233
Recurrence
The potential for recurrence varies from 10-30% with be­
nign tumors to over 50% with malignant tumors14,15. Epider­
moid carcinomas tend to recur during the first 2 years after treat­
ment. Adenocarcinomas may recur later. The need for follow-
up and observation of the margins of the defect is a strong argu­
ment in favor of prosthodontic rehabilitation instead of surgical
reconstruction.
Surgical Modifications Enhancing the Prosthetic
Prognosis
Interaction between surgeon and prosthodontist is neces­
sary if optimum levels of rehabilitation are to be achieved in
patients with maxillary defects16. This communication can re­
sult in surgical defects which are better suited for a prosthesis
without compromising the resection of the tumor. There are a
number of modifications of surgery which may improve the
prognosis for prosthetic rehabilitation17.
In the prosthodontic section of this chapter, the terms total
and partial maxillectomy will be used instead of radical (the
term, radical, is often used by surgeons for most any resection
of the maxillae). Since the upperjaw contains 2 maxillary bones,
or maxillae, a total maxillectomy is the complete resection of 1
of the 2 maxillae, or resection to the midline. A partial
maxillectomy is a bony resection which is less than a total
maxillectomy. The terms may be combined if the resection is
more extensive than a total maxillectomy. We feel that these
terms are more descriptive.
Fig. 6-11.
Bony cuts of palate, orbital
rim, and maxilla. Pterygoid
plates and soft tissues of
the pterygomaxillary space
are resected at the base of
the skull.
234 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Hard Palate Skin Grafting

An attempt should be made to save as much of the maxil­
lae as possible consistent with tumor control. Today, presurgical
radiographic studies (CT, MRI) enable the surgeon to outline
the extent of the tumor quite accurately. Significant portions of
the maxilla, particularly the premaxillary segment on the tumor
side, can often be identified as being free of disease. In both
dentuious and edentulous patients, retention of the premaxil­
lary segment improves the prosthodontic prognosis immeasur­
ably by enhancing stability and support for the prosthesis (Fig­
ure 6-12). Retention of the premaxillary segment is particularly
helpful in patients with severely tapering arches.
In edentulous patients, the premaxillary segment is the most
effective site for implant placement. If more of this segment
can be retained, then a greater number of implants can be placed.
In addition, the anterior-posterior spread of the implants will
allow them to better withstand the forces produced during mas­
tication.
The surgeon improves the tolerance and retention of the
obturator if the reflected cheek flap is lined with a split thick­
ness skin graft (Figure 6-13). This keratinized surface is more
resistant to abrasion than is respiratory mucosa and, therefore,
is a more suitable denture bearing and supporting surface. The
graft also limits scar contracture and increases the flexibility of
the cheek flap. This enables the prosthodontist to displace the
cheek on the resected side more readily, thus achieving rela­
tively normal mid-facial symmetry. Additional benefits are de­
rived from the scar band formed at the skin graft-mucosal junc­
tion. As this area contracts longitudinally during healing, it does
so like a purse string, often creating a sizable lateral undercut
superior to the scar band. This scar band is most prominent lat­
erally and posterior-laterally, tending to blend with the normal
oral mucosa anteriorly and posteriorly1718. Engaging the scar
band superiorly and inferiorly with the prosthesis serves to en­
hance stability, support, and retention.

c d

Fig. 6-12. a: Tapering arch with resection to midline. Stability and support for the prosthesis would be enhanced if premaxillary
segment on the defect side could have been retained, b: Ovoid arch with resection to midline. Note potential for
improved stability and support for prosthesis, as compared to tapering arch, because of increased palatal shelf
area, c: Resection of entire premaxillary segment, resulting in a linear arrangement of remaining teeth. Indirect
retention becomes impossible, and retention and stability are compromised, d: This defect has minimal impact on
retention, stability, and support, and the removable partial denture may be designed more conventionally.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 235

Retention of key teeth

The cuspid tooth is of particular importance to the prosth­

Fig. 6-13. Right maxillectomy defect with skin graft lining
cheek surface. Note skin graft-mucosal junction.
If the surgeon is planning a total maxillectomy, consider­
ation should be given to stripping the nasal mucosa from the
sinus side of the floor of the orbit, followed by placement of a
skin graft. If oral access permits, engaging this surface
postsurgicaUy will dramatically improve the support for the pros­
thesis. However, postsurgical trismus may preclude the supe­
rior extension of the prosthesis into this area.
odontist because of its greater bony support when compared to
its immediate neighbors. The transalveolar resection should be
made as distant as feasible from the tooth adjacent to the resec­
tion. The next distal tooth should be extracted and the
transalveolar cut made through the distal portion of this socket.
This will result in the retention of more bony support and ex­
tend the clinical usefulness of the tooth adjacent to the resection
(Figure 6-14 a,b). The tooth adjacent to the resection will soon
be lost if the resection is made through the transeptal bone ap­
proximating the tooth bordering the proposed defect (Figure 6-
14 c,d). The tooth adjacent to the resection may become mobile
or symptomatic, often necessitating endodontic therapy, ampu­
tation at the gingival maigin, or extraction.

Fig. 6-14.
a: In this drawing, resection is contemplated for this left partial maxillectomy. The left lateral incisor is extracted and a bony cut
is made through center of socket. As the wound organizes and heals, ample bony support should remain for the left central
incisor tooth. Note incision through oral mucosa made laterally to the proposed medial resection of the bony palate. This
mucosa is reflected and used to cover the medial margin of the defect after the bony resection is completed, b: The central
incisor adjacent to defect has ample bone and gingiva on mesial, and it can be used as a partial denture abutment, c: Bony cut
made too close to the root of this tooth, resulting in significant loss of bony support, d: Radiograph showing loss of bone.
236 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Palatal Mucosa

If the surgeon can save some of the palatal mucosa nor­

mally included in the resection, and reflect this tissue during
the bony resection of the palate, it can be used later to cover the
cut medial bony margin of the palatal bones. This bony margin
should be carefully rounded before it is covered with the palatal
mucosa. The palatal margin of the defect often is the fulcrum
around which the prosthesis rotates during function, particu­
larly in edentulous patients. If this margin is allowed to granu­ a
late and epithelialize spontaneously, it usually will be lined with
poorly keratinized squamous epithelium. This unkeratinized
palatal mucosa is an inferior denture bearing surface. If the pala­
tal margin of the defect is covered with keratinized mucosa, the
prosthesis may engage this surface, thus facilitating the lateral
stability of the obturator prosthesis (Figure 6-15a). If an ad­
equate amount of palatal oral mucosa is not available, due to
the extent of the tumor, consideration should be given to cover­
ing the cut medial surface with a split thickness skin graft (Fig­ b
ure 6-15b). Fig. 6-15. a: Palatal mucosa used to cover mid palatal bony
resection, b: Skin graft employed for the same purpose. Skin
Soft Palate graft also lines lateral surface of the defect

It is important that the remaining portion of the soft palate

retain the ability to affect velopharyngeal closure. With a
maxillectomy or palatectomy that involves a significant por­
tion of the soft palate, or with resection of tumors primarily
confined to the soft palate, the remaining portion of the soft
palate m ust no t block access to the proper level of
velopharyngeal closure— otherwise, speech and swallowing
may be compromised. If the resection includes the anterior and
middle third of the soft palate, a posterior, narrow, nonfunc­
tional band of intact soft palate may remain postsurgically (Fig­
ure 6-16a). This remnant may lack innervation and/or the ca­
pacity for normal elevation19. These bands of residual soft pal­
ate often contract superiorly, thus preventing proper position­
ing of an obturator prosthesis designed to interface with the
residual velopharyngeal musculature. Resultant speech may be
hypemasal, and leakage of fluids into the nose will occur dur­
ing swallowing. Therefore, if less than one-third of the poste­
rior aspect of the soft palate is to remain postsurgically on the
resected side, the entire soft palate should be removed. An ex­
ception should be made for the edentulous patient undergoing a
total maxillectomy. Retention of the obturator prosthesis is al­ Fig. 6-1
ways difficult in this situation and the extension of the obtura­ of the soft palate remaining postsurgically. Remaining por­
tor prosthesis onto the nasal side of the residual soft palate is an tion of the soft palate was nonfunctional and it contracted
advantage that outweighs the possible speech and leakage prob­ superiorly, blocking access to the lateral posterior pharyn­
lems previously mentioned. (Figure 6-16b). geal wall movement, b: Posterior one-third of the soft palate
was maintained for this edentulous patient to aid retention of
the complete maxillary resection denture by extending den­
ture base superiorly over nasal surface of residual soft palate.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 237

Access to the Defect
The surgeon should provide access to the superior and lat­
eral aspects of the defect for the prosthodontist. Extending the
obturator up the lateral wall of the defect enhances the retention
and stability of the prosthesis. Engaging the lateral nasal side of
the orbital floor provides support for the obturator prosthesis.
Structures, such as the turbinates and bands of oral mucosa,
may prevent the prosthesis from engaging key areas of the de­
fect, which would dramatically compromise function (Figure
6-17a). If the postsurgical defect is large, these structures pro­
vide little benefit to the patient, and they severely limit the abil­
ity of the prosthodontist to seal the defect and provide proper
obturation. Further, the turbinates may enlarge due to changes
in the normal nasal environment, and from the leakage of food
and liquids into the nasal cavity, which irritate these delicate
structures. Edematous turbinates may extend inferiorly below
normal palatal contours, thus distorting the contour of the pala­
tal portion of the prosthesis, which, in turn, may impair tongue
function and disrupt speech and swallowing. Consequently, these
structures should be considered for resection during surgery.
This suggestion may not apply to small midline defects of the
hard-soft palate junction, as extension superiorly is not as criti­
cal. Maxillectomy defects should not be closed, either prima­
rily or with flaps (Figure 6-17 b,c). Closure may preclude fabri­
cation of a prosthesis, leading to compromise of mid-facial con­
tours, speech articulation, and swallowing. Palatal contours need
to be reestablished, and replacement teeth properly positioned,
if speech and swallowing are to be restored.
Osseointegrated Implants
In edentulous patients, or when the prognosis for the re­
maining dentition is poor, placement of osseointegrated implants
at the time of tumor resection should be considered (Figure 6-
18). These implants can be placed immediately after tumor re­
moval and require little additional operating time. The most
suitable sites for placement of implants are the remaining pre­
maxillary segment and the maxillary tuberosity. In some eden­
tulous patients, there may be sufficient bone remaining in the
alveolar process below the maxillary sinus. Except in extraor­
dinary circumstances, the use of bony sites within the defect
should be discouraged. When implants are positioned in the
surgical defect, proper hygiene of these implants is often diffi­
cult, adversely affecting the tissue health around them. Although
pre- or postoperative radiation does not appear to preclude the
use of osseointegrated implants in these patients, preliminary
studies20,21 and clinical reports22 indicate that, with doses above
5,000 centigray, remodeling of the bone at the bone-implant
interface may be compromised and thus may predispose to bone
recession and premature implant loss.
Rehabilitation
Surgery Versus Prosthodontics*
The etiology and size of the defect are important consider­
ations in choosing the method of rehabilitation. If the defect is
the result of trauma, immediate surgical closure or reconstruc­
tion is indicated. The soft tissues are approximated, the mucosa
is closed, and raw surfaces are left to granulate or are covered
with a split thickness skin graft. If the defect is large, then clo­
sure may require local or regional flaps. Closure with local flaps,
myocutaneous flaps, or free vascularized flaps can be accom­
plished immediately, but is not recommended until the likeli­
hood of recurrence is minimal. In benign tumors, negative mar­
gins from frozen sections (which are later confirmed by perma­
nent section) are a minimal requirement for surgical closure of
a palatal defect. If there is any doubt about the margins, or about
the benign nature of the tumor, the defect should remain open
until the permanent histologic sections are available for scru­
tiny. Closure of the defect could make the subsequent surgery

Fig. 6-17. a: Residual turbinates restrict access to the defect, b: The defect cannot be used to facilitate retention, support, and
stability of the prosthesis because of limited access, c: Myocutaneous flap is used to close the defect surgically,
making prosthetic rehabilitation impossible. Note inappropriate palatal contours.

Sections on surgery versus prosthodontics and surgical reconstruction contributed by Horst R. Konrad.
238 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

a b
Fig. 6-18. a and b: Osseointegrated implants are inserted immediately after tumor resection. Use of surgical template ensures
proper implant position.

for persistent tumor more difficult for the surgeon and result in
a greater loss of tissue for the patient. In adenocarcinoma and
epidermoid carcinoma, inspection of the surgical defect for 3 to
5 years is required before surgical reconstruction is considered.
In adenoid cystic carcinoma, reconstruction should not be con­
sidered.
Patients occasionally survive with palatal defects, from
midline granuloma. Since impairment of blood supply is the
reason for these defects, surgical reconstruction is contraindi­
cated during the active disease process. Closure of such defects
when the disease is in remission may be considered, but such
cases have not been reported.
The size and location of the defect also influences the
method of restoration. Small defects of the alveolar ridge and
hard palate are easily closed surgically with local flaps (Figure
6-19). Larger hard palate defects are more amenable to
prosthodontic obturation. In borderline situations, a trial period
with an obturator will permit the patient to express his or her
preference for the method of rehabilitation.
Large soft palatal defects are difficult to restore to normal
function surgically. The quality of function obtained with pros­
thetic obturation makes this the preferred method of treatment.
Velopharyngeal function requires a coordinated effort from a
number of adjacent muscle groups. With the loss of significant
amounts of soft palate, pharyngeal flaps are not sufficient for
reconstruction.
b
Surgical Reconstruction Fig. 6-19. a: A small defect, located at junction of the hard
and soft palates, is amenable to surgical closure,
Surgical repair of palatal defects extends from the suture b: A larger defect in same area. Surgical closure
of minor lacerations to reconstruction, using major regional flaps could be considered after control of the tumor was
and free tissue transfers. Split thickness skin grafts are used to assured, but it would be difficult.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 239

cover raw surfaces and to reduce scarring and contracture23, but
do not provide bulk or structural support. Tongue flaps and buc­
cal mucosal flaps are useful to repair small medial defects24,25'26’27
and to reconstruct the free margin of the soft palate and the
tonsillar pillars. Nasolabial flaps are well suited for anterolat­
eral defects28. Hinged nasal septum flaps provide tissues for clo­
sure and support for defects of the hard palate29’30.
Forehead flaps have a good blood supply, a large surface
area, and do not produce functional impairment31. The cosmetic
deformity from forehead flaps may be undesirable and should
be discussed with the patient prior to surgery. These flaps, like
the preceding methods of surgical flap reconstruction, do not
require a delay period for survival. Occasionally, a time delay is
utilized to line the raw underneath surface of the flap with split
thickness skin and thus obtain a flap with 2 cutaneous surfaces.
Medially-based deltopectoral flaps alone, or in combination with
neck and forehead flaps, are the most versatile methods for clos­
ing large defects32.
Recently, free tissue transfers have been used to reconstruct
palatal defects33,34,35. Cutaneous (radial forearm) and
osteocutaneous (iliac crest) flaps have proven effective in re­
storing the partition between the oral and nasal cavities. How­
ever, these flaps are frequently over-contoured, making it diffi­
cult to restore proper palatal contours which are in the proper
relationship. Consequently, speech and swallowing may be
impaired. In addition, reconstruction with these flaps may de­
lay recognition of a recurrent tumor. These flaps are most use­
ful in restoring the cheek flap in patients who have undergone
maxillectomy and orbital exenteration, wherein significant
amounts of cheek skin have been resected. The radial forearm
flap is particularly useful in reconstructing these defects; it re­
stores the cheek tissues but does not interfere with the fitting of
a palatal prosthesis with proper palatal contours, and the den­
ture teeth can be positioned appropriately. (Figure 6-20).

Fig. 6-20.
a: Large maxillectomy-orbital, exenteration-cheek defect, b: Cheek defect suc­
cessfully reconstructed with radial forearm flap, c: Palatal defect remains, allow­
ing for normal palatal contours and proper positioning of denture teeth, d: Max­
illary obturator prosthesis. Teeth are properly positioned and palatal contours
restored, e: Prosthesis inserted.
240 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
In summary, a thorough evaluation by both die surgeon
and prosthodontist permits selection of the best method of re­
habilitation, and it allows the patient to make an informed deci­
sion concerning the management of his or her palatal defect.
Suigical reconstruction is preferable in patients with lacerations,
or traumatic defects, where tissue loss is minimal. In patients
with larger defects, particularly those secondary to tumor re­
section, prosthetic rehabilitation is the treatment of choice; palatal
contours can be faithfully restored and teeth can be properly
positioned.
Prosthetic Rehabilitation
If the defect is to be restored prosthetically, the prosthodon­
tist should (prior to surgery) examine the patient thoroughly,
make impressions for diagnostic casts, mount these casts on a
suitable articulator with a jaw relation record, and obtain ap­
propriate dental radiographs. Some compromises may be nec­
essary because of the immediacy of surgery and the distance
the patient may have to travel. If time permits, a routine pro­
phylaxis can be performed, salvageable teeth with large carious
lesions can be restored, and arrangements can be made for the
extraction of unsalvageable teeth at surgery.
During this appointment, the plan for rehabilitation is dis­
cussed with the patient. Most patients will be unfamiliar with
both the term “prosthodontist” and the services a prosthodon­
tist can provide2. The benefits, limitations, and sequence of pros­
thetic care should be explained to the patient. A few patients
will have many questions, whereas others will not prefer exten­
sive information, as discussion of the subject will evoke further
anxiety. With the diagnostic aids he or she has obtained, the
prosthodontist is prepared to consult with the surgeon and dis­
cuss the myriad of factors related to prosthetic rehabilitation.
Prosthodontic therapy for patients with acquired surgical
defects of the maxilla can be arbitrarily divided into 3 phases of
treatment, with each phase having different objectives. The ini­
tial phase is called surgical obturation and entails the place­
ment of a prosthesis at surgery or immediately thereafter. This
prosthesis must be modified at frequent intervals to accommo­
date for the rapid soft tissue changes that occur within the de­
fect during the organization and healing of the wound. The pri­
mary objective of immediate surgical obturation is to restore
and maintain oral functions at reasonable levels during the ini­
tial postoperative period. The second phase of postsurgical
prosthodontic treatment is called interim obturation. The ob­
jective of this phase is to provide the patient with a comfortable
and functional prosthesis until healing is complete. The timing
of the interim obturator phase is somewhat variable. This phase
may not be necessary if the defect is small and the patient is
functioning well with the immediate surgical obturator. How­
ever, variations in the extent of surgery as determined
presurgically, rapid tissue changes immediately following sur­
gery and extensive surgical defects may necessitate fabricating
either a new interim prosthesis, or major modifications to the
surgical obturator. The timing of the interim phase is dependent
upon the level of patient function and, if treatment is necessary,
it is usually instituted 2 to 6 weeks postsuigically. Three to 6
months after surgery, the surgical site becomes well-healed and
dimensionally stable, thus permitting construction of the de­
finitive prosthesis or the third phase of prosthodontic therapy.
Surgical Obturation
Surgical obturation has been accomplished with a variety
of restorations and materials, including sponges36, gutta­
percha3738, and inflatable bulbs39. We prefer the use of an acrylic
resin prosthesis. This prosthesis initially is limited to the resto­
ration of palatal integrity and the reproduction of palatal con­
tours. Surgical packing is used to occlude the defect. Obtura­
tion may be accomplished either with the placement of an im­
mediate surgical obturator at surgery, or with the placement of a
delayed surgical obturator 6 to 10 days postsurgically. Immedi­
ate surgical obturation is indicated for most patients40’41,42.
Immediate surgical obturation Immediate surgical obturation
is particularly well-suited for dentuious patients requiring a par­
tial or total maxillectomy because the remaining teeth can be
used to help retain the prosthesis in position. The advantages of
immediate surgical obturation are as follows:
1 The prosthesis provides a matrix on which the surgical
packing can be placed. On closure of the wound, the obtu­
rator maintains the packing in the proper relationship, thus
ensuring close adaptation of the skin graft to the raw sur­
face of the cheek flap.
2 The prosthesis reduces oral contamination of the wound
during the immediate postsurgical period and thus may
reduce the incidence of,local infection.
3 The prosthesis enables the patient to speak more effectively
postoperatively by reproducing normal palatal contours and
by covering the defect.
4 Theprosthesis permits deglutition, thus eliminating the need
for a nasogastric tube, for some or its earlier removal for
others.
5 The prosthesis lessens the psychological impact of surgery
by making the postoperative course easier to bear. The pa­
tient is reassured that rehabilitation has begun.
6 The prosthesis may reduce the period of hospitalization43.
This benefit assumes even greater importance with the es­
calating costs of hospitalization.
Immediate surgical obturators are fabricated on a maxil­
lary cast obtained prior to surgery. If the extent of surgery is in
question, it may be necessary to fabricate 2 or more prostheses
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
presurgically in order to be prepared for most eventualities. The
surgical prosthesis should be left in place for at least 6 days
postsurgically. Retention from the wire clasp retainers may not
be sufficient to accomplish this objective in many patients. In
these instances, the prosthesis is ligated to the remaining teeth
or wired (or pinned) to available bony structures.
There are several principles relative to the design of imme­
diate surgical obturators which the prosthodontist should con­
sider:
1 The obturator should terminate short of the skin graft mu­
cosal junction initially. As soon as the surgical packing is
removed, extension into the defect may be accomplished
with tissue treatment* or interim soft reline materials**.
2 The prosthesis should be kept simple, lightweight, and in­
expensive. Round 18-gauge wrought gold or stainless steel
wire retainers are sufficient for dentulous patients.
3 The prosthesis for dentulous patients should be perforated
with a small dental bur at the interproximal extensions to
allow the prosthesis to be wired to the teeth at the time of
surgery.
4 Normal palatal contours should be reproduced to facilitate
postoperative speech and deglutition. If the disease pro­
cess has distorted palatal contours, normal palatal contours
should be reestablished on the cast. If palatal tori are evi­
dent, arrangements should be made for their removal dur­
ing surgery, and normal contours should be established on
the presurgical cast17.
5 Posterior occlusion should not be established on the defect
side until the surgical wound is well organized. However,
if the patient is scheduled for a total maxillectomy with
resection to the midline, the 3 maxillary anterior teeth in­
cluded in the resection may be added to the prosthesis to
improve esthetics.
6 The surgical obturator for edentulous patients should be
fabricated much like a record base, with no replacement
teeth. The prosthesis is wired to the zygoma or residual
alveolar ridge, or pinned (or screwed) into the palate for
retention at the time of surgery. After 7 to 10 days, the sur­
gical obturator is removed and discarded, and the patients’
conventional maxillary complete denture is converted into
an interim prosthesis.
7 In some patients, the existing complete or partial prosthe­
sis may be adapted for use as an immediate surgical obtu­
rator. However, the buccal flange of the prosthesis corre­
sponding to the proposed defect requires reduction, and
the posterior denture teeth on the defect side should be re­
moved prior to surgery. Interim lining materials may be
added to the revised prosthesis at the time of surgery to
improve adaptation.
Visco-gel, Dentsply, York, PA.
** Trusoft or Rimseal, Harry J. Bosworth Co., Skokie, IL.
241
Most surgical procedures involving the maxillae may in­
clude variable amounts of soft palate on the afflicted side. There­
fore, standard maxillary impression trays must be extended
posteriorly with waxes or modeling compound to record the
desired portion of the soft palate in the impression. The patient
should be placed in an upright position so that the soft palate
assumes a relatively normal and relaxed position. If the patient
has an active gag reflex, topical anesthetics and rapid-setting
irreversible hydrocolloid impression material are useful. It is
important to make an accurate impression of the vestibular depth
on the resected side so that the approximate position of the skin
graft-mucosal junction can be determined. The adapted wire
retainers should engage sufficient numbers of teeth in order to
insure adequate retention of the prosthesis after the wire liga­
tures have been removed. Minimal tooth preparation may be
required for these retainers, but provision must be made for
occlusal clearance. Occlusal interference is difficult to identify
in the operating room and can result in unnecessary discomfort
during the immediate postoperative period. If the patient has
fixed partial dentures or splinted teeth, and if the proposed sur­
gical margin will bisect these fixed units, it may be necessary to
remove or segment selected fixed units prior to surgery. After
the maxillary and mandibular impressions are made and the
casts retrieved, the casts are mounted on a suitable articulator
with the aid of a jaw relation record.
The surgeon and prosthodontist should discuss the surgery
together and outline the proposed surgical margins on the max­
illary cast (Figure 6-21a). The lateral boundary is usually the
labial and buccal reflex, and the medial boundary is the midline
of the palate. The most questionable extensions are the anterior
and posterior margins.
The maxillary cast is altered to conform to the proposed
surgical resection. Teeth to be included in the resection are re­
moved from the cast, but alveolar height is maintained. The
residual alveolar ridge is trimmed modestly, particularly in the
anterior region to reduce the tension upon the skin and lip clo­
sure (Figure 6-21 b,c). If the tumor or tori has distorted palatal
contours, the cast must be altered (Figure 6-22) to establish
normal contours. In dentulous patients in whom the extent of
the surgical margin is in doubt, multiple obturators should be
fabricated. It should be noted that, when the anterior portion of
the soft palate is to be resected, the remaining portion of the soft
palate will often droop inferiorly-and may exhibit little motion
during the immediate postoperative period. This factor should
be anticipated and the cast altered accordingly. In patients with
excessive vertical overlap, the obturator extension anteriorly
must be thinned to avoid occlusal interference with mandibular
anterior teeth. Avoid extension of the prosthesis lateral to the
pterygoid hamulus. If the pterygoid hamulus is removed during
the maxillectomy procedure, the attachment and/or function of
the tensor veli palatini, buccinator, and superior constrictor
muscles can be compromised, resulting in the medial collapse
242 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 6-21. a: Margins of the proposed surgical resection outlined on the presurgical maxillary cast, b: Cast trimmed appropri­
ately for fabrication of the immediate surgical obturator, c: Teeth included in resection are removed, and alveolar
ridge area is reduced modesty anterolaterally and distolaterally. Vestibular depth on side of resection determines
superior extension.

a b e d
Fig. 6-22. a and b: Tumor-distorted palatal contours, c: Cast altered to restore palatal contours, d: Completed immediate
surgical obturator on the cast.

of the distolateral portion of the defect41. A prosthesis overex­
tended laterally in this area will cause tissue irritation and sig­
nificant patient discomfort. If this situation is anticipated, the
cast should be reduced 2-3 mm medially. After the cast is al­
tered, the wire retainers are adapted and the prosthesis is waxed,
invested, and processed in autopolymerizing acrylic resin, and
finished and polished in the customary manner (Figure 6-23).
Clear resin is suggested so that the extensions and possible pres­
sure areas can be more easily visualized at surgery.
In resection of unilateral tumors, the prosthodontist is not
often required in the operating room for placement of the pros­
thesis. However, in resection of bilateral tumors, or if alterations
of the prosthesis are anticipated, appropriate instrumentation
must be available. Armamentarium at surgery will vary with
each clinician, but the following items are suggested:
autopolymerizing acrylic resin, tissue conditioning materials,
suitable dental burs, clasp adjusting pliers, and a vulcanite
scraper. Most head and neck operating rooms possess either
belt, air-driven or electric handpieces, or similar devices which
accept dental burs. Scissors, scalpels, marking pens, hemostats,
and so on are always available in the operating room if needed.
Operating room protocol will vary with the hospital and/or
surgeon. However, strict conformity to set operating room pro­
cedures must be observed, with the prosthodontist scrubbed,
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 243

Fig. 6-23. a: Cast has been prepared and retainers adapted, b: Immediate surgical obturator has been completed, c: Some
clinicians prefer to add anterior teeth to the prosthesis. Note interproximal perforations.

gowned, and gloved. The required instruments and the prosthe­
sis should be delivered to the surgical area the afternoon prior
to surgery. The instruments are autoclaved, the dental materials
are sterilized, and the prosthesis is immersed in a disinfectant
If the prosthodontist performs this procedure routinely, the re­
quired instruments can be assembled and stored in the surgical
area.
In most instances, the immediate suigical obturator is eas­
ily fitted and secured (Figure 6-24). Care should be taken to
adjust the lateral extension of the obturator short of the skin
graft mucosal junction in order to avoid pressure to this area.
The lateral and anterior aspects of the prosthesis should be re­
duced until correct facial contours are obtained, without creat­
ing excessive tension during closure.

Fig. 6-24. a: Total maxillectomy defect. Note that a Webber-Fergusson surgical exposure was utilized. Tension on the cheek
flap was adjusted before the prosthesis was retained and the defect packed with gauze, b. The prosthesis serves as
a platform for placement of surgical packing, c: When the wound is closed, facial contours are nearly normal.
244 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
The surgical packing will accommodate for most discrep­
ancies. However, if the surgery was more extensive than planned,
or in large bilateral defects, it is often preferable to add an inter­
mediate denture reline material* to the prosthesis. A thick mix is
made and added to the deficient areas. The prosthesis is inserted
and, as the material sags, it is manipulated into position with a
wet, gloved finger. If the deficiencies are modest, a thinner mix
of material is made and the same procedure performed. Ad­
verse tissue reactions have not been reported with these materi­
als. If the surgery has proceeded as planned, the application of
lining materials is rarely required.
In the past, many clinicians have used autopolymerizing
acrylic resin, gutta percha, or modeling plastic for major addi­
tions to the obturator prosthesis at surgery. However, resin is
difficult to manipulate and there is a concern over the adverse
effect of the free monomer on raw tissue surfaces. Modeling
plastic deteriorates rapidly intraorally, especially if used in con­
junction with tissue conditioning materials.
If a Weber-Fergusson exposure is used, the prosthesis should
be inserted prior to closing the cheek flap, as tension on the flap
can be judged more accurately with the prosthesis in place. When
positioned, the prosthesis can be used as a platform for place­
ment of the surgical packing. After the prosthesis is secured, the
defect is packed with gauze and the cheek flap is closed (Figure
6-24). In dentulous patients, retention can be obtained by wir­
ing the prosthesis to existing teeth. In edentulous patients, the
prosthesis is wired or pinned to the alveolar ridge, zygomatic
arches, and/or anterior nasal spine (Figure 6-25). If a transoral
surgical approach is used, the surgeon will pack the defect prior
to inserting the prosthesis.
Six to 8 days postsurgically, the prosthesis and packing are
removed. The prosthesis is cleansed and adjustments are made.
Occasionally, there are minor occlusal discrepancies, or reten-
Fig. 6-25. In this edentulous patient, an immediate surgical
obturator was wired to the alveolar ridge.
Trusoft or Rimseal, Harry J. Bosworth Co., Skokie, IL.
tive deficiencies, associated with the wire retainers that require
attention. A new application of interim treatment liner will im­
prove adaptation, seal, and comfort. The lateral extension into
the defect can be developed consistent with easy insertion and
removal of the prosthesis. Instructions are given in the care of
the prosthesis and the patient is dismissed with reappointment
in 1 week. The prosthesis should be cleaned with a mild soap
and water and a soft brush after every meal. During the early
stages of healing, we recommend that the prosthesis be worn at
night, because rapid contraction of the surgical wound during
these early stages may make reinsertion of the prosthesis the
following morning both painful and difficult.
Instructions are also provided regarding the irrigation and
cleansing of the surgical defect. Mucous crustings occur fre­
quently in the untidy patient. Their removal may be difficult
and may precipitate some discomfort. Mucous and/or mucous
crusting can be removed by using 2 x 2 or 4 x 4 gauze pads
soaked in warm water. As the defect heals, mineral oil may be
used to soften and remove the dried mucous crustings. Oral
hygiene instructions are best reviewed in the presence of a fam­
ily member, because the patient is not often capable, either physi­
cally or emotionally, of cleansing the defect properly during the
immediate postsurgical period. A pulsating stream irrigator is
useful in selected patients44.
As healing progresses in the non-radiated patient, trismus
usually abates, allowing extension of the prosthesis further into
the defect to improve seal and retention. If the patient has re­
ceived preoperative radiation therapy, or is scheduled for post­
operative radiation therapy, trismus may persist and occasion­
ally limit the superior-lateral extension of the obturator. The
patient is usually seen every 2 weeks, when the lining material
is changed to account for tissue contracture. During these fol­
low-up visits, it is best to remove all of the old interim lining
material, as these materials are porous, predisposing to micro­
bial contamination and precipitation of undesirable odors and
mucosal irritation. If the surgical resection included a anterior
portion of the soft palate, more frequent adjustments are usu­
ally required. As healing progresses, the remaining posterior
portion of the soft palate will be elevated superiorly and pulled
anteriorly to adjust for scar contracture (Figure 6-26). In lateral
soft palate defects, increased movement of the residual pharyn­
geal musculature may be noted as edema and discomfort sub­
side. The obturator must maintain functional contact with these
dynamic pharyngeal tissues if speech and swallowing are to be
optimized. In large posterior-lateral defects, it is usually neces­
sary to correct for eccentric mandibular movements, since, in
defects extending posterolaterally, the coronoid process will
move forward and limit the posterior lateral contours of the pros­
thesis.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
Position of remaining
soft palate after
scar contracture
Position of soft palate
1 week post resection
a b
Fig. 6-26. a and b: The soft palate margin of the resection is subject to rapid contraction anteriorly and superiorly during the
first 3 weeks following surgery. On rare occasions, velopharyngeal closure can be compromised.
Delayed Surgical Obturation
An alternative to the placement of a prosthesis at surgery is
the placement of a delayed surgical obturator 6 to 10 days
postsurgically. If the patient is edentulous, the surgical defect is
to be extensive, and margins are in question, this approach may
be an acceptable alternative.
When the packing is removed from the defect, and before
the patient is dismissed from the hospital, a maxillary impres­
sion is obtained with irreversible hydrocolloid impression ma­
terial. The surgical area will be tender and the patient apprehen­
sive. Therefore, this procedure must be accomplished carefully
and considerately. The impression should record as much of the
lateral portion of the defect as is possible. A soft metal edentu­
lous tray is altered so that approximately a quarter-inch clear­
ance exists in all dimensions. In the area of the defect, it may be
necessary to remove some of the flange of the tray or bend it
medially. All flanges are covered with peripheral beading wax,
with additional wax added in the area of the defect to provide
support for the impression material. The tray is coated with a
suitable adhesive* to aid retention of the impression material.
Major medial undercuts are generally not useful and should be
blocked out with gauze lubricated with petrolatum. Sensitive
areas should be similarly blocked out. The lubricated gauze can
also be used to limit the extension of the impression material
into the defect. If an orbital exenteration has been performed,
the patch covering the orbit can be removed and observations
made regarding the fitting and placement of the tray. Impres­
Hold, Teledyne Dental Corp., Elk Grove Village, IL.
245
Position of remaining
soft palate after
scar contracture
Position of soft paiate
1 week post resection
sion material should be placed on the lateral side of the tray
corresponding to the defect in order to record the contour of the
lateral cheek surface. It may be useful to inject impression ma­
terial into the lateral portion of the defect (using a disposable
syringe) just prior to seating the impression material and tray.
After the tray is positioned and seated, the cheek and lips
should be carefully manipulated, especially on the defect side.
The sutures will still be present, but, fortunately, they tend to
pull out of this elastic impression material quite easily. A well-
adapted irreversible hydrocolloid impression creates a vacuum;
therefore, the impression will cause some pain upon removal.
The impression is gently released from the mouth and exam­
ined for proper extension and adaptation (Figure 6-27). If this
procedure is carefully performed, the necessity for remaking
the impression can be avoided. Some surgeons will choose to
remove the packing in the operating room while the patient is
under heavy sedation. In this situation, the impression can be
made in the operating room with less discomfort to the patient.
If the patient is dentulous, the prosthesis is constructed as
previously described. The prosthesis must be constructed
quickly, since dismissal of the patient from the hospital is de­
pendent upon delivery, adjustment, and acceptance of the pros­
thesis. The prosthesis is delivered and adjusted using pressure
indicator paste, disclosing wax, and articulating paper. If the
prosthesis fits well and has adequate retention, it may not be
necessary to add a temporary lining material. As healing
progresses, posterior occlusal ramps can be established with
the addition of autopolymerizing acrylic resin. Posterior occlu-
246 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 6-27. a: Edentulous patient 8 days after maxillectomy. b: Edentulous tray selected for the impression procedure. Flange
on the defect side is bent medially, and wax is added on the side of the defect. Impression recorded oral surface of
lateral cheek flap.

sion helps the patient retain the prosthesis in position, which is

especially helpful for edentulous patients. Follow-up care should
follow the same regimen as described with prostheses placed at
the time of surgery.
In edentulous patients, it is preferable to utilize the patient’s
existing maxillary prosthesis as a delayed surgical or interim
obturator. The existing prostheses should be inspected carefully
to insure that it will adequately obturate the surgical defect. The
buccal and/or labial flanges of the complete or partial denture
must be shortened on the side of the defect (Figure 6-28a).
Often, it is necessary to extend the prosthesis with
autopolymerizing acrylic resin to cover the margin of resection
on the soft palate. After the prosthesis is adjusted, it is relined
with an intermediate reline material* (Figure 6-28b).
One other approach should be mentioned, since it has ap­
plication to the practice of maxillofacial prosthetics in a private
office setting. The placement of immediate surgical obturators
is not a scheduling problem in a medical center with a maxillo­
facial training program; most head and neck surgery is performed
on specific days of the week and schedules can be adjusted
accordingly. However, the placement of immediate surgical
obturators can be inconvenient in a busy private practice. Usu­
ally, there is litde notice prior to surgery; often surgical sched­
ules are not finalized until the afternoon of the day preceding
surgery and, invariably, surgeries fall behind schedule. There­
fore, an alternative sequence is suggested that fits conveniently
into a private practice environment yet allows placement of a
b
delayed surgical obturator 7 to 10 days postsurgically. Diag­
nostic casts are obtained and the maxillary cast is delivered to Fig. 6-28. a: Patient's existing dentures were adequate, and
the surgeon prior to surgery. Immediately postsurgically, the were modified and used as delayed surgical ob­
surgeon outlines the surgical margins on the cast. The prosth­ turator following removal of surgical packing. La­
odontist picks up the cast, alters it to correspond with the out­ bial and buccal extensions on the defect side were
line, and constructs the prosthesis. On the day the packing is reduced (arrow), b: Maxillary denture is relined
removed, the prosthodontist delivers and adjusts the prosthesis with an intermediate reline material. Obturator
in the hospital. portion is hollowed to reduce weight.

Rimseal, Harry J. Bosworth Co., Skokie, IL.

 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
Interim Obturation
The objective of immediate and delayed surgical obtura­
tion is to serve the patient through the immediate postoperative
period. In some patients, these prostheses can be maintained
until the definitive obturator is constructed. A definitive pros­
thesis is not indicated until the surgical site is healed and di-
mensionally stable, and the patient is prepared physically and
emotionally for the restorative care that may be necessary. For
some patients, particularly with large defects, appropriate func­
tion and comfort cannot be sustained without construction of
either a new prosthesis, or a significant modification of the im­
mediate or delayed obturator. The interim obturator prosthesis
“bridges the gap” between the immediate surgical obturator and
the definitive prosthesis. The division between an immediate
surgical obturator and an interim obturator prosthesis is not well
defined, but both have the same objective of maintaining pa­
tient comfort and function until the definitive prosthesis can be
fabricated.
There are several reasons for constructing a new prosthe­
sis: First, the periodic addition of interim lining materials in­
creases the bulk and weight of the prosthesis, and these tempo­
rary materials tend to become rough and unhygienic with time.
Second, if teeth were included in the resection, the addition of
anterior and, possibly, posterior denture teeth to the obturator
can be of great psychological benefit to the patient. Third, if
retention and stability are inadequate, reestablishing occlusal
contact on the defect side may improve these aspects. Fourth, a
well-made interim obturator can serve 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 prosthesis45 (Figure 6-29). If the pa­
tient is dentulous, a new application of interim lining material
is placed over the tissue surface and the prosthesis is seated
firmly to maintain correct relationships. As the material begins
to set, the lips and cheek are manipulated and the patient is
mstructed to perform eccentric mandibular movements. When
the material has set, the prosthesis is removed and any excess
material is trimmed from inappropriate areas. The prosthesis is
reinserted and its effectiveness is tested by directing the patient
to speak and swallow fluids. If these tests confirm that the pros­
thesis has adequate extension and adaptation, a jaw relation
record is obtained. An irreversible hydrocolloid impression is
made over the prosthesis and remaining teeth (Figure 6-29f).
The impression is poured with dental stone, then the maxillary
cast with the prosthesis is related to the mandibular cast with
die jaw relation record and mounted on a suitable articulator.
The prosthesis may be rebased, jumped, or entirely rewaxed.
Anterior teeth may be added appropriately. The laboratory pro­
cedures should be completed quickly and the old prosthesis re­
am ed to the patient. A new application of temporary denture
247
reline material may be required prior to dismissal of the patient,
as the interim lining material may tear or distort with retrieval
of the cast. The new obturator is processed and hollowed (Fig­
ure 6-29 g,h). The new prosthesis is relined periodically with an
intermediate reline material as necessary. Follow-up care con­
tinues as previously described.
There are several clinical applications for the use of visible
light-cured resins in maxillofacial prosthetics, primarily due to
time constraints. It is not unusual for an out-of-town patient to
require a surgical obturator for the following day. Many times,
additions to prostheses, or conversion of a surgical obturator
into an interim prosthesis, must be completed within a few hours
because the patient cannot function without a suitable prosthe­
sis. Light-cured resin technology facilitates these changes and
can minimize the time the patient is without his or her prosthe­
sis4^47,48.
Definitive Obturation
Three to 4 months after surgery, consideration may be given
to the construction of a definitive obturator prosthesis. The tim­
ing will vary depending upon the size of the defect, the progress
of healing, the prognosis for tumor control, the use and timing
of postsurgical radiation therapy, the effectiveness of the present
obturator, and the presence or absence of teeth. The defect must
be engaged more aggressively for edentulous patients to maxi­
mize support, retention, and stability; therefore, the recovery
period is often extended for these patients. As with conven­
tional immediate dentures, changes associated with healing and
remodeling will continue to occur in the border areas of the
defect for at least 1 year. However, in contrast with immediate
dentures, dimensional changes are primarily related to the pe­
ripheral soft tissues rather than to bony support areas. By this
time, the mental outlook of most patients will have improved.
They realize that speech, mastication, and deglutition will not
be compromised significantly. Most dentulous patients are pre­
pared physically and emotionally for the extensive restorative
procedures that may be required prior to the construction of a
definitive obturator. If osseointegrated implants have been placed
at the time of tumor resection, the fabrication of the definitive
prosthesis is delayed until the implants are exposed and the pe­
ripheral soft tissues around them have healed.
In addition to treatment planning associated with a stan­
dard prosthodontic evaluation, the clinician should elicit infor­
mation relevant to the prognosis for tumor control as well as the
general health and desires of the patient A patient’s poor prog­
nosis, or poor health, does not preclude the construction of a
definitive obturator prosthesis, but the treatment plan should
reflect the possible altered needs of such a patient. Mounted
diagnostic casts are essential, and new radiographs of question­
able teeth should be obtained. The evaluation should include
opinions from the surgeon, the radiation therapist, the medical
248 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 6-29. Interim obturation, a: Patient 1 week post-surgery with packing removed, b: Immediate surgical obturator after
thorough cleaning, c: Immediate surgical obturator converted to an interim obturator prosthesis, d: Interim prosthe­
sis in mouth, e: Anterior teeth have been added to this immediate surgical obturator, f: Further revision of interim
obturator 1 month later. Impression made over prosthesis in preparation for major revision, g and h: Revised pros­
thesis.

oncologist, and the clinical social worker. Most patients will be
functioning well with their interim prosthesis, so the treatment
plan may be developed systematically and thoroughly.
Treatment concepts Several concepts will be discussed re­
garding the definitive obturator prosthesis.
Movement o f the prosthesis The prosthesis will move
significantly during function if the maxillary alveolar ridge and
teeth are involved in the resection (as is the case with most
maxillary surgical procedures). The obturator will be displaced
superiorly into the defect with the force of mastication, and it
will tend to drop without occlusal contact. The degree of move­
ment will vary with the number and position of teeth or im­
plants (if any) that are available for retention as well as with the
size and configuration of the defect.
Tissues changes Dimensional changes will continue to
occur for a least 1 year secondary to scar contracture and fur­
ther organization of the wound. Movement of the prosthesis
during function may in itself contribute to tissue changes. If a
removable partial prosthesis is indicated, the obturator portion
should be constructed of aciylic resin in order that the prosthe­
sis may be relined or rebased to compensate for these changes.
Oral-nasal partition Obturators for acquired defects of
the maxillae are basically covering prostheses, primarily serv­
ing to reestablish the oral-nasal partition. The obturator pros­
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
thesis is extended into the defect in order to enhance retention,
stability, and support. The contours of the defect are relatively
static during function, aside from the movement of the soft tis­
sues displaced by the movement of the coronoid process and
the anterior border of the ramus of the mandible, the slight
movement of the lips and cheek, and, in some patients, the el­
evation of the residual soft palate. In contrast, obturators which
restore velopharyngeal competency must function in concert
with tissues exhibiting extensive functional movements (see
Chapter 7).
Extension into the defect The degree of extension into
the defect is dependent upon the requirements for retention, sta­
bility, and support. If these properties can be obtained from the
remaining maxillary structures, then extension into the defect
need not be extensive. In most defects, however, the defect must
be used to improve these qualities. In addition, the extension of
the prosthesis into the defect will vary according to the con­
figuration of the defect and the character Of its lining tissue.
Extension of the prosthesis superiorly along the nasal septum
offers little mechanical advantage. In addition, the ciliated
psuedostratified columnar epithelium, lining the nasal septum
and other nasal structures, will tolerate little stress. In contrast,
extension superiorly along the lateral margin of the defect will
enhance retention, stability, and support. Stress is well-toler-
ated by the skin graft and oral mucosa lining the cheek surface
of the defect.
Fig. 6-30. a: Implants placed in premaxillary segment, b: Implants placed in maxillary tuberosity.
Fig. 6-31. a and b: Obturator prostheses hollowed to reduce weight.
249
Teeth As with all maxillofacial prostheses, the presence
of teeth enhances the prosthetic prognosis. Every effort should
be made to maintain and enhance the longevity of teeth—or
even roots of teeth—to assist with the retention, stability, and
support of the prosthesis.
Implants The placement of osseointegrated implants will
dramatically improve the function of the obturator prosthesis,
particularly for edentulous patients. Implants can be placed ei­
ther in association with resection of the tumor, or at some ap­
propriate time thereafter. The most desirable locations for the
placement of implants are the premaxillary segment and the
maxillary tuberosity (Figure 6-30).
Weight Bulky areas should be hollowed to reduce weight,
so that teeth and supporting tissues are not stressed unnecessar­
ily. Weight reduction is especially important when the obtura­
tor prosthesis is suspended without bony or posterior tooth sup­
port on the defect side, as is the case with most maxillary resec­
tion prostheses49. Wu and Schaaf found that a hollow maxillary
obturator prosthesis reduced the weight of the prosthesis from
1% to 33%, depending upon the size of the maxillary defect50.
The superior surface can be either left open or closed (Fig­
ure 6-31). Clinicians who prefer the closed top maintain that, if
the obturator is left open, nasal secretions accumulate leading
to odor and added weight. Accumulation of secretions with an
open obturator is not significant for patients who have previ­
250 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
ously been irradiated. We prefer to leave the top open because
an open obturator has less weight and is easier to adjust, plus
speech may be better with this configuration.
Speech performance and the weight of a maxillary obtura­
tor prosthesis may have some relationship to the length of the
extension superiorly into the defect and to the configuration of
the superior surface of the obturator. Aramany and Drane stud­
ied 6 patients with varied defects of the maxillae but with nor­
mal velopharyngeal closure51. Patients were provided with 2
identical prostheses, with the exception of the obturator seg­
ment. One obturator was extended maximally up into the de­
fect, whereas the second extended only to the level of the nor­
mal partition between the oral and nasal cavities. Speech samples
were recorded, randomized, and evaluated by 7 speech patholo­
gists. Speech quality, using the prosthesis with the limitedly
extended obturator prostheses, was significantly better (p=0.05),
as compared with the maximally extended obturator prosthe­
ses.
Oral compared the speech of 10 patients with maxillary
obturator prostheses with both open and closed superior con­
figurations52. All 10 had normal velopharyngeal mechanisms.
Initially, an open obturator was fabricated with a lengthy supe­
rior extension along the lateral and posterolateral aspect of the
defect, but with only a limited extension medially. After speech
was recorded, a lid was added to create a hollow, closed obtura­
tor. Speech was recorded again, and the speech samples were
randomized and evaluated by 5 speech pathologists. Of the 50
evaluations (5 speech pathologists, each evaluating the 10 pa­
tients), 32 rated the open configuration best, while 18 favored
the closed, hollow obturator. After the speech study was com­
pleted, the 10 obturators were left open and the patients fol­
lowed for 1 year. Two patients complained of leakage and/or
the accumulation of fluids within the obturator well. This con­
dition was corrected for 1 patient by improvement of the lateral
seal of the obturator, while the second patient required conver­
sion of the open obturator to a closed hollow bulb.
It is interesting to speculate as to the reason for these small
differences in speech between the 2 configurations. The lengthy
superior extension along the lateral and disto-lateral aspect of
the defect is essential for stability, support, and retention of the
prosthesis. If a lid is added to the hollow obturator, a significant
portion of the nasal and maxillary sinus cavities is now occu­
pied by the closed obturator bulb. Sharry stated that it may not
be necessary for the obturator to occupy the entire defect supe­
riorly for effective obturation53. The study by Aramany and
Drane51, Parel and Drane54, and Oral52 support this conclusion.
If the obturator is extended maximally laterally and disto-later-
ally and is converted to (or processed as) a hollow bulb, the
obturator will occupy a significant portion of the defect. This
may change the configuration, resonance balance, and airflow
characteristics of the nasal cavity. The open obturator design
may be less obtrusive in the nasal cavity and permit more nor­
mal airflow, nasal resonance, and speech.
We prefer the open top design because of its simplicity,
lighter weight, and ease of adjustment. Our experiences with
the open top are similar to Oral52. On occasion, a patient will
require obturator modification and/or conversion to a closed-
top hollow obturator bulb. If secretions do tend to accumulate,
a small diagonal opening may be made between the inferior-
lateral floor of the open top obturator through to the cheek sur­
face for drainage. The cheek will close against the opening so
seal is not compromised. A pipe cleaner is suggested for clean­
ing and maintaining the patency of this drainage channel55.
The treatment of paranasal sinus neoplasms often require
cancerocidal doses of radiation therapy, hi these cases, the mi­
nor salivary glands found in the adjacent mucosal lining exhibit
a vastly reduced output of secretions. The skin graft lining the
cheek surface has no secretory potential. Therefore, in such
patients, nasal secretions are minimal and an open top is ac­
ceptable. However, sealing the top of the obturator may be an
advantage if the patient demonstrates normal secretory output
or complains of accumulation of secretions. The technique, sug­
gested by Bimbach and Bamhard56, of adding a lid works well.
If the clinician desires a closed top hollow obturator bulb at the
initial placement, the techniques described by Chalian and
Barnett57, Matalan and La Fuente58, or Parel and La Fuente59are
recommended. In general, leakage of the hollow obturator bulb
is less likely to occur if the hollow bulb is processed initially, as
a completed unit, rather than by adding a lid after processing.
Another alternative is to fabricate a removable superior lid, pro­
viding the patient with both alternatives, along with access for
cleaning. The lid is vacuum-formed with mouth-guard mate­
rial, but must be replaced periodically60.
After the treatment plan has been established, explained,
and accepted by the patient, treatment is ready to proceed. The
construction of the definitive prosthesis will vary with the type
of resection and the presence or absence of teeth. Techniques
will be described for both edentulous and dentulous patients.
The prosthodontic treatment for the edentulous patient will be
described first, as the defect must be engaged more aggressively
for retention, stability, and support for the prosthesis. The use
of the defect for dentulous patients will vary depending upon
the size and configuration of the defect, the number and con­
figuration of teeth that remain postsurgically, and the presence
of implants. If the prosthesis is not properly designed and con­
structed, the stress upon the remaining hard and soft tissues can
be pathologic, leading to premature loss of abutment teeth or
implants and the subsequent chronic irritation of the supporting
soft tissues.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
Edentulous patients with total maxillectomy defects Fabrica­
tion of a prosthesis for an edentulous patient with a large max­
illary defect will challenge the skill of even the most experi­
enced clinician. With any sizable palatal perforation, retention,
in the classical sense of a complete denture prosthesis, is im­
possible. Air leakage, poor stability and support, and reduced
bearing surface will compromise adhesion, cohesion, and pe­
ripheral seal. Therefore, the contours of the defect must be used
to maximize the retention, stability, and support for the prosthe­
sis18. The surgical defect should be well-healed prior to the fab­
rication of the definitive obturator prosthesis.
Maxillary obturator prostheses for edentulous patients will
exhibit varying degrees of movement, depending upon the
amount and contour of the remaining hard palate, the size, con­
tour and lining mucosa of the defect, availability of undercuts,
and the support areas that can be engaged within and peripheral
to the defect. As previously mentioned, the prosthesis moves
superiorly into the defect during mastication. With the release
of occlusal pressure, the prosthesis drops in the opposite direc­
tion. In the edentulous patient with a total maxillectomy defect,
the axis of rotation is located along the medial palatal margin of
the defect (Figure 6-32a). The portion of the obturator at right
angles and most distant from this axis will exhibit the greatest
degree of motion. In a posterior maxillary defect, where the
premaxillary segment is retained, the axis of rotation moves
posteriorly (Figure 6-32b). With these smaller defects, the de­
gree of movement during function is considerably less as addi­
tional maxillary structures remain for support and stability. With
anterior resections of the maxillae, the axis of rotation is lo­
cated along the posterior margin of the defect. The anterior lip
margin of the prosthesis will exhibit the greatest potential for
movement (Figure 6-32c).
Retention, stability, and support Retention is defined as
the ability of the prosthesis to resist the vertical forces of dis-
a b
Fig. 6-32. a: Edentulous patient with a total maxillectomy defect. Axis of rotation (dotted line) of prosthesis is along medial
margin of defect, b: Edentulous patient with a partial maxillectomy defect. When more of hard palate remains, more
stable prostheses can be fabricated, c: In anterior defects, axis of rotation of the prosthesis is located along the
posterior margin of the defect.
251
lodgment. Stability is defined as the ability of the prosthesis to
withstand the horizontal forces of dislodgment. Support is de­
fined as the resistance to the vertical forces during mastication
and swallowing. In most patients, acceptable retention, stabil­
ity, and support can be gained from the residual palatal struc­
tures and by engaging the defect appropriately.
Remaining palatal structures Arch form, the amount of
palatal shelf remaining, and the character of the residual alveo­
lar ridge influence the stability and support for the prosthesis.
The palatal shelf is often located perpendicular to the direction
of occlusal force and provides considerable support during func­
tion. Invariably, a square or ovoid arch will exhibit more palatal
shelf area following a total maxillectomy (Figure 6-33a). The
reduced amount and undesirable angulation of the palatal shelf
found in tapering arches does not provide as much support and
stability for the prosthesis during mastication (Figure 6-33b).
For this reason, palatal tori should be removed at the time of
surgery. If the tori are not removed, the remaining palatal shelf
cannot be used for support of the prosthesis, and the thin mu­
cosa over the tori will likely be irritated by the additional move­
ment of the obturator prosthesis.
The height and contour of the residual alveolar ridge and
the depth of the sulci are important considerations. A healthy,
well-formed edentulous ridge with extensive sulci will enhance
stability and support. If pendulous soft tissues are evident, con­
sideration should be given to modifying these structures at the
time of the resection. If a partial maxillectomy is performed,
the increased amount of hard palate and alveolar ridge on the
side of the defect will enhance the stability and support for the
prosthesis.
The defect As previously explained, retention in the clas­
sical sense is not possible, but acceptable retention can usually
be obtained by engaging key areas within the defect. Neverthe-
c
252 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Additional retention may be gained by extending the pros­

thesis along the nasal surface of the soft palate and/or anteriorly
into the nasal aperture (Figures 6-37 and 6-38). If the vomer
was removed at surgery, an undercut may exist superiorly along
the medial margin. However, this is a bony undercut lined with
respiratory mucosa; therefore, this area is of limited use pros-
thetically unless a flexible obturator is utilized62,63-64. At the
present time, flexible materials have limitations, such as short
length of service secondary to fungal contamination, decreased
wetability, and poor adjustability. However, these materials per­
mit engagement of bony undercuts more profoundly and may
be particularly useful for some edentulous patients64,65,66.
Engagement of key portions of the defect can improve sup­
port and stability. Stability is enhanced by engaging the supe­
rior lateral portion of the defect and the medial margin of the
defect when both are lined with keratinized epithelium. Some
support is obtained from the oral side of the skin graft-mucosal
junction and from the oral surface of the soft palate. If the lat­
eral portion of the orbital floor has been resurfaced with a skin
graft, engagement of this area will significantly improve sup­
b
port.
Fig. 6-33. a: Patient with an ovoid arch form following total
maxillectomy. Note amount and angulation of
palatal shelf area, b: Tapering arch provides much
less support because of reduced palatal shelf
area.

less, edentulous patients should be informed that their prosthe­

sis will exhibit considerable movement during function. Most
patients will be aware of any retentive deficiencies because of
their experience with the immediate suigical and interim obtu­
rator prostheses. However, it is advisable to reemphasize this
deficiency prior to the fabrication of the definitive prosthesis so Fig. 6-34. Lateral cheek surface of a total maxillectomy de­
that expectations will be realistic. fect with split thickness skin graft lining the raw
Engagement of the skin graft, and the scar band formed at surface of cheek. Note scar band formed at skin
the skin graft mucosal junction, will improve retention signifi­ graft-mucosal junction (arrow).
cantly. As this scar band organizes, it contracts longitudinally in
the manner of a purse-string, thus creating an undercut superi­
orly and a concavity inferiorly (Figure 6-34). This band is most
prominent laterally and posterolaterally, tending to blend with
the oral and nasal mucosa more anteriorly. The scar band is
flexible and permits the prosthesis to be inserted; yet it tends to
resist dislodging forces. The skin graft above the scar band will
tend to stretch, so modest pressure by the prosthesis against the
skin graft laterally will enhance both retention and support of
the prosthesis. If the raw cheek surface is allowed to granulate
and epithelialize spontaneously, this scar band will not form,
resulting in a less favorably-shaped defect (Figure 6-35). Since
the lateral portion of the obturator exhibits the greatest degree Fig. 6-35. Defect was allowed to granulate and epithelialize
of movement, retention can be improved by appropriate obtu- spontaneously, resulting in a defect with unfavor­
rator-tissue contact superior-laterally61 (Figure 6-36). able contours and tissue lining.
 Restoration o f Acquired H ard Palate Defects: Etiology, Disability, and Rehabilitation 253

I^ Nasal septum J

Lateral wall-,
Maxillary sinus
of defect

Skin graft- - , Occlusal rest

mucosal junction > (axis of rotation)

1 y
\ U
Obturator "\\
Fig. 6-37. Extension onto the nasal side of the soft palate
(arrow).

Palatal mucosa

Given
horizontal Fig. 6-38. Extension into the nasal aperture (arrow).

Lesser vertical
displacement
Greater vertical
displacement
Short
radius sweep
C configuration of the remaining maxilla. The tray is altered as
Fig. 6-36. a: Cross-section illustration showing a peripheral
extension of the obturator against the lateral wall
of the surgical defect. In a total maxillectomy de­
fect, this peripheral extension will exhibit the great­
est range of motion, b: Enlargement of the circle
in frame a. c: Diagrammatic illustration showing
the variance in vertical displacement which 2 dif­
ferent radius lengths produce when arcing through
a given horizontal dimension. (Redrawn from:
Brown KF. Peripheral considerations in improv­
ing obturator retention. J Prosthet Dent. 20:176;
1968.)
Impressions Prior to making the impression, the clinician
should make sure that the defect is clean and free of mucous
crustings. If these crustings are not removed, the irreversible
hydrocolloid impression material used for making the prelimi­
nary impression will remove at least some of them with with­
drawal of the impression. If they are not removed from die im­
pression surface of the defect, these crustings will transfer to
the cast. Therefore, the defect and peripheral soft tissues should
be clean prior to any impression procedure.
The objective of the preliminary impression is to record
Axis of
the remaining maxillary structures and the useful portions of
rotation the defect. An edentulous stock tray is selected according to the
described previously. Prior to making the impression, the me­
dial and anterior undercuts are blocked out with gauze lubri­
cated with petrolatum because they are seldom engaged by the
prosthesis. Adhesive is applied to the tray and wax. The irre­
versible hydrocolloid impression material is mixed and loaded
into the tray; care must be taken to place impression material
laterally so as to record the lateral configuration of the defect.
Prior to seating the tray, impression material is wiped or in­
jected into posterior and lateral undercuts. An accurate diag­
nostic cast, which reproduces the usable undercuts, will aid the
clinician in evaluating the degree of retention, stability, and sup­
port provided by the defect.
254 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
The undesirable undercuts recorded in the cast are blocked
out with a suitable wax prior to constructing the custom tray.
Relief of 1 thickness of baseplate wax is provided for the skin
graft-mucosal junction and the superior lateral aspect of the
defect. The residual palatal structures are relieved in the cus­
tomary way and the tray fabricated with acrylic tray resin (Fig­
ure 6-39a). It may be necessary to fracture the cast to retrieve
the tray.
Extensions of the tray are verified in the mouth. Inacces­
sible areas can be checked with disclosing wax for possible
overextension or excessive contour. Conventional border mold­
ing techniques are advocated using modeling plastic. Low fus­
ing compounds* which provide more working time, are recom­
mended. It is suggested that border molding be completed ini­
tially on the unresected side, since this serves to stabilize and
orient the tray to the defect (Figure 6-39b). The medial palatal
margin of the defect is then developed. The superior height of
this extension should terminate at the junction of the oral and
respiratory mucosa, or at the level of the nasal floor. Further
superior extension medially will only serve to impede nasal air­
flow. This is especially important if a Webber-Fergusson proce­
dure was performed. Following this surgery, the nostril on the
defect side may collapse somewhat, leading to the potential loss
of airflow through the affected nostril.
Next, the soft palate extension is border molded. The im­
pression should extend about 1 cm onto the oral surface of the
residual soft palate. The extent of movement of the soft palate
postsurgically will depend not only on the amount of soft palate
resected but also on the amount of bony attachment remaining
for the residual soft palate. If the soft palate exhibits significant
elevation during function, this area may require refinement later
with a thermoplastic wax**. At this point, the tray should be
relatively stable. Stability is a key factor in obtaining an accu­
rate reproduction of the lateral, anterior, and posterior borders
of the defect.
The lateral, posterior, and anterior aspects of the defect are
recorded sequentially in 2 sections. First, the area below the
skin graft-mucosal junction (lined with oral mucosa) is molded
(Figure 6-39b). Care should be taken to avoid overextension of
the modeling plastic in the anterior portion of the defect (Figure
639c). These tissues are heavily scarred and, if displaced dur­
ing impression making, ulceration may develop upon delivery
of the definitive prosthesis. Next, the lateral, posterior, and an­
terior aspects above the scar band are developed (Figure 6-39
d,e). As previously mentioned, modest pressure should be de­
veloped laterally above the scar band as the skin graft does tend
to stretch. In molding the posterolateral aspect (both above and
below the scar band), the patient should be instructed to per­
form eccentric mandibular movements to account for the move­
ment of the anterior border of the ramus and the coronoid pro­
cess of the mandible. The lateral extension is developed superi­
* ISO Compound, G.C. Dent Industrial Co., Chicago, IL.
** Kerr Impression Wax, Kerr, U.S.A., Romulus, MI.
Light Body Permlastic, Kerr, U.S.A., Romulus, MI.
orly as far as is feasible, engaging the lateral portion of the or­
bital floor when appropriate. However, the clinician must make
sure that the length of this extension is compatible with inser­
tion and removal of the tray.
The impression is completed with an elastic impression
material***. Thermoplastic wax** is generally not indicated for
edentulous patients because of the difficulty in obtaining tissue
stops on the defect side. Thermoplastic waxes are useful for
making reline impressions for edentulous maxillectomy patients,
or when making altered cast impressions with the aid of a re­
movable partial denture framework. Prior to making the master
impression, the modeling plastic is relieved approximately 1
mm in all areas (Figure 6-39f). Several perforations are made
for the escape of the impression material, with at least 3 perfo­
rations along the medial palatal margin. Impression material
can be trapped along the medial palatal margin, preventing cor­
rect orientation and seating of the tray. The tray and modeling
plastic are painted with adhesive. The elastic impression mate­
rial is prepared by the dental assistant while the clinician re­
moves excess secretions. Then, while the clinician loads the
tray, the dental assistant loads a large-barreled syringe with the
elastic impression material. The material is injected into desir­
able undercut areas and the impression tray is seated into posi­
tion. The lips and cheek are manipulated and the patient is in­
structed to perform eccentric movements of the mandible. Af­
ter the material has set, the impression is removed, using a gentle
teasing action, and inspected (Figure 6-39 g,h). The impression
may be difficult to remove because of the extension of the elas­
tic impression material into multiple undercuts in the defect. If
so, the lateral portion of the impression should be released ini­
tially, as the flexibility of the scar band will enhance this ma­
neuver67.
If the anterior margin of the soft palate exhibits consider­
able elevation during speech and swallowing (Figure 6-40a),
the portion of the impression which engages the soft palate both
superiorly and inferiorly is cut away with a scalpel, and a func­
tional impression is made with thermoplastic wax (Figure 6-
40b). In order to reinsert the impression, it may be necessary to
trim the impression material which has engaged undesirable
undercuts, particularly those along the medial margin of the
defect.
If the patient exhibits extreme trismus, border molding can
be a frustrating experience for both the prosthodontist and the
patient. Therefore, an alternative impression technique, which
makes use of the interim prosthesis, is suggested for edentulous
patients. By the time the patient is ready for a definitive pros­
thesis, the interim prosthesis is usually well-adapted and prop­
erly extended, and the effectiveness of obturation can be ascer­
tained. If the prosthesis is acceptable, a new. application of tis­
sue treatment material (or impression material) is made, and
this impression is used as the master impression.
 Restoration ofAcquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 255

g h

Fig. 6-39. Impression for an edentulous patient, a: Impression tray. Defect was blocked out on cast with 1 thickness of base­
plate wax. b: Border molding of the nondefect side, c and d: Completed border molding. Note border molding of the
lateral aspect of the defect and indentation created by lateral scar band, e: Posterior view of border molding, f: Cut
back of modeling plastic of approximately 1 mm. Area of scar band was relieved about 1.5 to 2 mm. g and h:
Completed impression.

Fig. 6-40.
Obturator a: Obturator should maintain
contact with soft palate dur­
ing elevation; otherwise,
Soft palate elevated troublesome leakage of fluids
Soft palate relaxed may occur, b: This area can
be molded with a thermoplas­
tic wax.
256 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Vertical dimension o f occlusion Two methods are sug­
gested for the fabrication of record bases. If the defect is large,
and stability and support are difficult to obtain with a conven­
tional record base, the prosthodontist should consider process­
ing the definitive base from the master cast (Figure 6-41). This
base is used to obtain jaw relation records; the denture teeth are
added at a later date with autopolymerizing aciylic resin. If sta­
bility and support appear to be adequate, a conventional
autopolymerizing acrylic resin record base can be constructed
after ensuring that all undercuts and the rugae area are blocked
out for protection of the master cast (Figure 6-42).
F ig . 6-41. Definitive record base processed from the mas­
ter cast and used to obtain centric relation records.
The teeth are attached later with autopolymerizing
acrylic resin.
b when the orbital opening is larger than the palatal defect.
Fig. 6-42. a and b: Master cast with conventional record
base and wax rim.
MDX-4-4210, Dow Coming Co., Midland, MI.
The vertical dimension of occlusion is established in the
customary manner, with wax rims on the record bases. Con­
ventional methods of determination and identification of the
proper vertical dimension can be followed if the patient does
not exhibit excessive trismus. Trismus is usually most evident
in patients who have received pre- or postoperative radiation
therapy, where the surgical resection has resulted in edema and/
or scarring of the muscles of mastication, or when the ptery­
goid plates or adjacent musculature are involved in the resec­
tion. If trismus is extreme, the vertical dimension of occlusion
should be reduced to allow passage of the bolus of food be­
tween the denture teeth.
Occasionally, trismus may be so severe as to limit the use
of a conventional maxillary resection prosthesis, especially for
edentulous patients. Severe trismus may be defined as occur­
ring in any edentulous patient with 10 mm or less of interridge
distance. The flexibility of the cheek on the defect side will
often be of some help in the insertion and removal of the pros­
thesis, especially if the cheek flap is lined with a skin graft dur­
ing the surgical procedure. The limited superior extension into
the defect can be rotated out on the defect side due to cheek
flexibility. However, this maneuver will not account for the depth
of the residual palatal vault on the non-defect side. Therefore, if
the depth of the residual palatal vault on the non-defect side is
greater than the interridge or intertooth distance, the resin pros­
thesis cannot be inserted or removed.
Extreme trismus is not as complex for partially edentulous
patients. If an accurate impression can be made of the teeth, and
sufficient palatal structures exist to fabricate a cast removable
partial denture framework, the defect can be recorded with an
altered cast impression. The limited superior extension can then
be rotated out on the defect side.
Two authors have described unique approaches to the treat­
ment of patients with extreme trismus. Lauciello68describes the
fabrication of a flexible baseplate type of prosthesis from sili­
cone* for an edentulous patient with extreme trismus. The pros­
thesis must be replaced frequently, as silicone is subject to dete­
rioration and fungal infections, especially if radiation therapy is
used in treatment. However, the flexibility of the material per­
mits insertion and removal of the prosthesis. Taylor described
the obturation of a palatal opening through a contiguous orbital
defect for a patient with no oral access69. The prosthesis was
fabricated with silicone in the form of a button. The flexible
button snapped into the defect from above through the orbit. A
long, cylindrical handle extended superiorly to the inferior level
of the orbital opening so the prosthesis could be inserted and
removed by the patient. This concept can only be employed
The wax rims are reduced to the proper level, an arbitrary
face bow transfer is obtained, and centric relation is recorded
using the recording medium of choice. Care must be exercised
to ensure that the maxillary record base is not displaced during
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
the registration. In edentulous patients, reproducible centric re­
lation records may be difficult to obtain because the prosth­
odontist must manage 2 relatively unstable record bases. Inac­
curacies associated with jaw relation records are most evident
with unstable bases and abnormal jaw relationships70. These
conditions exist in many intraoral maxillofacial defects, par­
ticularly in edentulous patients following a total maxillectomy.
Graphic centric relation records produced by intra- or extraoral
tracing devices are contraindicated. Even though a maxillary
record base may exhibit acceptable stability, pressure on the
defect side will result in some displacement superiorly into the
defect, compromising the accuracy of the recording. We prefer
soft wax*, registration paste**, or silicone*** as the recording
medium. Lateral records are usually not useful for the afore­
mentioned reason, but a protrusive record can often be obtained,
especially if the bases are relatively stable.
Because of the size of the maxillary cast, due to the supe­
rior and posterior extension of the defect, a high post articula­
tor, such as TMJ articulator****, is suggested. The thick cast
may also preclude the proper maxillary cast mounting with a
face bow and/or the use of a third point of reference. An accept­
able alternative is lengthening the articulator posts of conven­
tional articulators, as suggested by Hadeed and Sprigg71 and
Marunick and Ma72, to accommodate these large casts. With
these altered articulators (Figure 6-43), large and thick maxil­
lary casts can be mounted in their appropriate position with the
aid of a face bow. .
Fig. 6-43. A rticulator modified to accept large maxillary
casts.
Aluwax, Aluwax Dental Products Co., Grand Rapids, MI.
Super Bite, Harry J. Bosworth, Skokie, IL.
257
Occlusal schemes The teeth are set to contours estab­
lished by the wax rims and conventional anatomical landmarks.
In edentulous patients, nonanatomical and/or functional poste­
rior teeth are arranged according to neutrocentric or lingualized
occlusal concepts73,74. Both concepts minimize lateral forces and
deflective occlusal contacts and thus improve prosthesis stabil­
ity. The teeth are set in centric relation and adjusted to eliminate
lateral interferences. The trial dentures are tried in the mouth
and changes are made to accommodate the esthetics agreed upon
by the patient and the prosthodontist. At this time, centric rela­
tion, the vertical dimension of occlusion, and the interocclusal
space should be verified.
Processing, delivery, and follow-up The dentures are pro­
cessed in a standard manner, with heat-cured methyl methacry­
late. If more profound retention is necessary, consideration may
be given to using a soft silicone material for the obturator seg­
ment of the prosthesis64,65’66. This soft material allows the pros­
thesis to engage undercuts more aggressively. The obturator
segment may be attached to the maxillary denture with a snap-
on stud type of connection. The silicone obturator snaps into
undercuts in the protruding studs so the obturator segment may
be replaced as required without disturbing the tissue surface of
the denture. However, we prefer methyl methacrylate if adequate
retention, stability, and support can be achieved with this mate­
rial.
Several factors should be discussed regarding the configu­
ration, processing, and polishing of the obturator. In waxing the
obturator, the clinician must remember that the master impres­
sion may extend further superiorly, medially, or laterally into
the defect areas than is consistent with insertion, removal, and
function. On delivery, the resin extensions into undercut areas,
or the height of the superior surface, may require considerable
relief in order to permit seating of the prosthesis. We have found
it easier to make these alterations after the prosthesis is pro­
cessed. Those areas which may require considerable reduction
should be waxed accordingly to permit these contour changes
without perforation of the hollow obturator, if the hollow, closed
design is used. If a closed top design is used, the superior sur­
face of the obturator should be well-polished, have a slightly
convex contour, and slope medially and posteriorly to help di­
rect nasal secretions into the oral pharynx. Sharp projections on
the lateral surfaces of the obturator should be rounded and lightly
polished with fine pumice. Polishing improves cleansibility and
results in less friction at the prosthesis-soft tissue interface dur­
ing functional movements. Gross overextensions into undercut
areas are reduced prior to delivery, but the final adjustment of
these areas must be determined during the delivery of the pros­
thesis.
Delivery and adjustment are performed in a conventional
manner. Pressure-indicator paste is used to delineate areas of
excessive tissue displacement on the unresected side (Figure 6-
*** Blue Moose, Parkell Co., Farmingdale, NY.
**** TMJ Instrument Co., Norco, CA.
258 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
44). Disclosing wax is useful for checking peripheral exten­
sions or monitoring tissue displacement in skin lined areas, or
areas where access is difficult (Figure 6-45). With the aid of
these materials, the least desirable undercuts are reduced until
the prosthesis is seated appropriately. Rarely is it necessary to
reduce the undercuts located along the lateral and posterolat­
eral surfaces, which are so vital for retention, stability, and sup-
Fig. 6-44. Pressure-indicating paste is useful to delineate
areas of excessive tissue displacement on the
unresected site.
Fig. 6-45. Disclosing wax is useful in checking extension
areas, monitoring tissue displacement in skin lined
areas, or where access is difficult. When a
Webber-Fergusson exposure is employed, scar
tissue is prevalent in area of the labial reflex and
upper lip. Disclosing wax is very useful to detect
excessive pressure in this and other such areas.
port. We prefer to remount die prostheses with new maxillo­
mandibular records in order to perfect the occlusion (Figure 6-
46). Home care instructions are reviewed and recall appoint­
ments arranged. Invariably, most maxillary obturator prosthe­
ses will require relining within the first year of delivery because
of continued organization of the defect with subsequent dimen­
sional changes.
Edentulous patients with partial maxillectomy defects Fabri­
cation of definitive obturator prostheses for partial resections of
the edentulous maxillae are similar to the prostheses for total
maxillectomy resections. In these defects, more of the hard pal­
ate remains and, consequently, the prosthesis has more stability
and support. However, retention may be compromised, as com­
pared to more extensive defects, because access to and use of
the defect may be impaired (Figure 6-47a). The defect should
be utilized as much as is feasible in order to enhance the func­
tion of the prostheses. Soft silicone materials may be useful in
selected edentulous patients with partial maxillectomy defects
(Figure 6-47b). Implants are especially useful for this group of
patients since the premaxillary segment on the defect side is
likely to be available for implant placement and access to the
defect may be limited. With a smaller defect, many of the pros­
thetic procedures are more easily accomplished. The delivery
and follow-up care should follow the same sequence as described
previously. However, relining may not be necessary as fre­
quently.
Implant-retainedprosthesesfo r maxillary defects Placement
of osseointegrated implants can have a dramatic effect on the
function of the prosthesis for the edentulous maxillectomy pa­
tient. Implants provide retention, enhance support, and improve
the stability of the obturator prosthesis. Mastication is signifi­
cantly improved, and speech and swallowing are made more
efficient. Thus, adaptation to the prosthesis is much easier for
the patient.
Clinical data Two recent studies describe the indications,
locations, and prognosis for implants used to support and retain
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
Fig. 6-47. a: Relatively small partial maxillectomy defect, b: Definitive silicone obturator prosthesis. A
flexible obturator permits engagement of bony undercuts.
maxillofacial prostheses21,22. Roumanas gathered data from 23
patients with maxillary defects in whom implants were used to
retain, support, and stabilize obturator prostheses22. From 1985
to 1994, 89 implants were placed and 82 of these were avail­
able for follow-up. The overall success rate was 67.7% (Table
6-6); 75.9% for implants placed in non-irradiated bone sites
and 60.6% for irradiated bone sites. Twenty-six implants were
placed in the residual premaxillary segment; 28 in the posterior
portion of the alveolar ridge, 24 in the maxillary tuberosities, 4
in the pterygoid plates, 4 into the residual zygoma bony sites in
the defect, and 3 in the residual palatal shelf horizontal to the
occlusal plane. When considering the 3 most common sites, the
success rates were highest in the anterior maxilla (80.9%), low­
est in the maxillary tuberosities (65%), and low in other poste­
rior maxillary sites (62.5%).
A pattern of failure and bone loss was detected around
implants placed in each of the 3 most common sites. Failures
were grouped into 2 categories; namely, (1) early, when the
implants failed to achieve osseointegration within 6 months
following the 2nd stage surgery, and (2) late, when implants
failed after being subjected to clinical function for a year or
more. Minimum bone loss was defined as bone loss limited to
1-2 threads, moderate as 3-4 threads, and severe as more than 4
threads (Table 6-7). In the anterior maxilla, 3 failures occurred
“late”, and were secondary to progressive bone loss around die
implants. Almost one-half of those implants currently in func­
tion demonstrate severe bone loss. In contrast, in the maxillary
tuberosity (where the bone quality is generally poorer), virtu­
ally all of the implant failures were “early” or prior to func­
tional loading. However, once osseointegration was achieved
and the implants were placed into function, bone levels did not
appear to deteriorate over time (Table 6-8). The Roumanas re­
port22 is a preliminary study, but it indicates that occlusal load­
ing and the delivery of excessive lateral torquing forces to the
implants may be responsible for the pattern of failures and bone
loss.
259
The retention bar attachment system used in the Roumanas
study (when the implants were clustered in the residual anterior
maxillary segment) is shown in Figure 6-48b. This bar-attach-
ment design may not accommodate to the multiple axes of rota­
tion that develop from bolus manipulation, mastication, and other
mandibular movements, which may be a reason why so many
of these implants demonstrate advanced bone loss. In large bi­
lateral maxillectomy defects, where only tuberosities remain
(Figure 6-49), the implants were used almost entirely for reten­
tion. The axes of rotation were predictable, and the attachments
were compatible with these axes, when occlusal forces were
generated anteriorly.
Implant sites The number of implants and their location
is determined by the nature of the defect and the available bony
sites. The most ideal location for implants for most edentulous,
total maxillectomy patients remains the residual premaxillary
segment (Figure 6-48). This site is preferred because the ante­
rior maxillary segment is opposite to the most retentive portion
of the defect located along the posterior lateral wall. In addi­
tion, a satisfactory volume and density of bone can be found in
the premaxilla in most patients. The maxillary tuberosity site is
considered only when there is insufficient bone in the residual
premaxilla (Figure 6-49). Since the bone is not very dense in
the maxillary tuberosity, the bone implant interface that devel­
ops may not ensure a predictable outcome, as evidenced by the
high failure rates at stage n surgery. Because of this factor, some
clinicians have recommended placing longer and mesially in­
clined implants in the pterygoid plates. The edentulous poste­
rior alveolar process may serve as an alternative site for im­
plants if there is at least 10 mm of bone available beneath the
maxillary sinus. If insufficient bone is present, the site may be
augmented by elevating the sinus membrane and inserting an
autogenous bone graft (Figure 6-50). This technique's becom­
ing a popular option when treating nonsurgical patients, but its
predictability in maxillary defect patients is yet to be determined.
260 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Table 6-6. Obturator Implant Sites*.

Iipplan t Sites N um ber o f Im plants

Placed Uncovered Buried Failed S u c c e s s (%)
A n te rio r M axilla 26 /%5 -21 7 ’k; ' l i i i 80.9

+-
CO
2 4

OJ
CO
P osterior Maxilla 16 *4 ,62.5

-H-
Oil
o
Tuberosities 24 1 i'-7' 65.0
P terygoid Plates 4 n s r *3 0 mm I o'o
Zygom a 4 4 2 0 50:0
Palate ■■ W i 0 o ff HH |||||

Total 8 9 .f1 3 : ^2 t i4 5 15,, 67.7

t 3 patients (13 implants)— recurrence of disease or patient Expired prior to stage II

t 2 patients^l 4 implants)— await stageflj;

Table 6-7. Maxillary Obturator Implants*.

Patients Number o f Im plants

Treated Placed Uncovered Buried Failed Success (%)
Irradiated 13 54 t? 33 t1 4 2 11 60.6
Non-lrradiated 10 35 t6 29 3 4 75.9

Total 23 89 62 5 15 67.7

f 3 patients (13 implants)— recurrence of disease or patient expired prior to stage II

$ 2 patients (14 implants)— await stage 11

Table 6-8. Obturator Implant-Bone Levels*.

Im plant Sites D eterioration

M inim um Moderate Severe Failed
A nte rio r Maxilla 5 4 8 3 '
P osterior Maxilla 8 vS : •v-W :; 4
Tuberosities 8 1 1 7
Pterygoid Plates — g jjjl 1
Zygom a — — ■ — •|
Palate — ■ ■

* Source: Roumanas E, Nishimura R, Beumer J. Use of osseointegration for the maxillary resection patient. In:
Proceedings of the 1st International Congress on Maxillofacial Prosthetics. Zlotolow I, Esposito S, Beumer J, eds.
1995.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 261

Fig. 6-49. a: Single implant in maxillary tuberosity, b: Large prosthesis retained with attachment.
262 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Residual elements of the zygoma have also been used as
implant sites (Figure 6-51). However, there are important dis­
advantages to be considered. First, the implants will be located
high in the defect, making oral hygiene very difficult for the
patient. Second, because the implants are generally positioned
parallel to the plane of occlusion, they cannot be engaged ag­
gressively. They can be used to facilitate retention, but lateral
torquing forces delivered to the implants must be minimized
(Figure 6-52). In defects lined with a skin graft which has good
posterior lateral undercuts, these implants make only a limited
contribution to retention.
Fig. 6-51. a: Two implants placed in residual zygoma and 1
in opposite tuberosity. Note angulation of the im­
plants in zygoma and their relationship to the oc­
clusal plane, b: Radiograph of implants.
Fig. 6-52. a and b: Magnetic retention used for implants placed in the residual zygoma of the defect,
c: “0 ”-ring-type attachment used in opposite tuberosity.
Clinical procedures Prosthodontic procedures parallel those
used for more conventional patients. Following implant place­
ment, the implants are left buried beneath the mucosa for 6 to 8
months. During this period, the patient will continue to use the
surgical or interim obturator prosthesis. When the implants are
exposed at second stage surgery, the surgeon will facilitate im­
plant maintenance if he or she carefully thins the mucoperios-
teum and creates a zone of keratinized, attached mucosa around
the implants. Otherwise, the resorption of bone, particularly in
the premaxillary segment, may result in thick, redundant soft
tissues. Therefore, the mucoperiosteum should be thinned so
the periimplant pockets are reduced to 5 mm or less. Pockets in
excess of this depth predispose to a high rate of local soft tissue
infection. If the implants exit in mobile, unattached tissues, an
attempt should be made to replace this nonkeratinized tissue
with keratinized attached tissues. Free palatal grafts are an ex­
cellent source of keratinized tissue.
In many patients, insufficient interocclusal space may pre­
clude the use of conventional abutment cylinders. In these pa­
tients, healing abutments can be attached and the retentive bar
fabricated using the UCLA abutment technique75(Figure 6-53).
If conventional abutments are contemplated, lengths should
be selected so that the abutments project 1-2 mm above the
periimplant tissues. If they protrude further, it may be difficult
to properly position the retentive apparatus and denture teeth.
Following abutment connection, plastic healing caps are con­
nected to the abutment cylinders. The healing caps temporarily
extend the abutment cylinders above the implant tissues, which
facilitates oral hygiene and promotes healing. Healing should
be complete within 2 to 3 weeks. Following epithelialization of
the wound, oral hygiene is facilitated w ith the use of
chlorhexidine.
Fabrication of the definitive obturator prosthesis can com­
mence when the periimplant tissues are well healed. It is usu­
ally desirable to fabricate a trial denture before designing the
retention apparatus. Tapered impression copings, which engage
either abutment cylinders or implant fixtures, are selected, in-
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
Fig. 6-53. The retention bar is fabricated with the UCLA abut­
ment because of limited interocclusal space.
Fig. 6-54. Stone template containing maxillary teeth used
to design retention bar.
F ig. 6-55. Template mounted on the lower member of ar­
ticulator to aid in preparation of the bar.
spected, and screwed tightly into position. An edentulous stock
tray is chosen and the defect portion of the tray augmented with
periphery wax, as previously described. After application of a
suitable tray adhesive, the impression is made with irreversible
hydrocolloid material*. Care should be taken to record the lat­
eral wall of the defect and any desirable undercuts which may
be engaged by the definitive prosthesis. Following removal of
the impression, the impression copings are removed, attached
to either abutment analogues or fixture analogues (as required),
and inserted into the impression. A preliminary cast is poured
with dental stone.
Jelltrate Plus, L.D. Caulk Division, Dentsply International Inc., Milford, DE
263
The resin tray for the master impression is fabricated as
previously described, except that the tapered impression copings
remain on the cast. The impression tray is designed to record
the position and angulation of these copings as well as the re­
sidual normal tissues and the defect. When the border molding
is completed, as previously described, the tapered impression
copings are secured tightly in position and an elastic impres­
sion material is used to make the impression. The impression
and the tapered impression copings are removed, attached to
either fixture or abutment analogues, and reinserted into the
impression. The impression is boxed and the master cast pre­
pared in the usual manner.
Record bases are now fabricated. If conventional abutments
were used, gold cylinders are incorporated within the acrylic
resin record base. These cylinders are used to retain the record
base during the making of centric registration records. If the
UCLA abutment technique is used, the areas over the implant
fixtures are generously blocked out with wax prior to making
the record base. A face bow transfer record is obtained and trans­
ferred to an articulator that will accept the bulky maxillary cast.
The centric relation record is secured, and the opposing man­
dibular cast is mounted on the articulator.
The anterior teeth are selected and arranged, using estab­
lished criteria, and the posterior teeth are selected and arranged,
according to neutrocentric or lingualized occlusal concepts. The
waxed trial dentures are tried in the mouth, and centric relation
and the vertical dimension of occlusion are verified. The ante­
rior teeth are evaluated for acceptable speech and esthetics. The
trial dentures are repositioned on the articulator, and a stone
template is fabricated with the maxillary teeth incorporated
within it (Figure 6r54). This stone template is mounted on the
lower member of the articulator and used to design and prepare
the wax pattern for the retentive apparatus (Figure 6-55).
Retention bar design In most instances, we prefer to unite the
implants with a rigid, precision-fitted bar, with retentive ele­
ments attached to it. Ideally, the retentive elements should be
designed to direct occlusal forces along the long axis of the
implant fixtures. They should not be the sole means of reten­
tion, stability, and support for the prosthesis, but should be used
in concert with those enhancing factors associated with the de­
fect and remaining normal structures. The most damaging forces
on implants can result from occlusal loading. Gravitational
forces, which are much less of a concern, can be reduced by
aggressively engaging undercuts within the defect.
Osseointegrated implants are subject to bone loss when
excessive lateral torquing forces are applied. When the hard
palate is intact, it is relatively easy to design a retentive appara­
tus so that occlusal forces are properly directed and shared be­
tween the implants and the normal denture bearing surfaces.
Implants are placed in the cuspid regions, and the retentive bar
is arranged so it is perpendicular to the midline and parallel to
264 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
the occlusal plane (Figure 6-56). When an occlusal load is ap­
plied posteriorly, the prosthesis is compressed into the denture
bearing surfaces, and the retention clips allow the prosthesis to
rotate freely around the bar. This design allows most occlusal
forces to be directed along the long axis of the implants.
Numerous factors complicate the design of the bar and the
distribution of occlusal forces for total maxillectomy patients.
For example, when the patient is subjected to a total
maxillectomy, fewer implant sites are available and the ante-
rior-posterior spread of the implants in the remaining edentu­
lous premaxilla is limited. In addition, occlusal loads produce
multiple axes of rotation of the obturator prosthesis. These axes
are dependent upon the position of the implants and the point of
load application on the prosthesis. For example, consider the
configuration presented in Figure 6-57, where 3 implants were
placed in the remaining premaxillary segment. These implants
were splinted together with a bar so occlusal forces can be equi­
tably distributed between them. ERA-type attachments have
been connected to each end of the bar. The axis of rotation (ful­
crum lines) will vary, depending upon the site of load applica­
tion. Clinically, the most common sites of load application will
be position #1 and #2. When a load is applied to position #1, the
prosthesis will rotate around axis AB and through the distal at­
tachment. When a load is applied to position #2, the prosthesis
rotates around axis CD and through the mesial attachment. When
a load is applied to position #3, the prosthesis will rotate around
axis EF. In general, the axis of rotation will always run through
the attachments and, consequently, they are subject to rapid and
excessive wear, possibly resulting in exposing the implants to
unwanted and destructive lateral torquing forces. The UCLA
experience indicates that designs similar to the one in Figure 6-
57 result in significant bone loss around the implants (Table 6-
8). Therefore, we began to question the wisdom of using reten­
tion bar-attachment designs that were developed for conven­
tional, nonsurgical patients with implants.
Fig. 6-56. Two implants placed in anterior maxilla and united
with a bar. Note the retention bar is perpendicu­
lar to the midline and parallel to the occlusal plane.
APMS, Stem Gold, Attleeboro, MA.
** Attachments International, San Mateo, CA.
Davis developed a photoelastic model to determine the best
retention bar attachment design in which implants were placed
in the residual premaxilla following a total maxillectomy76. The
purpose of this study was to compare and evaluate the effects
on the different bar-implant substructures used in the restora­
tion of a total maxillectomy defect when subjected with known
occlusal forces. A photoelastic model was fabricated based on a
human maxilla that had undergone a total maxillectomy to the
midline. Photoelastic materials were used to simulate the bone
around the implants and the bone along the medial and lateral
aspects of the defect. Three implants were used on the non­
defect side to simulate a common clinical situation, and bar
designs were fabricated with a gold alloy, duplicating various
clinical conditions.
C
Fig. 6-57. Diagrammatic representation of 3 implants placed
in residual premaxiila and splinted with a bar. ERA
attachments are connected to either end of the
bar. Fulcrum lines pass through the attachments.
The following designs were tested (Figure 6-58):
1 Three implants support a bar with Hader clips placed to
the mesial of the anterior implant and distal to the posterior
implant.
2 Three implants support a bar with ERA* attachments placed
to the mesial of the anterior implant and distal to the poste­
rior implant.
3 Three implants support a bar with ERA attachments placed
to the mesial of the anterior implant and distal to the poste­
rior implants, with occlusal rests between each of the im­
plants.
4 Three implants support a bar with OSO** attachments placed
between the implants.
5 Three implants support a bar with an ERA attachment
placed to the mesial of the anterior implant and a Hader
clip distal to the posterior implant
6 Three implants support a bar with an OSO attachment
placed on the anterior and posterior implants.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 265

The acrylic resin obturator extension base was fabricated
to extend into the defect to transmit occlusal forces to the cast
The loading regions selected for testing were anterior and pos­
terior to the implants. Each loading zone had a ramp so that a
force of 12 pounds could be applied in both a vertical and lat­
eral direction at each location. The photoelastic cast was firmly
fixed to the base of the stage of a straining frame. A force of 90
grams was applied to the acrylic resin extension base to corre­
spond to the weight of the obturator. Circularly polarized light
was used to illuminate the cast, and the results were recorded
photographically. The stress patterns developed by the differ­
ent designs were compared by placing them on the cast without
exerting any type of external load. The resulting stresses were
observed and recorded with a camera having an appropriately
oriented set of polarized and quarter-waved plates affixed to
the lens.
The most pertinent conclusions of the study were as fol­
lows (Figure 6-58):
1 Anterior loads caused higher and more concentrated stresses
around the anterior and middle implants, as compared to
posterior loads, since more posterior loads are partially
supported by the residual edentulous denture bearing sur­
faces.
2 The addition of occlusal rests on the bars between the im­
plants increased the stability of the prostheses and allevi­
ated the stresses around the posterior implant when a pos­
terior force was applied.
3 The “0 ”-ring-type attachment resulted in the most favor­
able stress distribution, as compared to the bar-clip or the
bar-ERA designs. However, the “0 ”-ring designs were not
as retentive as the other attachment systems tested.
Davis concluded that proper attachment selection and de­
sign of the bar is a compromise between retention and the need
for stress distribution and maintenance of the bone around the
implants76. Based on this work and our clinical experience22,
we propose the following guidelines. With the use of an attach­
ment like the ERA, which allows for a vertical compression of
the prosthesis on application of an occlusal load, the addition of
occlusal rests improves the distribution of stresses. Now, when
a load is applied to point #1, the prosthesis will rotate around
the new axis AB, which passes through the distal occlusal rest
(Figure 6-59). More of the occlusal loads are absorbed by the
residual denture bearing surfaces posteriorly, and these forces
are directed more favorably along the long axis of the implants.
The concave rest, milled into the occlusal surface of the bar, is
in the shape of a half circle, and is the only part of the bar that is

d e

Fig. 6-58. a: Hader bar assembly on photoelastic model, b: Bar with ERA attachments, c: Bar with “0 ”-ring attachments, d:
Stress patterns around implants with centrally located “O" rings, e: Stress patterns with 2 Hader clips. Note higher
levels of stress with the Hader bar and clip system.
266 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

engaged by the prosthesis other than the attachments. The at­ the denture bearing surfaces, without applying excess torquing
tachments allow the prosthesis to be compressed into the bear­ forces to the implants. If 6 or more implants are placed, and if
ing surfaces, but provide retention when dislodging forces are the anterior posterior (A-P) spread is greater than 2 cm (Figure
applied. The attachments on either side of the bar should not 6-61), the overlay obturator prosthesis can be designed so that
serve as rotation points, as the plastic attachments housed in the occlusal forces are primarily supported by the implants (Figure
prosthesis will wear rapidly, rendering the attachment ineffec­ 6-62).
tive. Ultimately, the rigid denture base will contact the cantile-
vered portion of the bar and create excessive cantilevering forces,
predisposing to bone loss around the implants. The placement
of rests at either end of the bar enables the prosthesis to rotate
around these rests, reduces wear on the attachments, and di­
rects more of the occlusal forces along the long axes of the
implants (Figure 6-59).

Fig. 6-59. Preferred design, with 3 implants placed in re­

sidual premaxillary segment. Note presence and
location of occlusal rests. Axis of rotation becomes
favorable with the addition of rests.

These design principles have much in common with those

proposed by Kratochvil77for Class I or Class II distal extension
removable partial dentures using the “I” bar, mesial rest con­
cept. The patient should be advised against applying occlusal
forces posteriorly on the defect side, since there is little support
available to counteract these forces. Forceful occlusion on the
defect side will result in rapid wear of the attachments and sub­
sequent bone loss, especially around the implant adjacent to the
defect.
If the entire premaxilla remains, the number of implants,
their distribution, and the design of retention bar follows more
conventional prosthodontic principles. If only 2 implants are
placed, 1 in each cuspid site, the retention bar is designed as
shown in Figure 6-56, using a Hader bar. If 4 or more implants c
are placed, we advocate the design shown in Figure 6-60. In
this design, the support is provided posteriorly by the residual Fig. 6-60. a: Maxillary defect and premaxillary segment prior
denture bearing surfaces and anteriorly by the implants. The to implant placement, b: Mirror view of 4 implants
attachments connected to the distal portion of the bar allow for placed in premaxillary segment, c: Recommended
compression of the distal extension area of the prosthesis into bar and attachment design.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
• Location o f the defect Invariably, the surgical resection
• Movement o f the prosthesis In conventional prosthodon-
Fig. 6-61. Six implants placed in premaxilla permits obtura­
tor prosthesis to be implant-supported.
• Length o f the lever arm In conventional prosthodontics,
Fig. 6-62. With 6 implants, there is an ample A-P spread for
the retention bar, fully supporting forces of masti­
cation. A milled bar is shown.
Maxillary defects, where only 1 or both maxillary tuber­
osities remain, are particularly difficult to restore. Implants are
useful in retaining these restorations, but they should not be
used to provide support or to be the primary means of stability
for the prosthesis. “0 ”-ring-type of attachments are preferred
because they allow the prosthesis to rotate in multiple direc­
tions when either an occlusal load is delivered, or when the
prosthesis drops as a result of gravity (Figure 6-49).
Dentulous patients with total maxillectomy defects It is axi­
omatic that prognosis improves with the availability of teeth to
assist with the retention, support, and stability of the removable
prosthesis. This concept certainly applies to patients with ac­
quired defects of the maxillae.
Treatment concepts The following concepts are unique
to this group of dentulous patients and should be considered by
the prosthodontist:
267
includes the distal portion of the maxilla, and rarely does a
distal abutment tooth remain following surgery. The ex­
tent of the surgical resection anteriorly does vary consider­
ably. Therefore, a Kennedy Class II partial denture with an
extensive lever arm is required for most patients.
tics, the degree of displacement of a Class II partial den­
ture is dependent upon the quality of the edentulous alveo­
lar ridge and palate, and the ability of the prosthodontist to
balance the support available from both the edentulous seg­
ment and the remaining teeth. With resection of the max­
illa, the mucosal and bony support are compromised or
may be lacking completely. Hence, the defect must be
employed to minimize the movement of the prosthesis,
thereby reducing the stress on the abutment teeth. In most
defects, if forceful mastication occurs on the defect side,
the prosthesis can be displaced significantly into the de­
fect, and that has the potential to expose abutment teeth to
damaging lateral torquing forces.
the most common Class II removable partial prosthesis in­
volves an edentulous area distal to the cuspid. Consider­
ably longer lever arms are encountered in patients with in­
traoral surgical defects. It is not uncommon for the defect
to extend from the midline anteriorly into the soft palate
area posteriorly (Figure 6-63).
Fig. 6-63.
Tissue surfaces of 2
different defects, a:
C ast of a tapering
a arch (lin e a r o cclu ­
sion), with long lever
arm. b: Cast of ovoid
arch, with less lengthy
arm; however, this de­
fe c t encom passes
more area.
268 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

• Arch form As previously mentioned, square or ovoid arch Partial denture designs, such as the swing lock-type, which
forms possess more palatal-bearing surface perpendicular lock onto remaining dentition, have been questioned by some
to occlusal stress. This provides for a more stable prosthe­ clinicians. Retention can be excellent with these designs, but
sis during function. This support area must be utilized by they may subject abutment teeth to additional stress80,81, result­
the prosthodontist in the same manner as the buccal shelf ing in wear of labial and buccal surfaces of the abutment teeth
area is used for support for mandibular partial prostheses. (Figure 6-64) and possible premature tooth loss. However, cir­
Tapering arch forms provide less palatal shelf area; there­ cumstances are encountered where the gate design concept may
fore, support is compromised, possibly leading to signifi­ be used with minimal stress to abutment teeth. These circum­
cant rotation and subsequent movement of the prosthesis stances include when key anterior abutment teeth have severe
up into the defect during mastication. labial inclinations and/or high heights of contour, and where
• Teeth In prosthodontics, the preservation of that which surveyed crowns and conventional retainers are not a viable
remains (i.e., teeth and supporting structures) is an impor­ alternative. Edentulous modification spaces and/or interproxi­
tant objective, along with function, comfort, and esthetics. mal spacing on the non-defect side facilitates the placement of
Preservation of the remaining teeth is of particular impor­ the distal portion of the gate. The vestibule must be of adequate
tance because retention of the prosthesis is far less in the depth for the placement of the gate without encroaching upon
corresponding edentulous patient. Partial denture designs the free gingival margins. The abutments should have well-pre­
must anticipate and accommodate to the movements of the pared rest seats. The retainers emerging from the gate should be
prosthesis during function, without exerting pathologic
stresses upon the teeth. Maximum retention, stability, and
support should be obtained from the use of the defect. How­
ever, there may be occasions where partial denture designs
cannot be fabricated without stressing teeth. It should not
be forgotten that, to function properly, the prosthesis must
be retained in proper position. In such situations, close at­
tention should be directed to the occlusion on the defect
side to minimize occlusal forces.
• Partial denture design The basic principles of partial den­
ture design should be followed; namely, (1) major connec­
tors should be rigid, (2) occlusal rests should direct oc­
clusal forces along the long axis of the teeth, (3) guide planes
should be designed to facilitate stability and bracing, (4)
retention should be within the physiologic limits of the
periodontal ligament, and (5) maximum support and sta­
bility should be gained from the residual soft tissue den­
ture bearing surfaces, including the defect.

Several concepts of partial denture design have been sug­

gested for dentulous patients with acquired defects of the max­
illa78,79. The diagnostic casts should be surveyed carefully for
location of undercuts, location and contour of potential guide
planes, and selection of the path of insertion. Often, a com­
pound path of insertion must be employed to use the undercuts
available in the defect adequately. For example, if the lateral
and posterior undercuts in the defect are to be engaged prop­
erly, the prosthesis must be inserted first up into the defect and
then rotated up into position onto the teeth.
Multiple rests are suggested in order to improve stability
and support for the prosthesis. The rest seats should be rounded
and polished so the rests on the partial denture framework can
rotate without torquing abutment teeth. Complete crowns on Fig. 6-64. a: Swing lock design used to retain an obturator
selected teeth may be required to establish ideal contours for prosthesis, b: Note wear on buccal and labial sur­
retention, guiding planes, and occlusal rests. faces of the teeth.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 269

thin, well-contoured I-bars of maximum length, engaging the
teeth in the gingival one-third, or at the same level as the cingu-
lum rests. To minimize stress on the teeth during closure of the
gate, the distal end of the gate (whether hinge or latch) should
be located 8 to 10 mm from the nearest abutment tooth engaged
by a retainer on the gate. The length of the gate should be kept
to a minimum. Conventional framework designs and retainers
can generally be used on the posterior teeth. Frameworks that
incorporate the gate design concept must be physiologically
adjusted, with attention paid to. the movements attendant to ob­
turator prostheses.
Partial denture design conceptsfo r maxillary defects
• Abutments adjacent to the defect A tooth closely adja­
cent to the anterior margin of the defect should have a rest
and retainer if adequate retention is to be achieved (Figure
6-65a). This anterior retainer and rest insures proper orien­
tation of the prosthesis. If this concept is not employed, the
prosthesis will tend to rotate out of retentive areas posteri­
orly. These abutments, which are subject to greater vertical
and lateral forces80, are more frequently lost than abutments
in other positions. This is due to a number of factors. First,
the extension area immediately adjacent to this abutment,
which is basically the defect, provides little support. Sec­
ond, the lever arms can become exceedingly long, ampli­
fying the forces delivered to the abutment. Therefore, the
placement of a rest on this anterior tooth (or teeth) is criti­
cal. If they are bicuspids, the rest seats should be on the
mesial-occlusal aspect. If this rest or rests are on one of the
anterior teeth, cingulum rests must be well-prepared so that
displacement of the framework can be avoided, especially
lingually or toward the defect. Often, compromised bony
support for the tooth adjacent to the defect does not permit
its use as a partial denture abutment. Consequently, the next
tooth, or other adjacent teeth, must be used for this pur­
pose. Frequently, these compromised abutment teeth can
be treated endodontically. The crown is then amputated;
the root will serve as an overdenture abutment (Figure 6-
66).

b
Fig. 6-65. a: On anterior teeth, the rest should be positioned at the junction of gingival and
middle one-third, if possible, b: Retainer should be positioned on the tooth so it disen­
gages during forceful closure.

a b e
Fig. 6-66. a: Two central incisors adjacent to the defect, with compromised periodontal bone support, b: These teeth were
treated endodontically and converted into overdenture abutments, c: A removable partial denture was designed to
overlay these abutments (mirror view).
270 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

• Fulcrum line For patients with acquired defects of the

maxillae, the fulcrum line, or axis of rotation of the partial
denture prosthesis, is influenced by the position of the oc­ D
clusal or cingulum rests, the size and configuration of the
defect, and the magnitude and location of masticatory forces
on the defect side of the prosthesis.
We believe that the fulcrum line for Class II
maxillectomy patients is dynamic in that it shifts or changes
during mastication in a manner relative to the size and con­
figuration of the defeet, the position of the bolus on the
defect side, and the masticatory force employed to pen­
etrate it. Thus, there may be multiple axes or fulcrum lines,
including the classically defined fulcrum line related to the
most posterior occlusal rests (Figure 6-67). The classical
fulcrum line may only be functional when little or no oc­
clusal force is evident on the defect side. For example, in
the defect represented in Figure 6-67, when a load is ap­
plied to the extension area #1, the prosthesis will rotate
around axis AB. When a load is applied in the anterior sec­ Fig. 6-67. Fulcrum line varies with the point of load applica­
tion on the defect side (#2), the prosthesis rotates around tion: Load #1, AB; Load #2, CD; and Load #3, EF.
axis CD. However, when the load is applied at point #3,
the axis of rotation shifts to EF. Partial denture designs must
consider these potentially shifting axes.
The configuration of the arch and the size of the de­
fect also influence the extent of movement around the ful­
crum line. For example, tapering arches invariably have
less palatal shelf available for support, and the remaining
dentition is more likely to exhibit a linear configuration. If
the teeth are in a linear or straight line, the fulcrum line will
essentially be identical with the tooth alignment (Figure 6-
68). Therefore, patients with tapering arches, having linear
tooth and arch arrangements, will tend to exhibit more
movement around the fulcrum line, as compared to pa­
tients with square and ovoid arch forms. This concept also Fig. 6-68. Maxillary defect with linear tooth arrangement.
demonstrates the importance of saving as many teeth and Indirect retainers are less effective, as the fulcrum
as much of the premaxillary segment as is possible on the line follows tooth alignment.
defect side. This will create less of a linear arrangement of
the dentition, improve the location of the fulcrum line, and
increase the effectiveness of indirect retainers (Figure 6-
69). We concur with Aramany78 and Parr79, who suggest
that more retention and bracing from multiple retainers is
required for maxillectomy patients with linear tooth align­
ments.
The dimensions of the defect exert some influence on
the dynamics of the fulcrum line. A typical total
maxillectomy defect will extend from the midline anteri­
orly to at least the anterior border of the soft palate posteri­
orly. However, it is not uncommon for a portion of the soft
palate to require resection, or for the resection to include
more of the bony palate, rendering less of the remaining ■ L .I S H IM J : .M m
palatal shelf available for support. Consequentially, these Fig. 6-69. Maxillectomy with ovoid arch form. Indirect retain­
prostheses are both heavier and less stable, and they will ers are more effective.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
usually exhibit more movement when subjected to the
forces of mastication on the defect side. Being heavier,
gravitational forces are more of a concern with bulkier pros­
theses.
• Degree o f movement As previously discussed, maxillary
resection prostheses tend to rotate up into the defect with
occlusal pressure on the defect side. When the pressure is
released, the prosthesis will return to its former rest posi­
tion under the influence of weight and gravity. The degree
of movement will vary with all the factors previously dis­
cussed, but, even under the best of circumstances, it will
always be significantly greater for a maxillary resection
patient than it would be for a nonsurgical patient, using a
similar Class II partial denture. If the contours of the defect
cannot be used effectively to enhance retention, stability,
and support of the prosthesis, then the degree of move­
ment will be even more extensive. The size of the defect is
the most important indicator of the degree of movement of
the prosthesis during function, as the larger the defect, the
greater the potential for movement. The partial denture
framework must be designed to anticipate these movements
around the axis of rotation, and be physiologically adjusted
to allow for them (Figure 6-70). Otherwise, the abutment
teeth will be subjected to damaging lateral torquing forces.
Fi g. 6-71. Cross-sectional diagrammatic representation of
b defect side since the width of the obturator seg­
Fi g. 6-70. RPD framework is being physiologically adjusted.
a: Using silicone type indicator, which is excel­
lent to gauge if rests are completely seated, b:
Using chloroform and rouge.
271
• Effect o f trismus Extreme trismus can be a very frustrat­
ing experience for both the partially edentulous patient and
the clinician, and may influence the design of the palatal
major connector. Most maxillectomy patients will receive
both surgical and radiation therapy some time during the
treatment of their disease. These treatment modalities, es­
pecially for more posteriorly located lesions, can result in
very significant trismus. It is not uncommon to have a
maximum opening of only 10 to IS mm or less between
the incisor teeth when the resection extends to the midline
and incisor teeth remain on the nondefect side. As Figure
6-71 depicts, it is the depth of the palate that may influence
the design of the removable partial denture, especially for
patients with tapering arches. Clinically, tapering arches
a posttreatment total maxillectomy patient with
extreme trismus, showing influence of depth of
palate. If the palatal depth, plus the length of any
replacement teeth and partial denture compo­
nents on nondefect side, is greater than distance
between maxillary and mandibular incisors at
maximum opening, extension into depth of the
palate and defect must be compromised. In other
words, if B plus C is greater than A, the partial
denture cannot be removed or inserted. The pros­
thesis cannot be rotated out of the mouth on the
ment is usually greater than the distance from the
commissure to the remaining maxillary central
incisor. An anterior palatal strap major connector
may serve as a design alternative.
 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

seem to exhibit greater palatal depth than do either square
or ovoid arches. If the depth of the palate plus the sum of
any replacement teeth or partial denture components on
the nondefect side is greater than the maximum opening
distance between the incisor teeth, die resection prosthesis
cannot be inserted or removed. The prosthesis cannot be
rotated out of the mouth on the defect side since the width
of the obturator is usually greater than the distance from
the lip commissure to the remaining maxillary central inci­
sor.
An alternative is to record as much of the palatal sur­
face, teeth, and defect as possible with the master impres­
sion for the removable partial denture framework. Often, a
sufficient amount of palate and teeth will have been re­
corded to accommodate an anterior strap palatal major con­
nector. While this type of major connector is not the major
connector of choice because of its flexibility, it may be the
best viable alternative.
After the partial denture framework is fitted and physi­
ologically relieved, the defect is recorded with an altered
cast impression. In these circumstances, trismus will also
limit the extension up into the defect, especially along the
lateral wall. However, the flexibility of the lateral cheek
and skin graft will often permit the prosthesis to be rotated
out of the defect and the mouth with a lateral displacement
of the cheek. In addition, the patient should be warned that
leakage will be a possibility because of the limited exten­
sions into the defect, especially along the medial margin.
totype defects; one design for a maxillary resection patient
with acceptable retention, stability, and support associated
with the defect, and the second design for the resection
patient lacking acceptable retention, stability, and support.
When stability and/or support are limited due to less
than ideal defect contours, a limited palatal shelf, or a ta­
pering arch form, the teeth may be used to improve these
aspects. Multiple, well-prepared and spaced rest seats, es­
pecially on posterior teeth, will enhance support. Incisal
and cingulum rests do not improve support as effectively
as do occlusal rests on posterior teeth. Less tooth structure
is available for rest preparation, and it may be more diffi­
cult to direct masticatory forces along the long axis of an­
terior abutment teeth. If stability is inadequate, consider­
ation should be given to the use of multiple circumferen­
tial retainers, minor connectors, and long and wide guid­
ing planes. The horizontal bracing associated with these
partial denture components will enhance the overall stabil­
ity of the prosthesis, especially if retention and support are
adequate.
FAVORABLE DEFECTS NONFAVORABLE DEFECTS

Defect and residual structures; their influence on partial

denture design Any Gass II maxillary partial prosthesis
must be effectively retained in order to achieve its func­
tional objectives. Support and, to a certain extent, stability
are important cofactors, as they help to maintain the cor­
rect retainer-to-tooth relationships; therefore, the retainers
serve primarily as a rescue force to compensate for dis-
lodgment or gravitational forces. While the compression
of healthy oral mucosa covering the edentulous segment
of a Gass II maxillary partial denture is significantly greater
than the compression potential of the periodontal ligament
apparatus of the supporting teeth for a nonsurgical patient,
the movement differential is much less than a comparable
scenario for a maxillary resection prosthesis.
If the support, stability, and retention for the resection
prosthesis can be enhanced by engaging selected areas
within and peripheral to the defect, the retention, stability,
and support available for the partial denture will be en­
hanced, and retainer-to-tooth relationships will be main­
tained. Thus, fewer retainers will be required, as compared
to the patient with a defect lacking these important physi­ Fig. 6- 72. Partial denture designs for retentive and non-
cal characteristics. Therefore, Figure 6-72 offers 2 differ­ retentive defects. Note impact of defect on de­
ent design suggestions for partial dentures for selected pro­ signs.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
Buccal versus Ungual retention Some clinicians have
used lingual retentive clasp arms with buccal reciprocat­
ing arms so that, as the prosthesis is displaced superiorly,
the lingual retentive arms will disengage from the teeth82.
Disengagement is an asset, but our clinical experience in­
dicates that these designs exhibit greater motion around
the fulcrum line, with reduced retention. The effectiveness
of lingual retention will depend upon the angulation of the
abutment teeth relative to the occlusal plane. Since there is
no cross arch reciprocation for either buccal or lingual re­
tention, a partial denture framework for a patient with a
total maxillectomy must be viewed in much the same light
as a unilateral removable partial denture, but with the im­
portant exception that the framework is supporting a large
“outrigger”. For this reason, both buccal and lingual reten­
tive arms may be considered in order to obtain “cross tooth”
retention and reciprocation. This design principle is espe­
cially relevant if the remaining dentition exhibits a linear
alignment pattern, as found in patients with tapering arches.
In this situation, the fulcrum line closely approximates the
teeth, and the indirect retainers will be close to or on this
fulcrum line and thus be less effective. Therefore, this par­
ticular prosthesis will have the potential for more move­
ment around the fulcrum line. Multiple circumferential re­
tainers may be necessary for proper retention and stability,
with the use of both buccal and lingual retention. If mul­
tiple buccal and lingual undercuts are available, some clasp
assemblies should employ buccal while others should use
lingual retention, but the net effect should be a prosthesis
that does not rotate out of position on either side of the
fulcrum line.
The primary fulcrum line for a nonsurgical patient with
a Kennedy Class II maxillary partial denture can be lo­
cated predictably on an axis passing through the most pos­
terior occlusal rests. The reason we have a fulcrum line is
due to the differential between the compressibility of the
periodontal apparatus of the abutment teeth and the mu­
cosa covering the edentulous ridge. Since the oral mucosa
is significantly more compressible, even with a well-adapted
prosthesis, a fulcrum line or axis of rotation is created. If,
for this same patient, the edentulous ridge and a portion of
the bony palate are replaced with a large maxillary defect,
the movement around this same fulcrum line will be sig­
nificantly greater and more variable, and this must be con­
sidered in the design of the resection partial denture.
Bolus manipulation We are not aware of any studies of
maxillectomy patients that have described the manipula­
tion or position of the bolus during mastication in patients
using maxillary obturator prostheses. We speculate that
dentate maxillectomy patients soon learn to masticate pri­
marily on the nondefect side, as instructed. Any segment
273
of the food bolus for a total maxillectomy patient would
most likely be placed on the more anterior teeth during the
act of incising. If the occlusal forces were, in this circum­
stance, applied to a bolus on anterior replacement teeth,
the fulcrum line would shift slightly posteriorly on the de­
fect side. The further the bolus and the forces are applied
posteriorly, the further the fulcrum line would shift poste­
riorly on the defect side. Unstable and nonretentive maxil­
lary resection partial dentures are likely to exhibit more
extensive movement, with a more posteriorly located ful­
crum line on the defect side. This concept helps to illus­
trate the importance of saving the premaxillary segment. If
the entire dentate premaxillary segment can be salvaged,
the fulcrum line will be quite similar to the fulcrum line for
a nonsurgical patient, and the indirect retainers will be more
effective.
Clinical procedures After the treatment plan has been
accepted by the patient, and the required restorative procedures
have been performed, the mouth preparation is completed as
outlined. During the restorative phase, it may be necessary to
make minor changes to the surgical prosthesis to adjust for tooth
contour changes resulting from restorative procedures.
The intended use of the master impression is to construct
the partial denture framework. Prior to obtaining this impres­
sion, the medial palatal undercut in the defect should be blocked
out with gauze lubricated with petrolatum. Bony undercuts in
this region can result in distortion of the palatal portion of the
impression. The lateral portion of the defect should be recorded
with this impression, as these contours will be necessary to fab­
ricate the tray for the future altered cast impression. The master
impression is made and the framework is designed and fabri­
cated as previously described. The obturator portion of the pros­
thesis should be constructed of acrylic resin to allow for adjust­
ment and relining. Finishing lines of the cast metal framework
should be established on palatal mucosa short of the palatal shelf.
The retention loops for the obturator portion should extend well
across the palate and, in some instances, into the defect, and be
located approximately 1 to 2 mm superior to normal palatal
contour. Placing the retention high into the defect should be
avoided because it becomes more difficult to hollow the obtu­
rator sufficiently without compromising the retention of the resin
portion of the prosthesis. The framework is physiologically ad­
justed to the abutment teeth using a suitable disclosing medium.
When the framework seats properly, and has been physiologi­
cally adjusted83, the undesirable undercuts within the defect are
blocked out on the cast with baseplate wax. Relief is also placed
over the scar band and lateral wall, as indicated for edentulous
patients. Tray resin is molded to the framework and the defect
in preparation for the altered cast impression (Figure 6-73a).
The prosthesis is placed in the mouth and the tray is exam­
ined for extension and proximity to the tissues. Modeling plas­
274 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 6-73. Altered cast impression, a: Tray resin attached to partial denture framework, b and
c: Border molding completed with modeling plastic, d: Completed altered cast im­
pression of the defect and peripheral tissues.

tic is added to the tray material, as previously described, until
the desired extensions have been achieved (Figure 6-73b). The
retention, stability, and seal of the prosthesis are checked and, if
inadequate, further extension into an undercut area may be in­
dicated to improve these features. The modeling plastic is then
relieved (Figure 6-73c). If an elastic impression material is used
to complete the impression, escape holes are placed along the
median palatal finish line in order to permit the escape of wash
material. Adhesive is applied and an elastic impression mate­
rial* is used to complete the altered cast impression. (Figure 6-
73d). After the casting is seated, the patient is directed to make
eccentric mandibular movements. Because of the prolonged
setting time of this material, these movements should be re­
peated several times. The impression is removed and examined
for tissue adaptation, proper extension, and excessive displace­
ment of tissue.
Thermoplastic wax can also be used to complete the im­
pression (Figure 6-74a). Modeling plastic is used as just de­
scribed to develop the contours of the impression that extend
Light body permlastic, Kerr U.S.A., Romulus, Ml.
into the defect, or to establish the extensions of other edentu­
lous areas. Modeling plastic is then added to develop occlusal
stops (Figure 6-74b). The modeling plastic forming the obtura­
tor is cut back 1-2 mm, and the entire impression is covered
with a thermoplastic wax. The impression is inserted and re­
fined using the bordermolding maneuvers previously described.
It may take several trials of insertion and removal with further
cut backs before the impression is covered with a suitable thick­
ness of wax. The patient is allowed to wear the prosthesis for
45-60 minutes. It is then chilled, removed, and inspected. Next,
the altered cast impression is poured, and the cast is mounted
on the articulator (Figure 6-74 c,d).
Elastic materials are favored in smaller static defects, or
when large undercuts exist that must be recorded. Thermoplas­
tic wax is preferred in larger defects, where the obturator ap­
proximates mobile border tissues or extend into the velopha­
ryngeal complex (see Chapter 7).
The master cast is segmented, the framework and altered
cast impression are seated on the tooth segment, and the im­
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 275

Fig. 6-74. a: Altered cast impression with impression wax. b: Occlusal stops were established with modeling
plastic, c: Preparation for pouring the altered cast, d: Casts mounted on articulator.

pression is boxed and poured in dental stone. Conventional
prosthodontic methods are followed to complete the prosthesis.
The obturator is processed in a hollow configuration, as previ­
ously suggested.
Delivery and adjustments are accomplished following ac­
ceptable prosthodontic guidelines. Slight pressure is desirable
against the skin graft and cheek mucosa to ensure maximal re­
tention, stability, and support. One caution should be mentioned;
pressure-indicating paste tends to stick to the skin graft or other
dry surfaces in the defect. In addition, pressure indicating paste
will be displaced or distorted when seating the prosthesis into
undercut areas. Therefore, disclosing wax is preferred over pres­
sure-indicating paste to identify areas of excessive tissue dis­
placement in the defect
The patient is given recall appointments in a manner de­
signed to gradually extend the interval between appointments.
After the adjustment phase is completed, the patient is placed
on a recall system, often coordinating prosthodontic recall ap­
pointments with visits to the surgeon and/or radiologist
Dentulous patients with partial maxillectomy defects The
prosthodontic considerations for the dentulous partial maxil­
lectomy patient are similar to those of the total maxillectomy
patient except that the prosthetic prognosis improves as the
margin of the resection moves posteriorly. If the maxillary cus­
pid on the defect side remains, the prosthetic prognosis improves
dramatically. Even the presence of a central or lateral incisor on
the defect side will enhance the stability and support for the
prosthesis. The fulcrum line is dependent on the placement of
occlusal rests. As more teeth are retained on the defect side, the
fulcrum line shifts posteriorly. If both cuspids remain, the ful­
crum line will be similar to a conventional Kennedy Class II
partial denture.
As the fulcrum line shifts posteriorly, the superior
distolateral extension of the obturator should be lengthened, as
extension into this area offers the greatest mechanical advan­
tage because it will be at a right angle and most distant from the
fulcrum line. Indirect retainers should be placed as far anteri­
orly as feasible from the fulcrum line. As with total maxillectomy
276 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

patients, placing a retainer on the tooth closely adjacent to the
defect increases stability and retention. The construction and
fitting of the prosthesis is carried out as described for the total
maxillectomy patient except in the treatment of small defects
(Figure 6-75a). Defects of this size should be blocked with gauze
prior to making impressions (Figure 6-75b) in order to prevent
escape and lodgment of impression material into the paranasal
sinuses. Occasionally, edematous turbinates will extend into the
oral cavity, preventing restoration of normal palatal contours
(see Figure 6-17a). If this has occurred, the edematous turbi­
nates should be removed surgically.
Other acquired maxillary defects A majority of patients with
benign neoplasms of nasal and paranasal sinuses will be treated
with a total or partial maxillectomy. However, resection of some
tumors will result in other types of defects. For example, pleo­
morphic adenomas and small, well-localized squamous cell
carcinomas may require a limited surgical resection at the junc­
tion of the hard and soft palates. Often, the alveolar ridge and
teeth are only minimally involved in the resection. Construc­
tion of an obturator for this type of defect is more difficult than
it appears, as the obturator must maintain contact posteriorly
and laterally during soft palate elevation (Figures 6-76 and 6-
77). Impressions for recording the functional movements of the
tissues bordering the defect are recorded with thermoplastic
waxes, as outlined in Chapter 7. Speech is usually normal after
delivery of the prosthesis. Occasionally, however, the patient
will note excess nasal leakage when swallowing. To alleviate
this problem, an extension of 5 to 10 mm is created across the
intact soft palate. The soft palate will lift from this extension in
function, but this shield will serve to direct liquids and food
into the oral pharynx (Figure 6-77). Leakage will be minimized
without interfering with tongue function. Extension into the
defect to establish contact with the nasal side of the soft palate
during elevation is also suggested.
Occasionally, an anterior resection of the maxilla is required.
A scar band is usually present at the junction of the oral and
nasal mucosa. If a skin graft is not placed, the nature of the

a b e
Fig. 6-75. a: Small defect, b: Gauze packing used to prevent impression material from entering nasal passages, c: Gauze
packing still imbedded in the impression.

Obturator

Soft palate elevated

Soft palate relaxed

Fig. 6-76.
a: Schematic drawing of the movement of the anterior margin of the soft palate
during palatal elevation, b: A patient with a defect of hard and soft palates, with
a soft palate at rest, c: Same patient and defect during palatal elevation. Note el­
evation and thickening of the anterior margin of the defect (arrow). Contact should
be maintained between the soft palate and the obturator bulb during elevation.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 277

defect anteriorly may limit anterior extension. However, the
prosthodontist should try to extend the anterior surface of the
prosthesis as far superiorly as possible without interfering with
nasal physiology (Figures 6-78 and 7-79).
Bilateral total maxillectomy defects do not occur frequently.
When both maxillae have been excised, the prosthetic progno­
sis is quite guarded. Prostheses constructed for these patients
are primarily for speech and esthetics. Surprisingly, they may
serve these functions well (Figure 6-80); however, without bony
support, the prosthesis will exhibit considerable movement dur­
ing swallowing and mastication. Consideration should be given
to creating undercuts during resection of the tumor. Retention,
stability, and support are enhanced if these suigical undercut
areas are located bilaterally and lined with a split thickness skin
graft. Engagement of the nasal aperture is useful in some pa­
tients. Silicone or a 2-piece prosthesis enable more efficient use
of available soft tissue retentive areas. Implants may be useful
when placed in the zygomatic buttress areas in selected patients.
On occasion, removal of large portions of the orbital floor
is necessary to ensure tumor control, resulting in ptosis and
enophthalmos. In spite of this cosmetic misalignment of the
eyes, few patients report with persistent diplopia84. Following
resection of the orbital floor, facial slings and split thickness
skin grafts are usually inserted for reinforcement of the orbital

a b c

Fig. 6-77. a: Defect of the border of the hard and soft palates, b: Prosthesis with shield extending over the soft palate. With
elevation of the soft palate, contact is maintained with an obturator bulb. Extent of shield can be visualized through
the clear resin (a/row), c: Prosthesis fitted for another patient with similar defect. Note extension onto the nasal side
of the soft palate.

a b

c d

Fig. 6-78. a: This defect resulted from resection of a squamous cell carcinoma of the maxillary anterior alveolar ridge. Anterior
alveolar ridge tumors are rare, b: Cast, c: Mounted casts showing the extent of the defect, d: Esthetics.
278 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 6-79.
a: Resection of the horizontal processes of both maxillae. Prosthetic prognosis
is favorable due to a full complement of teeth, but contact must be maintained
with the anterior margin of the soft palate during palatal elevation. To do so, a
functional impression is often required, b: Mirror view of a second patient with
a total resection of both maxillae, except for small segments of both tuberosi­
ties which remain. Implants are placed in each tuberosity, c: Direct view, show­
ing implants and intact soft palate. The 2 implants on the patient’s right side
were splinted together and support an ERA attachment, d: Prosthesis.

Fig. 6-80. a: Resection of both maxillae and entire soft palate, except for small segment of right tuberosity
which remains with sufficient bone for single implant, b: Prosthesis with “O ’ -ring attachment, c: Pros­
thesis with extension into nasal aperture, d: Aperture created for breathing beneath extension into
the nasal aperture, e: Prosthesis in place.
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation
contents. The fusion of the skin graft and periosteum creates a
hammock that, in some instances, adequately supports the or­
bital contents. However, when significant amounts of the
periorbita are removed, compromising adequate inferior oblique
and inferior rectus action, the incidence of diplopia increases.
In these patients, prostheses are often useful in providing sup­
port for the orbital contents. Uplifting the orbital contents will
improve cosmetic appearance and, often, reverse the diplopia85.
They may be fabricated as a 1-piece prosthesis, in which the
antral extension is attached directly to the obturator section, or
in 2 sections, in which the superior orbital extension is con­
nected via an attachment to the parent prosthesis. The antral
section may be flexible or rigid. A flexible apparatus is advan-.
tageous because it is light in weight and can be designed so that
transmission of movement generated by the parent prosthesis
during function is minimized. Care must be taken to avoid ex­
cessive contact and trauma to adjacent nasal mucosa.
Evaluation o f maxillary obturator prostheses With the deliv­
ery of conventional removable prostheses, both the prosthodon­
tist and the patient are concerned with the level of comfort, func­
tion, and esthetics achieved with the new prosthesis. In con­
trast, the evaluation of a new maxillary obturator prosthesis must
be concerned not only with these aspects, but also with any
functional limitations induced by the surgery. The efficiency of
mastication, air and/or fluid leakage into the nasal cavity, and
the possible impact upon speech must also be considered. Each
of these additional aspects will be discussed from the perspec­
tive of recent studies, as a clinical evaluation alone may not
reliably determine the adequacy of obturation86.
Functional and masticatory limitations Clinical obser­
vations indicate that edentulous patients with maxillary obtura­
tor prostheses do not function as effectively as do conventional
complete denture patients. In addition, there seems to be a greater
disparity between the level of function between dentate and
edentulous patients with maxillary obturator prostheses as com­
pared with the performance of dentate and edentulous patients
with conventional prostheses. The capability of bilateral chew­
ing and effective neuromuscular control are important cofac­
tors leading to the effective use of conventional complete den­
tures. A patient with a maxillary resection prosthesis is compro­
mised in both areas because of the defect and surrounding sen­
sory deficits. The added movement of the edentulous maxillary
resection prosthesis up into the defect accentuates this func­
tional disparity. Retention, in the classical sense of complete
dentures, is unobtainable because the surgical opening permits
the leakage of air beneath the prosthesis and eliminates the re­
tentive contribution of atmospheric pressure. While both den­
tate and edentulous maxillectomy patients may learn to confine
most of their mastication to the nondefect side, mastication is
comparatively much more effective in dentate patients. As pre­
279
viously discussed, the size and location of the resection, the
contours of the remaining alveolar ridge and palate, and the
potential for retention, stability, and support within the defect
will influence the level of function of both dentate and edentu­
lous patients.
Shipman studied 10 edentulous patients with maxillary re­
section obturator prostheses87. A gnathodynameter was attached
to each prosthesis. The maximum bite force recorded was ap­
proximately 50% of the forces reported for conventional com­
plete denture patients, and had little relationship to the size of
the maxillary defect. Denture adhesives improved performance
approximately 12%. However, there was considerable varia­
tion in the forces recorded between patients. These results sug­
gest that defect contours and neuromuscular control may be
important cofactors in the performance of patients with obtura­
tor prostheses.
Air and fluid leakage On delivery of a new obturator
prosthesis, patients occasionally complain of varying amounts
of fluid leakage around the periphery of the obturator and into
the nasal cavity. Obviously, this can be frustrating for both the
patient and the prosthodontist. Interestingly, even with some
leakage of air, speech is often within normal limits. Two recent
studies offer some explanation for this phenomenon by provid­
ing some insight into airflow and pressure characteristics through
the oral and nasal cavities.
Watson and Gray studied 5 patients with new obturator
prostheses using 2 complimentary methods; namely, (1) simple
lung function tests and (2) sequential radiographic assessment
of a radiopaque liquid during swallowing88. The effectiveness
of obturation was measured by comparing values during both
initial and sustained exhalation into a spirometer with and with­
out a nose clip. The difference was much greater during sus­
tained exhalation both with and without the nose clip. How­
ever, there was some air leakage under both initial and sus­
tained exhalation. The authors speculated that, during forced
exhalation, the soft tissues peripheral to the obturator contract
more vigorously, leading to improved seal. With sustained ex­
halation, forceful exhalation is not feasible and, therefore, leak­
age is more likely to occur.
Radiological evidence confirmed the leakage of contrast
medium around most obturators, especially along the posterior
and posterolateral margins of the defect Leakage may occur
posteriorly during swallowing due to the movement of the soft
palate. Posterolaterally, the functional movements of the coro-
noid process may contribute to leakage. During mandibular
movements, the coronoid process and/or the anterior border of
the ramus of the mandible displace the soft tissues along the
distolateral aspect of the defect, just as these structures influ­
ence the width and lateral contours of the buccal pouch area of
a maxillary complete denture. Movements of the coronoid pro­
cess must be accounted for or post-delivery soreness will re­
280 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
suit During swallowing, the mandible is closed and braced so
that a small space may exist where the soft tissues were dis­
tended during mandibular movements. During swallowing, the
dorsum of the tongue elevates forcefully against the hard and
soft palate, creating a pressure superiorly which may force flu­
ids around the obturator bulb and into the nasal cavity. The con­
clusion of the authors was that complete and total closure (or
seal) may be unobtainable at times, but a sufficient level of ob­
turation usually exists to permit acceptable speech and swal­
lowing.
Minsley studied 4 patients with maxillary obturator pros­
theses86, using the methodology suggested by Warren and oth­
ers89,90,91,92’93 (see Chapter 7 for a more complete discussion of
these and other related studies) based on airflow, pressure,
velopharyngeal orifice size, and respiratory volumes. The theory
developed by Warren and coworkers involves a modification
of hydraulic principles, and assumes that the smallest cross-
sectional area of a structure can be determined if the differential
pressure across this opening is measured simultaneously with
the rate of airflow through it. Of the 4 patients, 2 required par­
tial maxillectomies, 1 required complete resection of both max­
illae, and 1 required complete resection of the soft palate. Oral
pressures and respiratory volumes were recorded during the
production of consonant sounds, both prior to and during each
phase of prosthodontic treatment, with and without the prosthe­
sis. The authors found that the respiratory volume increased
approximately 3 fold as a compensatory mechanism while speak­
ing without the prosthesis. When the prostheses were inserted,
the respiratory effort and the oral pressure returned to near nor­
mal. The oral opening around the definitive obturators was less
than .05 mm2, which did not significantly impact on speech, but
might lead to the percolation of fluids into the nasal cavity dur­
ing swallowing. Reisberg and Smith confirmed the efficacy of
this methodology by reporting the data of 3 patients requiring
maxillary maxillofacial prostheses94.
Patients often experience difficulty identifying the exact
location where the leakage is occurring due to the sensory defi­
cits associated with the suigical resection and the altered and
compromised innervation with skin graft linings in the defect.
Therefore, direct visualization of the interface between the pe­
ripheral soft tissues and the obturator bulb during swallowing
can be helpful. Approximately 25% of the time, the contents of
the orbital cavity must be exenterated in continuity with the
maxillary resection for control of the disease, thus permitting
direct visualization of the superior surface of the obturator
through the orbit The use of oral and nasoendoscopy95,96 also
permits direct visualization with an endoscope and a fiberoptic
light source.
Speech considerations Surgical removal of portions of
the maxillae, if not restored surgically or prosthodontically, can
create a serious problem for the speaker for several reasons.
First, oral-nasal resonance balance is distorted, as the patient
cannot confine oral emissions within the oral cavity, leading to
hypemasal speech. Second, 17 of the 25 consonant phonemes
used in the English language require labiodental, linguodental,
and linguopalatal contacts. With the loss of palatal tissues, cor­
rect tongue-palatal contacts are impossible and articulation is
compromised19. Third, the loss of anterior teeth (associated with
a total maxillectomy) further compromises the articulation of
speech.
Several investigators reported normal speech after place­
ment of prostheses for patients with acquired suigical defects
of the maxillae19,97,98. Kipfmueller and Lang recorded the speech
of 6 patients who were to undergo maxillectomy procedures for
control of neoplastic disease99. After surgery, the same speech
sequence was recorded at intervals up to 9 months postsuigically,
with and without the prosthesis. Three of the patients were eden­
tulous and 3 had teeth remaining for retention and support of
the prosthesis. The results of this study demonstrated that speech
following placement of the prosthesis may not always be “nor­
mal”. Two of the dentuious patients demonstrated improved
speech, as compared to presurgical recordings. Of the remain­
ing 4 patients, 3 demonstrated a slight loss (up to 14%) of intel­
ligibility when speaking with the prosthesis, as compared to the
presurgical recordings. One demonstrated an 18% loss in intel­
ligibility, as compared to presurgical recordings (in this patient,
the resection extended well into the soft palatal area). Bloomer
and Hawk commented on this study and suggested that a max­
illary resection may affect velopharyngeal function by destroy­
ing the attachments for the palatal musculature, by coincident
denervation of the palatal muscles, or by the relative shrinkage
and immobilization of the soft palate through scar contracture19.
Plank studied the speech of 8 patients, some dentate and
some edentulous, rehabilitated with a maxillary obturator pros­
thesis following surgical resection of various segments of the
maxillae100. A speech sample was recorded presurgically with
the immediate surgical obturator and then again, following place­
ment of the definitive prosthesis. The speech samples were ran­
domized and evaluated by 10 untrained listeners, following a
period of instruction. The average intelligibility of all subjects
was 98.8 correct presurgically, 92.1% correct with their imme­
diate suigical obturators, and 97.3% correct with their defini­
tive prosthesis. One patient, with a prosthesis for a bilateral
maxillectomy defect, exhibited a 12% reduction in intelligibil­
ity with the definitive prosthesis.
Tobey and Lincks examined the acoustic speech patterns
of 5 patients, before and after prosthodontic reconstruction, to
determine the effectiveness of maxillary resection prostheses
in eliminating or reducing nasal resonance101. In 2 patients, the
resection was confined to the anterior maxillae while, in the
other 3, the resections included the posterior maxillae and vary­
ing portions of the anterior soft palate. Speech samples were
recorded presurgically and after prosthodontic rehabilitation
 Restoration o f Acquired Hard Palate Defects: Etiology, Disability, and Rehabilitation 281

using a digital sonograph with a 30 Hz filter. Vowels were pri­
marily studied as these phonemes are particularly sensitive to
changes in nasal resonance, and their production requires dif­
ferent areas of tongue-palate approximation. Excess nasal en­
ergy was found in the speech of all 5 patients, but with propor­
tionally less nasal resonance in the 2 with prosthodontic reha­
bilitation of the more anterior resections.
Based on clinical observations, we believe that, when the
maxillectomy is confined to the bony palate, the speech follow­
ing placement of a prosthesis is usually within normal limits.
Rarely is velopharyngeal function affected (either directly or
indirectly) through scar contracture, loss of bony attachment
for the soft palate, or denervation. However, it is not uncom­
mon to note slight articulatory deficiencies associated with
speech following placement of the definitive prosthesis. How­
ever, resonance balance usually is normal. These errors in ar­
ticulation tend to diminish as the patient utilizes the prosthesis,
and rarely is speech therapy required for these patients.
Kipfmueller and Lang noted this tendency for improvement in
articulation of speech following the placement of prostheses".
In a few patients, more extensive distortions in articulation
and resonance have been noted. These distortions seem to be
associated with more extensive resections of the soft palate and/
or when the patient is edentulous. On occasion, we have noted
that the speech results with the definitive prosthesis will not be
as effective initially as the results achieved with the surgical
prosthesis. Occasionally, the same slight deterioration in speech
may be noted following the construction of a new definitive
prosthesis. Fortunately, these sequelae do not occur frequently,
but, when they do occur, it is disheartening to both the patient
and the prosthodontist, and they may compromise adaptation
to the new prosthesis. Usually, with modification of the pros­
thesis, and adaptation and persistence by the patient, and sup­
port and encouragement by the prosthodontist, these speech
deficits are improved or eliminated.
Fortunately, few total maxillectomies adversely affect
velopharyngeal closure, in the maimer described by Bloomer
and Hawk19. When innervation is compromised, resulting in
velopharyngeal incompetence, or when scar contracture results
in velopharyngeal insufficiency, a palatal lift extension to the
obturator may improve velopharyngeal closure. Research and
controlled studies are indicated for further evaluation of speech
and fluid leakage following placement of maxillary prostheses
for acquired palatal defects.
Relines Relines are required more often for patients with max­
illary defects than for complete-denture patients. In large de­
fects, much of the support, retention, and stability for the obtu­
rator prosthesis is derived from the soft tissues of the defect,
and these tissues are subject to change. The cheek surface and

Fig. 6-81. a and b: Reline impression of a partially edentulous patient. These impressions were made with thermoplastic wax.
c: Reline impression completed with light body rubber base material, d, e, and f: Reline impression of implant-
retained complete denture with obturator using thermoplastic wax. We have come to prefer thermoplastic wax for
larger defects, due to their mobile peripheral tissues, and light body polysulfide material for smaller defects.
282 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
scar band at the junction of the skin graft and oral mucosa tends
to stretch with time. The posterior margin of the defect is also
subject to change if it extends into the area of velopharyngeal
function. In addition, the medial bony margin of the defect re­
models and becomes rounded. These changes are most notice­
able during the first 18 months following surgery.
The reline must be performed with care and precision,
maintaining centric relation and the vertical dimension of oc­
clusion. Undercut areas of the obturator portion are removed.
Acrylic resin adjacent to the finish line of the major connector
is reduced, and this zone is perforated in several regions with a
#4 round bur. The contours of the prosthesis are redeveloped
with modeling plastic, as previously described in this chapter.
When border molding is completed, the modeling plastic is re­
duced 1 to 2 mm and either a thermoplastic wax, or elastic im­
pression material is used to refine the impression (Figure 6-81).
We prefer thermoplastic wax when the defect is large and ex­
hibits mobile peripheral tissues. During border molding and
refinement of the impression, occlusal relationships and the
vertical dimension must be maintained. Upon completion, the
impression is boxed and poured, as previously described. A re­
line jig is used so that all relationships are maintained. The re­
line jig is disassembled, the impression material removed, the
residual acrylic resin reduced where necessary, and the reline
completed with autopolymerizing acrylic resin. The relined
obturator prosthesis is delivered, as described earlier. Pressure-
indicating paste and disclosing wax are used to verify that the
prosthesis is properly adapted and extended into the defect A
clinical remount will help to ensure that occlusal relationships
are maintained.
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Chapter 7
Speech, Velopharyngeal Function, and
Restoration of Soft Palate Defects
Thomas A. Curtis and John Beumer III
In maxillofacial prosthetics, the clinician may have the re­
sponsibility of reestablishing velopharyngeal integrity to pro­
vide the potential for acceptable speech. This additional dimen­
sion of prosthetic therapy requires a basic understanding of the
speech mechanism. Therefore, the objectives for this chapter
are to describe the components of speech, to explorethe anatomy
and physiology of the velopharyngeal complex, and to relate
this information to the rehabilitation of patients with defects or
deficiencies of the soft palate and pharyngeal walls.
Speech
Speech, as formulated, perceived, and decoded, is unique
to humans. Speech is a learned process which makes use of the
anatomical structures designed primarily for respiration and de­
glutition. The production of speech requires the selective modi­
fication and control of an outgoing airstream1. The source of
power, or air pressure, resides within the respiratory apparatus.
There are no organs for speech per se. Speech is a learning pro­
cess and develops over an extended period. Most girls master
the normal articulation of speech by 6.5 years of age, whereas
boys require an additional year of maturation2. As a learned
function, speech is more easily disturbed by ablative surgery or
congenital malformations, as compared to the primary and life-
supporting functions ofrespiration and deglutition. Yet, as speech
is a learned function, impaired speech is amenable to improve­
ment by accommodation or retraining3.
Components of Speech
Kantner and West divided speech into 5 components: res­
piration, phonation, resonation, articulation, and neurologic in­
tegration4. Chierici and Lawson added audition, or the ability to
hear sounds, to this list5. The successful performance of these
functions is necessary for the production of acceptable speech.
Respiration
During respiration, inhalation and exhalation are approxi­
mately equal in duration, and the air flow is regular and repeti­
tive. During speech, however, the inhalation phase is shortened
andthe exhalation phase is prolonged and not repetitive. In nor­
mal discourse, the volume and pressure of the expelled air is
comparable to vegetative breathing. Upward movement of the
diaphragm with contraction of the costal cartilages and con­
tiguous musculature creates an intrapulmonary pressure which
is greater than atmospheric pressure, thus permitting air to be
expelled from the lungs. Prolongation of exhalation is achieved
by the valve mechanisms along the laryngeal, pharyngeal, oral,
and nasal components of the respiratory tract. These valves
impede the expired air and help to create speech signals. Sub-
glottic pressure is maintained by the balancedelasticity between
the inspiratory intercostal musculature and the expiratory ab­
dominal musculature. If the vital capacity of the lungs is com­
promised, as in emphysema, speech will be perceived as
“breathy”. The poor projection of the voice, in such cases, is
due to the reduced volume and pressure of the expired air.
Phonation
The larynx provides the first level of constriction for con­
trolling the respiratory air stream. The primary function of the
vocal folds is to protect the lungs and the lower respiratory tract
from inhalation of particulate matter. This protective mecha­
nismrequires a simple, forceful approximation ofthe vocal folds.
Speech, conversely, requires a multitude of positions, varying
286 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
tensions and vibratory cycles, and an intricate coordination of
the vocal folds with other structures6. If the vocal folds are par­
tially or completely adducted or closed, they impede the ex­
pired air. With the proper degree of tension and sufficient
subglottal pressure, the vocal folds may be set in vibration and
thus impart phonation to the airstream. Whereas phonation is
essential for certain speech sounds, other speech signals do not
require phonation; hence, the vocal folds are abducted or open.
The tension and position of the vocal folds will, in part, deter­
mine the pitch of the phonated sound7. In the production of low-
pitched sounds, the vocal folds are relatively thick and flaccid.
In high-pitched sounds, the margins of the approximated folds
are thin and tense. If the larynx is resected, the patient must
leam to use the esophagus, or a substitute mechanical device
(electrolarynx), as an alternative phonating system. Since alter­
nate vibrating systems may produce a constant tone, the speech
of a laryngectomy patient often lacks the modulations and in­
flections of normal speakers. Neurologic disorders and vocal
cord pathoses, such as papillomas or contact ulcers, can also
produce phonatory defects in varying degrees.
Resonation
The sounds produced at the level of the vocal folds is not
the final acoustic signal which is perceived as speech5. Tins
sound is augmented and modified by the chambers and struc­
tures above the level of the glottis. The pharynx, the oral cavity,
and the nasal cavity act as resonating chambers by amplifying
some frequencies and muting others, thus refining tonal qual­
ity. The pharynx, being a muscular tube, serves as an excellent
resonating chamber. This tube is formed by 3 closely associ­
ated muscles; namely, the inferior, middle, and superior con­
strictor muscles. These muscles are unique in that they share a
common insertion, the medial pharyngeal raphe, but have a dif­
ferent anterior origin. Also, it appears that each constrictor, as
well as portions of each muscle, can contract selectively8. The
dimensional changes imparted by this muscular action influ­
ence the resonant characteristics of the pulsating air stream as it
emerges from the larynx. The velopharyngeal mechanism pro­
portions the sound and/or air stream between the oral and nasal
cavities and influences voice quality (or the basic sound) that is
perceived by the listener. If velopharyngeal closure is compro­
mised, or if the structural integrity or relative size of the oral,
pharyngeal or nasal cavities has been altered, voice quality can
be compromised.
Articulation
Amplified, resonated sound is formulated into meaningful
speech by the articulators, namely, the lips, tongue, cheeks, teeth,
and palate, by changing the relative spatial relationship of these
structures. The tongue is considered to be the single most im­
portant articulator of speech because of its ability to affect rapid
changes in movement and shape. The tongue may impede, se­
lectively restrict, and channel the air stream with precise con­
tact against the teeth and palatal areas, thus articulating the ba­
sic laryngeal sound, or the non-phonated air stream, into recog­
nizable speech. If oral structures, such as the tongue, adjacent
soft tissues, jaws, or lips, are altered surgically and/or neuro-
logically, articulation may be compromised (see Chapter 5).
Neural integration
Speech is integrated by the central nervous system both at
the peripheral and central levels. The sequential and simulta­
neous movements required throughout the speech complex de­
mand precise coordination. MacNeilage and DeClerk stated that
at least 17,000 different motor patterns are required during
speech9. Neurologic impairments may compromise a specific
component of the speech mechanism, such as the vocal folds,
soft palate, or tongue, or it may indirectly affect the entire speech
system. A cerebrovascular accident may compromise the abil­
ity of the patient to comprehend and/or formulate meaningful
speech, even though all structures used to produce speech are
anatomically within normal limits. In addition, a neurologic
impairment may produce a specific type of speech deformity.
For example, the loss of motor innervation to the soft palate
may compromise elevation and velopharyngeal closure.
Audition
Audition, or the ability to receive acoustic signals, is vital
for normal speech. Hearing permits reception and interpreta­
tion of acoustic signals and allows the speaker to monitor and
control speech output. Compromised hearing can preclude ac­
curate feedback and, hence, affect speech. Speech development
and subsequent speech therapy is hampered in patients with
hearing impairments10.
Speech and Maxillofacial Prosthetics
Of the 6 components of speech, resonance and articulation
are most readily influenced by maxillofacial prosthodontic re­
habilitation. These 2 components are intimately related and are
difficult to separate into distinct entities for purposes of clinical
evaluation. Patients with acquired defects or congenital malfor­
mations of die soft palate may exhibit excessive nasal resonance
because, without surgical and/orprosthodontic intervention, they
are unable to control and divert sufficient air flow into the oral
cavity. Whereas the degree of velopharyngeal closure remains
the major determinant of resonance balance, other factors, such
as tongue position relative to assistance in velar elevation11,12,13
and structural resistance within the nasal cavity31, influence the
perceived oral-nasal resonance balance.
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects
Resonance disturbances manifest as excessive nasal reso­
nance (hypemasality, nasality, and/or rhinolalia aperta) or in­
sufficient nasal resonance (hyponasality, denasality, or rhinola­
lia clausa). With hypemasality, excessive air escapes into the
nasal cavity and the patient sounds as though he or she were
speaking through his or her nose. In contrast, patients with
hyponasality exhibit insufficient air flow through the nasal com­
partments. Obturator prostheses, used for velopharyngeal in­
competence or, insufficiency, can create hyponasality14. More
often, however, the prosthodontist is challenged to provide suf­
ficient obturation to avoid hypemasality while maintaining pa­
tency for nasal breathing and the proper production of nasal
consonant sounds.
Articulation deficiencies are primarily seen in patients with
acquired defects of the mandible (see Chapter 5). In conjunc­
tion with the resections of portions of the mandible, adjacent
soft tissues may be sacrificed or sensory and motor innervation
of the lower lip, tongue, and cheeks may be compromised. Al­
though the misshaped oral cavity may produce changes in oral
resonance, it is not a major factor in speech distortions associ­
ated with these patients.
Congenital cleft lip or cleft palate patients may exhibit dis­
tortions in both articulation and resonance. Errors in articula­
tion may be classified as deficiencies of distortion, substitution,
or omission. Cleft palate patients may exhibit all 3 types of ar­
ticulatory deficiencies. When hypemasality and articulation de­
ficiencies coexist, resonance and articulation are difficult to dif­
ferentiate1516.
Table 7-1. Place and Manner of American-English Consonants.
PLACE
Plosive Fricative
Bilabial P b
(pole) (bowl)
Labial Dental f V
(fat) (vat)
Lingual Dental 0 a
(thigh) (thy)
Lingual Alveolar t d S ' z '
(toll) (dole) (seal) (zeal)
Palatal z ch
(ash) (azure)
Velar K g
(coal) (goat)
Source: EspositoS. Speech and palatopharyngeal function. In: Proceedings of the 1st International Congress on Maxillo­
facial Prosthetics. Zlotolow I, Exposito S, Beumer J, eds. 1995.
287
Speech Phonemes
Introduction, Classification, and Description
American English contains 44 different speech sounds, pho­
nemes, which are classified as vowels, voiceless consonants,
and voiced consonants. Phonemes vary in terms of the frequency,
intensity, and duration of the sound produced. Vowels are formed
primarily with little flow of air, accounting for their lower fre­
quencies and higher intensities. Vowel combinations, such as
“ie”, are called diphthongs. Voiceless consonants, such as “p”,
“t”, “f \ and “s”, are formed with a column of air (without la­
ryngeal phonation) that, when restricted, produces sounds of
moderately high frequency and low intensity. Voiced conso­
nants, such as “b”, “d”, and “g”, combine laryngeal phonation
and air flow with variable frequencies and intensities.
Consonants (voiced or unvoiced) can be further divided
by the duration of the sound, the principal resonating chamber
utilized to produce the sound, and the articulators used to form
the sound (Table 7-1). Some consonants, such as “b”, “g”, and
“s”, are prolonged while other consonants, such as “p” and “d”
are called stop-plosives because the air-sound volume is con­
tained and suddenly released. All vowels, and most consonant
sounds, use the oral pharynx and the oral cavity as the primary
resonating chambers. However, there are 3 nasal consonant pho­
nemes, namely, “m”, “n” and “ng”, that use the nasal cavity as
the primary resonating chamber. All speech sounds require at
least a modicum of nasal resonance, as evidenced by the distor­
MANNER OF PRODUCTION
Affrictave Semivowel Nasal
w m
(watt) (sum)
jljjl n
(lot) (suq)
j
(choke) (juke)
ng
(sing)
288 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 7-1.
a: Patient making T sound. Notice approximation of maxillary incisors with wet-dry
line of lower lip. b:. Patient making “s” sound in customary manner. Note
relationship of maxillary and mandibular anterior teeth, c: Patient with a severe
Class II, Division I relationship, d: Same patient making “s” sound by valving lower
lip with incisal edges of maxillary teeth.

tions in voice quality exhibited by individuals with severe nasal
congestion.
Speech Phonemes and Prosthetics
The articulation of individual or groups of phonemes is
beyond the scope of this review; however, we will describe the
articulation of fricative or sibilant consonant phonemes, as these
sounds are often utilized as guides for verification of the posi­
tion of anterior denture teeth. Fricative sounds, such as “f ’ and
“v”, are formed by constricting the air flow in a friction-like
manner. Hence, these phonemes are termedfricatives. Classi­
cally, these sounds are produced by the approximation of the
wet-dry line of the vermilion border of the lower lip with the
maxillary incisor teeth (Figure 7-1 a). Since the lips are flexible,
some accommodation to esthetic demands is possible without
phonemic distortion17. However, if the maxillary or mandibular
incisor denture teeth are positioned beyond the range of lip ac­
commodation or fail to provide proper lip support, fricative
sounds can be distorted.
Sibilant sounds, such as “s” and “z”, are produced in a
friction-like manner, resulting in a hissing sound that explains
the term sibilant. An acceptable “s” is produced in several ways.
Most individuals will elevate the tongue against the hard pal­
ate, forming a median furrow which directs the air stream be­
tween the incisal edges of the maxillary and mandibular incisor
teeth. The mandibular incisors are positioned slightly lingual to
and approximately 1 mm from the maxillary incisors (Figure 7-
lb). This is the “closest speaking space” referred to by
Silverman18 and is used by many clinicians to verily anterior
tooth position19,20. This evaluation is enhanced since sibilant
sounds are prolonged.
Fricative and sibilant sounds, along with continuous speech,
can be used to evaluate the vertical dimension of occlusion.
Premature tooth contact during articulation may indicate that
the appropriate vertical dimension of occlusion has been ex­
ceeded18,21. Conversely, if an excessive space exists between
the anterior and posterior denture teeth during continuous speech,
the vertical dimension of occlusion may need to be increased.
Some caution should be expressed regarding the use of
sibilant sounds as a diagnostic aid during the construction of
prostheses. The “s” sound is an unvoiced linguo-alveolar
fricative and the sixth most common consonant used in general
American English. Fairbanks and Lintner noted that approxi­
mately 90% of all speakers with defective articulation have dif­
ficulty with “s”22.
However, Pound feels that the mandible (dentulous or eden­
tulous) is carried anteriorly and superiorly to a precise position
during the production of the “s” sound, and that this position is
as definitive as is the terminal hinge position of the condyles20.
Although Pound noted some exceptions to this statement, the
literature does not support this premise of a reproducible “s”
position. For example, Benediktsson used cephalometric radio­
graphs to study the position and movements of the tongue and
mandible during the production of the “s” sound in 246 sub­
jects with normal and abnormal incisor relationships23. This study
revealed a variety of incisor, tongue, and lip approximations
during the production of the “s” sound with both normal and
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects 289

a b c
Fig. 7-2.
a: Complete denture patient making “s” sound in conventional manner
immediately after delivery of prostheses. b: Patient performing same task 1 week
later. Note that interdental space has increased, c: Another patient making “s”
sound immediately after delivery of the prostheses. Notice the excessive space
between incisors, d: Incisor approximation 1 week later. Notice change in incisor
relationship. Twelve patients were recorded in this manner. All prostheses were
constructed by students at University of California, San Francisco, using a
modified Patterson chew-in technique to record maxillomandibular relationships.
Anterior denture teeth were arranged for esthetics with a maximum of 1 mm of
vertical overlap. In most patients, some variability in “s” position was noted.
Distortion of speech was not evident after insertion appointment.

abnormal speakers. Subtelny and others compared 31 subjects
with a Class II, Division I malocclusion and normal speech with
20 subjects with a similar malocclusion but with defective
speech24. They found that excessive protrusion of the mandible
for incisor approximation did not occur as a generalized com­
pensatory adjustment to extreme maxillary variations—only 1
normal speaker demonstrated extensive mandibular protrusion
necessary for incisor approximation during speech. The lower
lip often created the restriction with the maxillary incisors for
the “s” sound production for these Class II patients (Figure 7-1
c,d).
In addition, mandibular movements during speech and “s”
sound production are not always precise. Gibbs and Messerman
found that mandibular movements during speech were quite
limited, as compared to the envelope of motion displayed by
the mandible during mastication25. Silverman noted that move­
ments of the mandible during the production of the “s” sound
are skeletal and are required to enhance the precise movements
of the tongue26. Speech pathologists and maxillofacial
prosthodontists now recognize that considerable positional varia­
tion can occur during articulation without causing phonemic
distortion. Our speech colleagues caution that sounds produced
in isolation are more likely to be correct than these same sounds
produced during spontaneous and continuous speech; therefore,
the clinician must consider the dynamics of the speech mecha­
nism27. Speech can and should be used as one of the guidelines
for placement of the denture teeth, yetjudgments regarding tooth
position and jaw relationships based solely upon speech should
be used with the understanding that there are many exceptions
from the norm (Figure 7-2).
Velopharyngeal Function
Hypemasality and decreased intelligibility of speech may
result from congenital or acquired defects of the velopharyngeal
mechanism. Velopharyngeal deficits may result from congeni­
tal malformations (such as cleft palate), developmental aberra­
tions (such as a short hard or soft palate, or deep nasopharynx),
acquired neurological deficits, or the surgical resection of neo­
plastic disease.
Classification and Etiololgy
Velopharyngeal deficiencies may be classified on the basis
of physiology and/or structural integrity. Palatal insufficiency
and palatal incompetency are often used to define velopha­
ryngeal deficits. Although these terms are often used interchange­
ably, there are subtle differences. Palatal insufficiency refers to
patients with inadequate length of the hard and/or soft palate to
affect velopharyngeal closure, but with movement of the re­
maining tissues within normal physiological limits. The defect
is secondary to a structural limitation. Patients with congenital
and developmental aberrations and acquired soft palate defects
would fall into this classification (Figure 7-3). Palatal incompe-
290 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

gross deficiencies of palatal tissues are best treated

Fig. 7-3.
Lateral cephalometric film of
cleft palate patient with
palatal insufficiency seen
during the production of “e”
sound. Note that patient is
unable to achieve closure
due to insufficient length of
soft palate.
tence refers to patients with essentially normal velopharyngeal
structures, but the intact mechanism is unable to affect velo­
pharyngeal closure. Patients with neurological diseases, such
as bulbar poliomyelitis or myasthenia gravis, or neurologic defi­
cits secondary to cerebrovascular accidents or closed head inju­
ries are included in this category.
The largest group of patients with soft palate defects are
those with congenital clefts of the palate (see Chapter 8). In
many patients, velopharyngeal function can be restored by sur­
gical reconstruction. However, residual palatal deficiencies may
remain after surgical treatment which would require placement
of an obturator prosthesis. Selected cleft palate patients with
prosthodontically, without surgical intervention. With develop­
mental deficiencies, such as a short hard and/or soft palate and
deep nasopharynx, and occult submucous cleft palate, struc­
tural integrity is present, but the velopharyngeal mechanism is
unable to affect closure. Palatal surgery is usually the treatment
of choice.
Most acquired soft palate defects result from surgical re­
section of neoplastic disease. However, reconstructive surgery
is generally not indicated for patients with acquired defects be­
cause of excessive tissue loss, or is contraindicated because of
the need to monitor the tumor site for recurrent disease. Surgi­
cal reconstruction of extensive acquired surgical defects of the
soft palate can result in a deficient, non-functioning
velopharyngeal mechanism, and compromise subsequent pros­
thetic intervention (Figure 7-4). Soft palate defects can also re­
sult from other diseases and from trauma. Patients with neuro-
logical deficiencies which impair motor control of the
velopharyngeal mechanism will benefit from prosthodontic
therapy. Palatal lift prostheses are often indicated for these pa­
tients.
General Considerations
The velopharyngeal mechanism is a precisely coordinated
valve formed by several muscle groups. At rest, the soft palate
drapes downward so that the oral pharynx and nasopharynx are
open and coupled, allowing for normal breathing through the
nasal passages (Figure 7-5a). Classically, when velopharyngeal
closure is required, the middle one-third of the soft palate arcs

a b

Fig. 7-4. a: Patient with lateral posterior border defect following resection of squamous cell carcinoma. Several attempts were
made to reconstruct the defect surgically. Unfortunately, breakdown of the flap and scar contracture compromised soft
palate elevation, closure, and subsequent prosthodontic therapy, b: Surgical closure was attempted primarily, which
tethered the soft palate in the inferior position. Prosthesis was fabricated, but patient could not tolerate it because of
its low position in oral pharynx, c: Soft palate defect closed with the tongue flap sutured to the posterior pharyngeal
wall. Speech was very defective, but obturator prosthesis could not be fabricated without surgical revision of the
tongue flap to achieve access to the normal area of velopharyngeal closure in the nasopharynx.
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects
upward and backward to contact the posterior pharyngeal wall
at or above the level of the palatal plane (Figure 7-5b). The
lateral pharyngeal walls move medially to contact the margins
of the soft palate at or slightly below the level of the torus
tubarius, and the posterior pharyngeal wall may move anteri­
orly to facilitate contact with the elevated soft palate. Complete,
or nearly complete, velopharyngeal closure is required for nor­
mal deglutition and the production of some speech sounds, such
as plosives. For other phonemes, such as vowels and nasal con­
sonants, the velopharyngeal port will be open in varying de­
grees.
Methods of Evaluations
Early investigations of the velopharyngeal mechanism cen­
tered upon anatomical dissection. The information gleaned from
these dissections was applied to the physiology of
velopharyngeal closure. These early investigators believed that
a simple elevation of the soft palate accounted for velopharyngeal
closure. Although Gustov Passavant in 1863 and 1869 described
a forward movement of the posterior pharyngeal wall, and the
medial movement of the lateral pharyngeal walls, in patients
with a cleft palate, his descriptions received little attention.
Previous Methods of Evaluation
Wardill28and Dorrance29were the first investigators to pro­
pose that normal velopharyngeal closure involved the synchro­
nous movement of selected portions of the pharyngeal muscu­
lature. Since that time, numerous methods have been devel­
oped to observe and assess the function and structures compris­
ing the velopharyngeal system. Among these investigations are
found aerodynamic and air flow studies30’313233; lateral and frontal
plane radiographic analyses3435; lateral, frontal, and base radio-
graphic analysis363738; spectrographic and coordination analy­
ses539; direct observation through large facial defects28,40; in­
strumentation for direct oral observation41; video fluoroscopic
and nasoendoscopic studies42,43,44; more recent anatomical dis­
sections45,46,47; electromyographic analysis48,49; and neurologi­
cal innervation50,51. These studies demonstrate that velopharyn­
geal closure is complex, especially when altered developmen-
tally, anatomically, physiologically, or neurologically.
Current Methods of Evaluation
Many current studies have employed the use of multiview
videofluoroscopy3738, nasal endoscopy42,43,52'53, and oral-nasal
airflow recording techniques54,55’56’57,58 to study the physiology
of the velopharyngeal complex during speech and non-speech
functions. Several studies have combined more than one of these
evaluation methods59,60. These methodologies are unique in that
the evaluation can be conducted with litde or no impact upon
291
a b
Fig. 7-5. a: Lateral cephalometric radiograph of the soft
palate at rest, b: Similar view with elevation and
closure of the soft palate against the posterior
pharyngeal wall. Closure is achieved with the
middle one-third of the soft palate.
the physiology of the region. These testing methods will be de­
scribed and their major contributions noted.
Multiview videofluoroscopy Skolnick and coworkers, in a se­
ries of classical studies, employed 3-dimensional video­
fluoroscopy to examine the velopharyngeal mechanism in the
frontal, sagittal, and base views simultaneously37,38,61,62. From
these recordings, they were able to trace the movements of the
soft palate, lateral pharyngeal walls, and the posterior pharyn­
geal wall from rest to complete closure during speech and non­
speech tasks (Figure 7-6). They confirmed that the character of
the velopharyngeal closure differs during speech, as compared
to swallowing and other non-speech functions37,40,63,64,65. This is
not surprising since swallowing is a primary physiological func­
tion62,66while speech is a learned function. In speech, only the
superior fibers of the superior constrictor muscle appear to be
involved during closure. In contrast to speech, the pharynx is
more forcefully involved in closure during swallowing40,64.
Shprintzen surmised that the superior, middle, and inferior con­
strictors fire in overlapping sequence during swallowing, and
that contact of the soft palate with the posterior and lateral pha­
ryngeal walls was more extensive and at a lower level than was
seen during speech62.
Walter studied velopharyngeal closure of 30 unoperated
cleft palate individuals with selectively placed pressure trans­
ducers and nasoendoscopy67. He noted that closure during swal­
lowing was sphincteric, with a lower and broader contact of the
velum with the posterior pharyngeal wall. Velopharyngeal clo-
292 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
ip
US
I 1 1 Velum
Base
a nasopharyngoscopy) is the second important diagnostic and
Fig. 7-6. a: Schematic view of a normal subject showing
sphincteric mechanism of velopharyngeal closure
from lateral, frontal, and base radiographic
projections. Dotted lines represent position of the
soft palate and pharyngeal walls at rest, and the
solid lines are the same structures during velopha­
ryngeal closure. (Redrawn from: Skolnick ML,
McCall GN, Barnes M. The sphincteric mechanism
of velopharyngeal closure. Cleft Palate J. 10:286;
1973). b: Tracings of frontal and lateral views for
normal subject during various activities requiring
velopharyngeal closure. Speech, whistling, and
blowing are often described as pneumatic activi­
ties, whereas swallowing and gagging are non­
pneumatic functions. Note variation in closure
patterns during various activities. (Redrawn from:
Sphrintzen RJ, Lencione RM, McCall GN, Skolnick
ML. A three-dimensional cinefluoroscopic analysis
of velopharyngeal closure during speech and
nonspeech activities. Cleft Palate J. 11:412;1974).
sure was also 5 to 15 times more forceful as compared to speech.
These studies confirm clinical and radiological observations that
some patients achieve velopharyngeal closure during swallow­
ing but inadequate closure may be evident during speech.
Skolnick and others noted in their videofluoroscopic stud­
ies that, while it was always sphincteric, closure occurred in 4
distinct patterns, depending upon the range of movement and
the manner of approximation of the soft palate with the lateral
and posterior pharyngeal walls38. These investigators delineated
these closure patterns as coronal, sagittal, circular, and circular
with Passavant’s ridge, based upon their appearance with base
view videofluoroscopy during closure.
Nasal endoscopy Nasal endoscopy (nasoendoscopy,
research tool that should be discussed52,53,68. The flexible nasal
endoscope has the advantage of visualization of the
velopharyngeal sphincter from above, in the nasopharynx, with­
out interference with the speech mechanism or exposing the
patient to radiation, as compared to video fluoroscopic tech­
niques. Because it does not disturb oral physiology, nasal endo­
scopy has largely supplanted the oral endoscope as a diagnostic
tool. With the aid of a local anesthetic, the flexible tube and tip
is inserted through the nostril, past the middle meatus, and into
the nasopharynx above the level of velopharyngeal closure. In
this position, the angle of the tip can be adjusted (through a
radius of 210°) in order to obtain the best view of this sphinc­
teric mechanism. The fiber optic cold light source provides suf­
ficient illumination for direct viewing and video recording dur­
ing speech (Figure 7-7).
It appears that multiview videofluoroscopy and naso­
endoscopy compliment each other59,60. Fluoroscopy is the choice
to delineate lateral wall motion, while nasal endoscopy is more
likely to note hypoplasia of the musculus uvulae, the position
and the contribution to closure of the adenoids, and gaps or
leakage around an obturator prosthesis57,69,70.
The value of nasoendoscopy is evident from a study by
Lewin of 131 patients with velopharyngeal insufficiency (VPI)
without cleft palate68. Twenty-nine of the 131 patients had pal­
ates that appeared normal, as viewed orally, both in appearance
and in the range of motion of the soft palate. These 29 patients
were classified as having congenital palatal insufficiency due
to a short soft and/or hard palate, with specific referral diagno­
sis (listed in Table 7-2). Twenty-six of the patients had under­
gone tonsillectomies and adenoidectomies. In 19 of the 26 pa­
tients, the symptoms became apparent after the operation while,
in 7 patients, the symptoms were preexisting and the tonsillec­
tomies and adenoidectomies were performed to correct the con­
dition. The subsequent nasal endoscopic evaluation in the clinic
revealed that, in all 29 patients, the correct diagnosis should
have been occult submucous cleft palate with nasal surface mid­
line gaps due to the absence or severe hypoplasia of the muscu-
 Speech, Velopharyngeal Function, and Restoration o fSoft Palate Defects 293

Fig. 7-7.
Nasoendoscopic view of attempted velopharyngeal closure of patient with
myasthenia gravis without and with palatal lift prosthesis, a: Velopharyngeal
mechanism at rest without prosthesis, b: Velopharyngeal mechanism during
attempted closure without prosthesis. Note space between soft palate and lateral
and posterior pharyngeal walls, c: Best attempt at closure without palatal lift
prosthesis, d: Velopharyngeal closure with palatal lift prosthesis. Note openings still
visible laterally, e: Complete velopharyngeal closure after modification of palatal lift
with the addition of an obturator bulb, as follows: at rest (1), during connected
speech (2), and complete closure (3). (Source: Esposito S. Speech and palato­
pharyngeal function. In: Proceedings of the 1st International Congress on Maxillo­
facial Prosthetics. Zlotolow I, Esposito S, Beumer J, eds. 1995.)

Table 7-2*. Referral Diagnosis.

lus uvulae muscle. Table 7-3 lists the specific gap size and the
Palatal paresis 10
associated severity of the hypemasality.
Congenital palatal insufficiency 9
Congenital short palate
Patterns o f closure Nasal endoscopy provides a perspec­
Idiopathic palatal insufficiency . 2
tive from above the velopharyngeal portal (Figure 7-7), which
Hysterial conversion reaction
has led to refinement of the 4 velopharyngeal closure patterns
29
initially described by Skolnick38 from base-view video­
fluoroscopy. For example, Siegel-Sadewitz and Shprintzen de­
Table7-3*. Velopharyngeal Insufficiency in 29 Patients with scribe the 4 closure patterns, as viewed with nasal endoscopy,
Occult Submucous Cleft Palate** as follows71 (Figure 7-8):
Gap Size Severity of Hypernasality
• Coronal Pattern The majority of the valving is palatal
and accomplished by the full width of the soft palate con­
Gross gap 3 Severe 9
tacting the posterior wall. The lateral walls exhibit limited
Large Central gap 4 Moderate 9 movement to contact the lateral margins of the velum. There
(More than 4 mm) is no posterior pharyngeal wall movement.
• Sagittal Pattern The majority of the valving is pharyn­
Small central gap 22 Mild 11
geal. The lateral walls move extensively to the midline and
(4 mm or less)
approximate each other. The velum does not contact the
posterior pharyngeal wall but elevates to contact the ap­
A total of 18 males and 11 females. Aging from
proximated lateral phaiyngeal walls. The posterior pharyn­
4 to 36 years, with an average of 9 years.
geal wall does not contribute to closure.
* Source: Lewin ML, Croft CB, Shprintzen RJ. Velopharyn­ • Circular pattern There is essentially equal participation
geal insufficiency due to hypoplasia of the mucu- from the soft palate and the lateral pharyngeal walls, with
lus uvulae and occult submucous cleft palate. the contracting musculus uvulae acting as a focal point.
Plast Reconstr Surg. 65:585;1980). The lateral walls contact the musculus uvulae as it con­
294 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
tracts and contacts the non-mobile posterior pharyngeal
wall.
• Circular Pattern with Passavant’s ridge The same pat­
tern as circular closure, except that the posterior pharyn­
geal wall (Passavant’s ridge) moves forward to complete
the closure pattern around the musculus uvulae posteri­
orly.
VELOPHARYNGEAL CLOSURE
PATTERNS
Passavant's ridge
Fig. 7-8. Artist’s representation of 4 patterns of velopharyn­
geal valving. See text for description. (Redrawn
from: Siegel-Sadewitz VL, Shprintzen RJ. Naso-
pharyngoscopy of the normal velopharyngeal
sphincter: an experiment of biofeedback. Cleft
Palate J. 19:194;1982).
How often do these 4 individual closure patterns occur?
Two studies have addressed this question. Croft used both
multiview videofluoroscopic and nasoendoscopic examinations
to study 80 patients with normal speech and 500 patients with
VPI52. The VPI group included 360 patients with repaired cleft
palate and 140 patients with unrepaired submucous clefts of the
palate. The results are listed in Table 7-4. Witzel and Posnick
reviewed 246 consecutive nasopharyngoscopy studies of pa­
tients with VPI53. The types of closure are listed in Table 7-5.
Gaps were found in 181 patients. Of these, 121 were consid­
ered centrally located and due to hyperplasia of the musculus
uvulae. The other gaps were variable and sometimes attributed
to the shape of the adenoids, or to the anatomy or function of
the posterior border of the soft palate. In both studies, the most
common pattern of closure was coronal. Witzel and Posnick
found proportionally more atypical valving associated with a
coronal pattern of closure72.
What determines the pattern of closure? Croft hypothesized
that the type of pattern in the normal population is influenced
by many factors, such as learning capability and slight anatomi­
cal variations52. Are we able to change with surgery our closure
pattern to compensate for anatomical changes to a portion of
the velopharyngeal complex? Some authors believe that the
development of Passavant’s ridge should be classified as a com­
pensatory mechanism developed by some patients due to
ypj73,74,75 Warren felt that Passavant’s ridge may be an airway
response to the loss of nasal pathway resistance, including
velopharyngeal dysfunction57.
Since Passavant’s ridge is only associated with a circular
closing pattern, are we able to change from a coronal or sagittal
pattern to a circular pattern if the need arises? These and other
related questions are impossible to answer at the present time,
but 2 interesting studies seem apropos to this speculative dis­
cussion. Siegel-Sadewitz and Shprintzen explored the possibil­
ity of using biofeedback to see if a normal subject (the first
author) could change her closure pattern71. The examinations
were performed so the subject could see a video monitor and
her circular pattern. During the course of 6 20-minute biofeed­
back sessions, the subject was able to change from a circular to
a sagittal pattern and use both patterns interchangeably in con­
tinuous speech without the aid of the monitor. Witzel used a
biofeedback-monitoring technique during speech therapy for 3
adult, cleft palate patients53. All 3 subjects had recently under­
gone a pharyngeal flap surgical procedure, but residual
hypemasality and articulation errors remained. With the com­
bination of biofeedback and speech therapy, 2 patients devel­
oped normal speech while the third demonstrated marked im­
provement. The authors caution, however, that this biofeedback
technique is expensive and does require both patient motiva­
tion and compliance.
Pressureflow studies The third noteworthy methodology for
evaluating patients with various velopharyngeal dysfunctions
was developed by Warren and coworkers at the University of
North Carolina14,58,76*77,78. While this methodology has been use­
ful as a diagnostic aid, the primary contribution of these pres­
sure flow studies has been in our understanding of the physiol­
ogy ofthe speech complex. These aerodynamic studies are based
on a modification of a theoretical hydraulic principle, which
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects 295

Table7-4. Individual Closure Patterns of 80 Normal and 500 ryngeal deficiencies have the capability of doubling their respi­
VPI Subjects. ratory volume, depending upon the degree of velopharyngeal
incompetence and the amount of resistance to airflow within
Pattern Normal Pathologic
the nasal cavity57. Oral pressure above 3 cmH^O were consid­
Coronal 55% (44) ' 45%(225)
ered adequate to provide the aerodynamic capability for plosive
Sagittal 16% (13) i1;%: (55)
and fricative phonemes. In studying 267 cleft palate subjects
Circular ' I :'':" ; ' ;;;v'; ' ; ; 10% (8)S 0 % p O O ) '
with various levels of speech proficiency, Dalston76found that
Circular with Passavant’s ridge .19% (1.5)... 2^%(120)
MUM 87% of these patients were able to produce pressures greater
than 3 cmH20 . This adaptive capacity occurred even though
Source: Croft CB, Shprintzen RJ, Rakoff SJ. Patterns of
speech was considered borderline or inadequate in 86 of these
velopharyngeal valving in normal and cleft palate
patients. Warren suggested that this adaptation may be a regula­
subjects: a multiview videofluoroscopic and
tion or control phenomenon and thus may have both beneficial
nasoendoscopic study. Laryngoscope. 91:265;
and adverse effects57. For example, an increase in oral pressure
1981.
along with velopharyngeal inadequacy may improve articula­
tion, but nasal airflow is increased, which, in turn, may increase
the perceived level of nasality.
Table 7-5. Patterns of VP Valving in Patients with Complete
VP Closure or VPI.
Nasal resistance We now know that the resistance to na­
sal airflow may contribute to increased oral pressure and, con­
VP Closure VPI Total
sequently, improve the effectiveness of speech for patients with
Pattern N % N m N %
larger velopharyngeal orifices. It is the sum of the resistance
Coronal; I 45 69 122 r 67 167 68 provided by the velopharyngeal mechanism, nasal resistance,
Circular 15 23 42 57 23 and the increase in respiratory effort that determines the oral
C ircular w ith pressure available for effective speech articulation.
Passavant’s ridge 3 5 10 6 13 5 An analog model was used by Warren and Ryon which
Sagittal 2. 3 .-.7 „ 4 9 4 demonstrated that, even in the slight to moderate range of
velopharyngeal incompetence (0.2 to 0.4 cm2), nasal resistance
Source: Witzel MA, Posnick JC. Patterns and locations of can account for as much as 30% to 90% of the recorded oral
velopharyngeal valving problems: atypical findings pressure amplitude31. Warren compared the difference in nasal
on video nasopharyngoscopy. Cleft Palate J. resistance to air flow of 25 cleft lip and/or cleft palate patients
26:63;1989. with a normal control group32. They concluded that the cleft
group had significantly greater nasal resistance to air flow. Re­
sistance within the nasal cavity may be created by maxillary
was first reported in 1964 by Warren and Dubois79. It assumes surgery for neoplastic disease or cleft lip and cleft palate repair,
that the smallest cross-sectional area of a structure can be deter­ enlarged turbinates, vomerine spurs, atresia of the nostrils, or
mined if the differential pressure across the structure is mea­ deviation of the septum. Clefts of the lip and palate produce
sured simultaneously with the rate of airflow through it. This deformities that tend to reduce the size and patency of the nasal
principle has been verified by other, independent investigators80,81. airway85. Interestingly, patients with repaired bilateral cleft lips
Prior to this body of research, we knew that complete sepa­ and palates have larger airways, less nasal resistance, and, con­
ration of the oral and nasal cavities was not essential for accept­ sequently, less effective speech articulation, as compared with
able speech82,83,84. We also knew that the degree of inadequacy, patients with unilateral cleft lips and palates86. Therefore, a nose
and the severity of the resultant speech disorder, does not ap­ that is “good” for breathing may be “bad” for speech under
pear to be linear15,54. Pressure flow studies have provided some these circumstances.
insight into these complex interrelationships.
Nasal valve Laine introduced die concept of the nasal
Velopharyngeal orifice size Warren, using these hydrau­ valve78. Hie valve is considered the area between the upper and
lic principles to compute velopharyngeal orifice size, found that lower lateral cartilages, the pyriform aperture, and the anterior
this opening should be less than 0.2 cm2during the production terminus of the inferior turbinates. In physiologic terms, the
of plosive and fricative sounds30. If the velopharyngeal opening nasal valve is considered as the regulator, with the smallest cross-
is greater than 0.2 cm2, the respiratory effort must be increased sectional area within the nasal cavity based on anatomical and
to compensate for velopharyngeal inadequacy and provide im­ flow-resistive characteristics. Laine used pressure flow studies
proved oral pressure for speech5637,76. Individuals with velopha­ to measure the cross-sectional area of the nasal valve during
296 MAXILLOFACIAL REHABILITATION: PROSTHODONI1C & SURGICAL CONSIDERATIONS
both inspiration and expiration78. The nasal valve dilates during
inspiration, and both active and passive flattening occurs dur­
ing expiration. The mean area of the nasal valve was 0.63 cm2±
0.17 cm2during inspiration and 0.56 cm2± 0.14 cm2during ex­
piration, which was significant (< 0.01). Therefore, these au­
thors concluded that the nasal airway is an active participant in
the breathing process rather than a passive conduit for airflow.
The nasal valve concept may explain the reason for facial
grimaces. Clinically, we observe facial grimaces associated with
some surgically repaired cleft lip and cleft palate patients, who
exhibit hypemasality during speech production. Facial grimaces
may be a physiologic adaptive process used to enhance the brak­
ing potential of the nasal valve to improve intraoral pressure for
speech58. The aerodigestive tract contains a number of valves or
restrictive braking mechanisms, such as the larynx,
velopharyngeal mechanism, tongue-oral approximations, and
the lips, which prolong expiration and, in turn, enhance speech
and the interchange of gases in the lungs. It appears the nasal
value should be added to this list.
A recent preliminary study by Dalston disclosed the rela­
tionship between the patency of the nasal airway and articula­
tion capabilities86. These investigators noticed that children with
bilateral cleft lip and palate were nearly twice as likely to ex­
hibit compensatory articulation errors as similarly aged chil­
dren with either unilateral cleft lip and palate, or cleft palate
only. When subjects were grouped according to speech perfor­
mance, pressure airflow evaluations suggested that children with
compensatory articulation patterns had significantly larger na­
sal cross-sectional areas, as compared with children without
compensatory articulation. These larger airways were more
likely to occur with children with bilateral cleft lip and palate.
This reduced level of nasal resistance was not as effective in
improving oral pressure for articulation.
Oral versus nasal breathing Restrictions within the nasal
cavity may lead to oral rather than nasal breathing in repaired
cleft lip and cleft palate patients56. The average cross-sectional
area of the nasal valve of non-cleft patients during inspiration
was 0.63 cm2± 0.17 cm2, as previously mentioned58. Warren, in
a study of 50 randomly selected cleft palate patients, found the
average nasal valve area was reduced to 0.38 cm2, and these
individuals were predominantly oral breathers56. Warren and
coworkers felt that individuals with nasal valve areas less than
0.40 cm2 should be considered to have impaired nasal airways,
and they will be predominately oral breathers with the potential
to alter the dentofacial complex87,88. Minsley cautioned that we
must consider the patency of the nasal airway in fabricating
obturators for cleft palate patients14. They measured the nasal
cross-sectional area of 8 cleft palate patients with obturatorpros­
theses. Four of these patients had nasal airways that measured
less than 0.40 cm2with their prosthesis, and thus they were clas­
sified as mandatory oral breathers.
Perci (Palatal efficiency rating computed instantly), Microtronics Corp., Carrboro, NC.
Timing o f velopharyngeal closure The timing of velo­
pharyngeal closure, in relationship to the phoneme being ar­
ticulated, has been studied using pressure flow techniques54. In
this study, the experimental group included 10 normal subjects,
20 patients with cleft palate with adequate velopharyngeal clo­
sure (0.0 through 0.09 cm2), 20 patients with borderline closure
(0.10 through 0.19 cm2), and 20 patients with inadequate clo­
sure (>0.19 cm2). The word hamper was used in this and in
most of these pressure airflow studies conducted by Warren and
colleagues. The nasal-plosive blend, “mp”, in hamper, tests the
velopharyngeal complex during an open-to-closed maneuver.
The isthmus must be open for the nasal phoneme, “m”, and
closed for the stop plosive, “p”. Airflow and pressure curves
were recorded simultaneously. This permitted these investiga­
tors to note the timing of closure to prepare for the articulation
of “p” and the amount of nasal airflow or perceived nasality
during the formulation of “p”. Thus, the timing errors noted in
this study seemed to compound the problems known to be as­
sociated with velopharyngeal inadequacy.
In a further study, 209 non-cleft adults with normal speech
and 26 adults with repaired cleft palates and normal speech were
studied aerodynamically77. While subjects in both groups
achieved velopharyngeal closure, the cleft group produced
speech with significantly less nasal airflow. In addition, the in­
traoral pressure curve shifted forward, indicating that certain
compensatory adjustments may be necessary for the cleft group
to produce closure due to differences in potential movement of
the velopharyngeal complex.
As previously mentioned, there is not a direct linear rela­
tionship between velopharyngeal orifice size and the level of
perceived nasality. This is understandable when you consider
the number of variables, including nasal resistance and timing,
that can impact on the aerodynamic characteristics of the speech
mechanism.
Prosthesis evaluation Unfortunately, the 3 speech evalu­
ation methods we have discussed (i.e. multiview video­
fluoroscopy, nasal endoscopy, and pressure airflow aerodynamic
assessment equipment) are usually found only in the more es­
tablished craniofacial rehabilitation centers, where a prosthodon­
tist and speech pathologist are included among the professional
staff. Rarely would a prosthodontist or a speech pathologist have
this equipment in the private sector. However, the nasal endo­
scope and the pressure airflow monitoring equipment*89, with
completely computerized, instantaneous results, are available
commercially. The nasal endoscope with a flexible tip has sup­
planted the oral endoscope for reasons previously mentioned.
Both nasal endoscopy and/or pressure airflow equipment
have been used as an aid during prosthetic treatment (Figure 7-
7). Berry discussed the use of an oral endoscope during
prosthodontic treatment90, while Kamell69, Walter67, and Turner
and Williams70 employed nasal videoendoscopy for the same
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects § 297

purpose. La Velle and Hardy91, Reisberg and Smith92, and head position results in a deeper nasopharynx than when the
Minsley14used oral-nasal airflow data to compute the velopha­ head is held in the Frankfort plane97. McWilliams, in a radio-
ryngeal orifice and nasal valve areas as guidelines during obtu­ graphic study of 101 children with repaired cleft palates, found
rator fabrication and adjustment. Riski demonstrated the ad­ that the inferior to superior length of contact of the soft palate
vantages of employing both pressure flow and nasal endoscopic with the posterior pharyngeal wall was reduced significantly
assessments in the successful revision of existing obturator pros­ when the head was in an extended position98(Figure 7-10).
theses93. These evaluations revealed that the obturator for one The pattern of soft palate movement varies between men
patient required sequential additions, while the speech of a sec­ and women99. This study disclosed that the soft palate was longer,
ond patient was judged to be hyponasal, which required sequen­ the elevation was greater, the amount of contact with the poste­
tial reduction of the obturator laterally to enhance nasal airflow rior pharyngeal was less, and the inferior point of contact with
and subsequent speech improvement. Wolfaardt monitored 32 the posterior pharyngeal wall was consistently higher in men
patients with palatal lift prostheses prior to, during, and-after than in women (Figure 7-11).
treatment using nasoendoscopy, pressure flow equipment, and
a Nasometer* (an instrument used to evaluate the perceived oral-
nasal resonance balance)94. With continued monitoring using
this equipment, these investigators were able to eliminate the
lift prosthesis for 14 patients by reassuring them that they had
now developed the aerodynamic capabilities for normal speech
without the need for their lift prosthesis. Hopefully, as these
technologies become more widely available, information will
emeige to improve the effectiveness of obturator prostheses.

Anatomy and Physiology

Fig. 7-9.
The anatomy and physiology of the velopharyngeal mecha­
nism will be described by dividing the descriptions into the fol­
lowing anatomical components; namely, the soft palate, the
posterior pharyngeal wall, and the lateral pharyngeal walls. The
reader must realize that this is an arbitrary division for descrip­
tive purposes, and that closure is usually achieved with syn­
chronous and sphincteric movements of this entire muscular
complex.
a: Five-year-old child. Closure is obtained with a
superior-inferior movement of soft palate at a level
below the palatal plane, b: Eighteen-year-old in­
dividual. At this age, velopharyngeal closure is
characteristically above palatal plane, with an an-
terior-posterior movement of the soft palate. (Re­
drawn from: Aram A, Subtelny JD. Velopharyngeal
function and cleft palate prostheses. J Prosthet
Dent. 9:149;1959.)

Soft Palate

Position and movement The position and movement of the

soft palate, in relation to the pharynx, changes with age95,96. At
birth and shortly thereafter, the soft palate at rest is roughly
parallel to the roof of the pharynx so that the upper nasophar­
ynx is only a narrow slot. Closure of the velopharyngeal mecha­
nism is accomplished by essentially a superior-inferior move­
ment of the soft palate. As growth occurs in the pharyngeal
area, and as the adenoidal tissues regress, the movement of the a b
soft palate takes on the characteristic anterior-posterior eleva­
tion displayed by most adults. When the adenoidal tissues are Fig. 7-10. a: Tracings from televex tapes demonstrating a
removed, the soft palate shifts to an anterior-posterior move­ patient with a repaired cleft palate achieving
ment very abruptly95. Velopharyngeal closure is slightly below velopharyngeal closure in upright position but not
the level of the palatal plane up to 8 years of age, and is consis­ in extension, b: Nasopharynx is deepened with
tently above the level of the palatal plane thereafter95’96 (Figure extended head p o sitio n . (Redrawn from :
7-9). McWilliams BJ, Musgrave RH, Crozier PA. The
The extent of the closure of the soft palate with the poste­ influence of head position upon velopharyngeal
rior pharyngeal wall varies with head position. An extended closure. Cleft Palate J. 5:117;1968).

Nasometer Model 6200, Kay Elemetrics Corp., Pine Brook, NJ.

298 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 7-11. “Squared off” female (a) and “acute” male soft
palate configurations (b). Broken lines indicate the
position of the soft palate at rest. Arrows delin­
eate directions of movement. (Redrawn from:
McKerns D, Bzoch KR. V ariations in ve lo ­
pharyngeal valving: the factor of sex. Cleft Palate
J. 7:652;1970).
Velar eminence and musculus uvulae While the entire soft
palate increases in length during closure63100, the posterior two-
thirds demonstrates a greater degree of lengthening and signifi­
cant thickening101. Several investigators noted a central longi­
tudinal thickening or elevation of the nasal surface of the soft
palate that was termed the velar eminence40>42-43’102. Pigott, in his
nasoendoscopic observations of 25 normal subjects, describes
the velar eminence as a large ridge occupying the central one-
third of the nasal surface of the soft palate and rising to a height
almost equal to its width42. He felt that the velar eminence was
an essential component of velopharyngeal closure.
Croft confirmed these observations102. These investigators
examined 20 patients, from 4 to 36 years of age, who demon­
strated hypemasal speech, small central gaps on velopharyngeal
closure (as determined from multiview videofluoroscopy), and
normal palatal morphology on oral examination. This triad of
conditions is delineated as occult submucous cleft palate (see
Chapter 8). These patients were reexamined, using direct view
nasoendoscopy during speech production. This examination
confirmed the presence of central gaps along the nasal surface
associated with the lack of a velar eminence in all 20 patients.
We now realize that the musculus uvulae is responsible for
the velar eminence, contributes to velar stretch, and is essential
for normal velopharyngeal closure102103,104. This paired muscle
is the only intrinsic muscle of the soft palate. Because it lacks
an attachment outside the velum, its contribution to
velopharyngeal closure was considered minimal. However, its
importance may be related more to its size and position than to
its physiological contribution. Each of the 2 bundles of the
musculus uvulae has its origin from the tendinous palatal apo­
neurosis, which is posterior to the hard palate and anterior to
the insertion of the levator veli palatini muscle. The bundles
converge above and at right angles to the sling of the levator
veli palatini, and redivide and insert into the basement mem­
brane and connective tissue of the uvula. The bulk of the uvula
consists of glandular tissue interspersed with muscle fibers103.
Using electromyography (EMG), Kuehn and others stud­
ied 3 normal adults104. They found that the EMG activity of the
levator veli palatini and the musculus uvulae were synchronous
during speech for all 3 subjects, but this synergistic activity was
not always present for non-speech activities. Thus, the levator
supplies the force with contraction and elevates the soft palate.
At the same time, the musculus uvulae contract to fill the cen­
tral gap between the soft palate, the lateral pharyngeal walls,
and the posterior pharyngeal wall along the central one-third of
the nasal surface of the soft palate. The contraction of the mus­
culus uvulae is considered essential for those individuals hav­
ing any circular pattern of closure71.
While the entire soft palate increases in length during clo­
sure63,100,105, the central and posterior portions demonstrate a pro­
portionally greater degree of lengthening along with thicken­
ing. This lengthening during closure has been termed velar
stretch. Simpson and Austin reported a 20.6% increase in length
or stretch from rest to the production of the “s” sound in normal
adult subjects101. The amount of velar stretch seems related to
the task and/or anatomical or functional variables associated
with the structures involved in closure105. These authors devel­
oped a “need ratio” by dividing the pharyngeal depth (posterior
nasal spine to the posterior pharyngeal wall) by the velar length
(posterior nasal spine to the tip of the uvula along the nasal
surface) at rest, as measured from lateral cephalometric x-rays.
Larger need ratios indicated the need for greater velar stretch in
order to achieve closure. Neiman and Simpson studied children
with normal speech with lateral cephalometric X-rays prior to
and following adenoidectomies106. Since the soft palate could
no longer close against the protruding adenoidal pads, velar
stretch increased from 12.7% to 27.8% postsurgically in order
to maintain normal closure patterns.
Histology Kuehn and Kahane, studying the soft palates of 10
normal human adult cadavers, found some interesting correla­
tions at the cellular level107. The soft palates were resected and
divided equally into 10 sections anterior-posteriorly, and 300
representative slides were prepared and examined histologically.
The nasal mucosa consisted of typical pseudostratified, ciliated
columnar epithelium anteriorly, but consisted of stratified squa­
mous epithelium posteriorly. This more posterior mucosa ap­
peared to be well-supplied with underlying mucous glands. Since
the nasal mucosal surface contacting the posterior pharyngeal
wall was lined with stratified squamous epithelium, it seems
well-adapted for the stress of repeated closures. The oral mu­
cosa surface of the soft palate consisted of stratified squamous
epithelium, with a basement membrane well-endowed with a
dense meshwork of elastic fibers. The underlying seromucous
glands serve to lubricate the bolus, while the large deposits of
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects
adipose tissue, located laterally, primarily provide protection
from the pressure generated during propulsion of the bolus.
Levator veli palatini and other muscles While opinions re­
garding the specific muscles responsible for lateral and poste­
rior pharyngeal wall movements are almost as numerous as the
authors who discuss them, there is general agreement that the
levator veli palatini muscles are responsible for palatal eleva­
tion65. Recent evidence suggest that the tensor veli palatini con­
tributes little to the form and function of the soft palate, and that
its primary function is dilation of the Eustachian tubes45108.
While the levator veli palatini muscles supply the force for
palatal elevation, the finite positioning of the soft palate may be
under the control of several other muscles acting in a reciprocal
manner with the levator. Kuehn studied the relationship between
muscle activity and velar position in 5 normal subjects109.
Hooked-wire electrodes were placed transnasally in the levator
veli palatini, palatoglossus, palatopharyngeus, and the superior
constrictor muscles, and their electromyographic activity was
measured during speech. A consistent interaction was observed
between the levator, the palatoglossus, and the palatopharyn­
geus. If the levator contracted forcefully, the palatoglossus and
the palatopharyngeus also contracted forcefully. The reverse
scenario was also true. The palatoglossus and the palatopha­
ryngeus create a downward pull on the soft palate and oppose
the upward contraction of the levator. Therefore, the levator
must contract more forcefully if the palatoglossus and/or
palatopharyngeus contract forcefully. The important function
of the palatoglossus and palatopharyngeus in speech is to aid in
positioning the tongue and pharynx. If the palatoglossus con­
tracts to aid in tongue elevation and/or the palatopharyngeus
contracts to restrict the pharynx, the levator veli palatini must
increase its contraction force proportionally to achieve the de­
sired velar elevation. Thus, there is a reciprocal relationship
between the 3 muscles in positioning the soft palate and the
tongue.
Kuehn found the level of electromyographic activity in the
superior constrictor to be inconsistent and variable, and not in
harmony with the activity level of the other 3 muscles109. It was
observed that speech segments requiring essentially complete
velopharyngeal closure could be produced with dramatically
different levels of electromyographic activity from the superior
constrictor among the 5 subjects. While activity was found in
all subjects during velar elevation, the specific role of the supe­
rior constrictor needs further investigation. Since the most su­
perior fibers of the superior constrictor insert into the soft pal­
ate110, Kuehn speculated that these muscle fibers may assist the
musculus uvulae to draw or stretch the velum posteriorly109.
These reciprocal muscular relationships help to explain the
interrelationship between tongue position (or velopharyngeal
closure) and speech. Tongue posture and movement may differ
with velopharyngeal incompetence or insufficiency. These pa­
299
tients often have a more posterior and superior tongue position
during speech64’11¥ 12,113!U*n5’U%Warren felt that a high tongue
carriage would increase vocal tract resistance for patients with
a velopharyngeal deficiency57. These investigators felt that this
compensatory tongue posture assisted with soft palate eleva­
tion, but also contributed to the faulty articulation reported for
these patients. For example, the tongue contacted the soft pal­
ate during speech in 13 of 28 cleft palate patients, whereas, in a
matched control group of normal patients, this contact was not
observed114. Kuehn studied the timing and speed ofpalatal move­
ments relative to articulatory activity with cineradiography, re­
porting that soft palate movements were generally slower than
tongue movements117.
Posterior Pharyngeal Wall
In 1863 and 1869, GustofPassavant described a horizontal
“cross roll” on the posterior pharyngeal wall which occurred
during speech and swallowing in cleft palate patients118. This
forward bulging, corresponding to the level of the atlas, has
been termed Passavant’s ridge or pad. This cross roll may vary
from a slight forward bulging of the posterior pharyngeal wall
to a very distinct roll extending horizontally across the poste­
rior pharyngeal wall to blend with the mediolateral movement
of the lateral pharyngeal walls. In its prominent form, Passavant’s
pad may extend forward and superiorly as much as 5 mm in
both directions. Passavant’s ridge serves as a guide for proper
placement of the soft palate obturator prosthesis (Figure 7-12).
Fig. 7-12.
a: Patient with
unrepaired cleft
palate dem on­
strating a defini­
tive Passavant’s
pad (arrow).
Molding obtura­
tor prosthesis is
in progress, b:
Patient following
total soft palate
resection for
squamous cell
carcinoma dem­
onstrating Pas­
savant’s pad (ar­
row).
300 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
The relative importance of any forward movement of the
posteriorpharyngeal wall, and its contribution to velopharyngeal
closure, is subject to debate among many knowledgeable in­
vestigators. There are several reasons for this controversy. For
example, most normal speakers do not exhibit any detectable
forward movement of the posterior pharyngeal wall during
velopharyngeal closure52,63. However, with velopharyngeal in­
competence or insufficiency, the degree of posterior wall move­
ment and/or Passavant’s ridge is more likely to be ob­
served38,52,74’118’119and may thus be compensatory in nature74. Yet,
many individuals with obvious hypemasal speech patterns and
observable velopharyngeal deficiencies do not exhibit any com­
pensatory forward movement of the posterior pharyngeal wall
during attempts at velopharyngeal closure.
While the degree of movement, if movement is present, of
the posterior pharyngeal wall is limited in extent in comparison
to the range of movement demonstrated by the soft palate and
the lateral pharyngeal walls, any movement of these structures
lateral and peripheral to the soft palate, and functioning in con­
cert with the velum during closure, is important. Both the surgi­
cal prognosis for a pharyngeal flap procedure and the prosthetic
prognosis for an obturator prosthesis are enhanced with any
movement of the posterior or lateral pharyngeal walls74,120. In
part, it is this peripheral movement that permits the patient to
control airflow and the degree of nasal resonance by the re­
quired intermittent approximation of these structures with the
pharyngeal flap or.obturator prosthesis.
The incidence of Passavant’s ridge has been reported by
several investigators. Calnan found that 32% of 105 patients
with inadequate velopharyngeal closure displayed considerable
forward movement of the posterior pharyngeal wall118. Nylen
reported that Passavant’s pad was present in 11 out of 27 cleft
palate patients with hypemasality119. Skolnick reported that 17
out of 62 patients with inadequate velopharyngeal closure dis­
played evidence of Passavant’s pad, whereas 1 out of 23 nor­
mal patients showed similar movement38. Croft examined 500
cleft palate patients with videofluoroscopic and nasoendoscopic
examinations, finding Passavant’s pad present in 24% of this
group52. This is in comparison to 17% of 80 normal subjects, as
determined by the same examination process. Casey and Ernrich
examined 29 patients with an oral panendoscope following re­
section of varying amounts of the posterior soft palate for oral
cancer74. They found that Passavant’s ridge was present in 83%
of these patients postsurgically.
To what extent does Passavant’s ridge contribute to
velopharyngeal closure? This point is debatable. Calnan reported
that Passavant’s ridge varied in location, tended to be located
below the level of palatal closure, contracted slowly and in an
uncoordinated manner, and tended to fatigue easily118. He con­
cluded that it contributed little to velopharyngeal closure. How­
ever, Carpenter and Morris selected 6 patients who exhibited
hypemasality and a detectable Passavant’s ridge73. Cinefluoro-
graphic films demonstrated that in 4 of 6 patients, Passavant’s
ridge was located at or above the level of the palatal plane (the
level of normal closure as suggested by Calnan), contributed to
closure during speech, and did not fatigue with sustained dis­
course.
Is the presence of Passavant’s ridge primarily a compensa­
tory mechanism due to altered velopharyngeal function? Glaser
studied 43 patients with a discernible Passavant’s ridge, using
multiview videofluoroscopy in conjunction with simultaneous
speech recordings121. These investigators found that Passavant’s
ridge corresponded to the level of normal velopharyngeal clo­
sure 88% of the time, while, in 12% of the patients, the ridge
was located too low for closure. In 37% of these cases, it was
the primary structure that closed, or locally narrowed, the
velopharyngeal portal. They observed that Passavant’s ridge was
most prominent with active lateral pharyngeal wall motion and
consistendy synchronous with velar movements.
Walter found that Passavant’s ridge was present in 10% of
normal speakers and 57% of unrepaired cleft palate subjects67,122.
He felt that evidence was lacking to suggest that the presence of
this entity was a compensatory factor associated with cleft pal­
ate. Walter felt that Passavant’s ridge was more likely a feature
of a syndrome due to altered muscle attachment and function.
Warren speculated that Passavant’s ridge may be a compensa­
tory response to inadequate velopharyngeal closure, or to re­
duced nasal resistance to airflow during speech57.
Casey and Emrich examined 29 consecutively seen partial
and total soft palatectomy patients with an oral panendoscope
following surgical resections for oral carcinoma74. Twelve of
the patients had total palatectomies while 17 had partial soft
palate resections. They found that 24 of the 29 patients (83%)
demonstrated a Passavant’s ridge. This study by Casey and
Emrich confirms the authors’ clinical impression that the evi­
dence of Passasvant’s ridge may be higher in patients with ac­
quired soft palate defects, as compared to patients with surgi-
cally-repaired cleft palates. Most postsurgical cancer patients
will have a detectable Passavant’s ridge if the posterior pharyn­
geal wall is not altered during the surgical resection; this for­
ward movement improves the prosthetic prognosis consider­
ably.
Isberg and Henningsson examined 80 patients with
hypernasal speech for Passavant’s ridge by means of
videofluoroscopy and nasoendoscopy75. The patients were di­
vided into 3 groups based upon a diagnosis of repaired cleft
palate, submucous or occult submucous cleft palates, or
velopharyngeal disproportion. Twenty-four of the 80 hypemasal
patients exhibited a Passavant’s ridge, and the incidence was
divided evenly among the 3 diagnostic groups. They found that
the ridge tended to disappear when complete velopharyngeal
closure was accomplished. Therefore, they felt that Passavant’s
ridge was compensatory in nature and did contribute to
velopharyngeal closure. Shprintzen, in his commentary on this
 Speech, Velopharyngeal Function, and Restoration o fSoft Palate Defects
paper, disagreed123. He felt that the presence or absence of
Passavant’s ridge was related to other factors, such as the method
of closure exhibited by the patient.
Passavant’s ridge is associated only with a circular pattern
of closure (Figure 7-13). As delineated in Table 7-4, Croft, us­
ing a nasal endoscope, studied 80 patients with normal closure
and 500 patients with VPI52. Nineteen percent of the normal
group exhibited a circular closure pattern with a Passavant’s
ridge, whereas 24% of the VPI group displayed the same con­
figuration. These investigators found the circular closure pat­
tern was more common with a discernible Passavant’s ridge
than without it In contrast, Witzel and Posnick reported that
23% of both the 64 normal and the 179 VPI patients examined
with a nasal endoscope had a circular closure pattern without a
visible Passavant’s ridge, as compared to approximately 5% of
both groups with a circular pattern and ridge53.
.
o o
Fig. 7-13. Various closure patterns in base projection. Left
column represents contour of the velopharyngeal
portal at rest, middle column shows partial clo­
sure, and the right column shows full closure, a:
Normal subject. Note the convex projection of
uvula portion of the soft palate into the velopharyn­
geal portal at rest, b: Repaired cleft palate sub­
ject. Note absence of uvula muscular bulge at rest,
c: Repaired cleft palate with circular closure pat­
tern. d: Repaired cleft palate with circular closure
pattern and Passavant’s pad (shaded area), e:
Repaired deft palate with sagittal closure pattern.
(Redrawn from: Skolnick ML, McCall GN, Barnes
M. The sphincteric mechanism of velopharyngeal
closure. Cleft Palate J. 10:286;1973).
301
Unanswered questions remain: Why do some patients with
VPI and a circular closure pattern have the capacity to develop
Passavant’s ridge while other VPI patients with the same clo­
sure pattern do not? Do some patients with VPI, such as pa­
tients with recent surgical resections of the soft palate for can­
cer, have the adaptive capacity to change to a circular closure
pattern and thus have the potential to develop Passavant’s ridge?
Hopefully, future research will answer these questions.
What muscles are responsible for posterior pharyngeal wall
movement? This point, also, is debatable. The lateral and pos­
terior walls of the oropharynx and nasopharynx are composed
of muscle fibers of the fan-shaped superior constrictor muscle.
The superior constrictor muscle has its origin along the ptery­
gomandibular raphae and the tuberosity of the maxilla, and its
fibers course posteriorly and horizontally to insert and anasto­
mose with its counterpart into the aponeurosis in the midline of
the posterior pharyngeal wall of both the oropharynx and na­
sopharynx. The anatomical components of Passavant’s ridge
have been debated, since fibers of the pharyngopalatinus muscle
were found to intermingle with those of the superior constric­
tor. Calnan speculated that it was the pharyngopalatinus that
comprised Passavant’s ridge11S. Others believe that fibers of the
superior constrictor form this unusual configuration, and they
are responsible for the anterior movement displayed by the pos­
terior pharyngeal wall73.
The Lateral Pharyngeal Walls
We now accept the fact that lateral pharyngeal wall move­
ment is essential if normal speech is to be achieved with either
prosthetic obturation or surgical reconstruction. Lateral pharyn­
geal wall motion is difficult to assess because the drape of the
soft palate precludes direct oral observation, and lateral radio-
graphic projections will not disclose lateral pharyngeal wall mo­
tion unless the head is extended posteriorly with the patient in a
supine position124.
Lateral pharyngeal wall motion requires different methods
of evaluation. Bloomer observed and photographed the
velopharyngeal mechanism of 2 patients through large facial
defects40. He traced lateral wall movements during speech and
swallowing from motion picture films and concluded that lat­
eral wall movements were an essential component of closure.
Kelsey studied 67 cleft palate patients with inadequate
velopharyngeal closure during speech125. These patients were
tested with an ultrasound apparatus, permitting monitoring of
lateral wall motion prior to and after pharyngeal flap surgical
procedures. Kelsey noted that patients with the best postopera­
tive result had acceptable lateral pharyngeal wall movement
prior to surgery.
Following placement of an obturator, or a pharyngeal flap
procedure, the adjacent pharyngeal tissues demonstrate increased
motion126'128,129. The physiologic basis for this phenomenon has
302 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
not been explained completely. Rosen and Bzoch found that a
number of patients required reduction of the obturator soon af­
ter placement of the prosthesis126. They reported that 53 of 163
cleft palate patients required a significant reduction of the obtu­
rator due to increased muscle activity. At the University of Or­
egon, Blakeley128, Weiss130, and Wong and Weiss131employed
this phenomenon to improve lateral wall movements and the
prognosis for pharyngeal flap procedures by serially reducing
the obturator. They reported a significant increase in lateral wall
motion to the point where the obturator prosthesis was elimi­
nated for a few patients. However, these results have been ques­
tioned by other clinicians who have not been able to achieve
similar results132,133.
Wolfaardt conducted a well-documented study of 32 pa­
tients with palatal lift prostheses94. All patients were evaluated
with nasoendoscopy, pressure flow equipment (Perci), and a
nasometer prior to, during, and following treatment. Twenty-
one of the 32 patients were selected for a reduction program
after using the prosthesis for 6 to 12 months. The prosthesis
was not reduced per se, but the amount of time the prosthesis
was used was gradually reduced until it was completely elimi­
nated in 14 of the 21 patients. During the reduction program,
the patients were continuously monitored with the 3 evaluation
methods so the patients could be reassured that they retained
the capability for normal speech without their palatal lift pros­
thesis. The authors believed that the continuous use of the pros­
thesis for 6 to 12 months helped the patient to learn the sound of
normal speech so that they could continue to function at this
level when the prosthesis was provisionally discarded.
Other forms of stimulation of the velopharyngeal mecha­
nism, such as muscle exercises133,134,135,136, speech therapy133, and
electrical stimulation136, have not been effective in demonstrat­
ing a sustained increase in pharyngeal movements leading to
improved speech.
Velopharyngeal closure tends to be sphincteric in na-
tm-g37.i37.i38 (Figure 7 - 13). Movement of the posterior pharyn­
geal wall blends with the movements of the lateral pharyngeal
walls and elevation of the soft palate. The level of closure is at
or slightly below the level of the tori tubari (the medial bulging
of the pharyngeal terminus of the Eustachian tube). Different
patterns of closure are present with variability being the rule
rather than the exception. Shprintzen, in a study of 5 patients
with palatopharyngeal insufficiency or incompetency, found that
the type of closure, and the amount of lateral pharyngeal wall
motion, varied considerably138.This study implied that the speech
deficiencies could be traced to either inadequate soft palate el­
evation or inadequate lateral wall motion. In addition, lateral
wall motion is not necessarily similar on both sides of the phar­
ynx124,125.
The muscles contributing to the movement of the lateral
pharyngeal walls, the direction of lateral wall movement, and
the level laterally of velopharyngeal closure remain points of
contention. The levator veli palatini muscle has its origin lateral
to the torus tubarius, without attachment to the Eustachian tube.
The levator courses downward, forward, and medially, and in­
serts into the central one-third of the soft palate. Because of its
position lateral to the torus tubarius, Dickson45 and Maue-
Dickson139postulated that lateral wall motion is achieved solely
by the contraction of the levator muscles. As the levator sling
contracts, it moves the torus tubarius and lateral pharyngeal walls
in a medial and, sometimes, posterior direction to engage the
lateral margins of the soft palate at the level of the torus tubarius.
Dickson45and Maue-Dickson139felt that, from a biomechanical
point of view, the superior constrictor could not contribute to
this vector of movement. Electromyographic studies by Bell-
Berti49supported this theory.
However, Skolnick38and Shprintzen62,137,138speculated that
lateral pharyngeal wall movements might have a 2-muscle
model, as the incongruous movements of the lateral pharyngeal
walls, noted in these and other studies, would be difficult to
account for solely with levator contraction. They postulated that
the superior constrictor muscle was responsible in some degree
for lateral pharyngeal wall motion. The electromyographic stud­
ies of Fritzell48and Kuehn109support this observation.
Recently, the level of lateral velopharyngeal closure has
been questioned. In the past, several authors felt that
velopharyngeal closure occurred at the level of the tori
tubarius49,139. However, Croft examined 80 normal adult sub­
jects with multiview nasoendoscopy, finding that the level of
closure generally was approximately 1 cm below the torus
tubarius, or at about the level of the palatal plane52. These in­
vestigators found that lateral wall movement during closure
occurred primarily in a medial direction, especially with coro­
nal and sagittal closure patterns. A posteromedial movement
was seen primarily with circular closure patterns. Croft sug­
gested that their results were consistent with the hypothesis that
the superior constrictor muscle contributes to lateral pharyn­
geal wall movement in patients with a circular closure pattern.
Why are there such diverse opinions regarding lateral wall
movements? Several authors have provided some thoughts and
information regarding this question. Shprintzen cautioned that
the velopharyngeal valve is 3-dimensional, with height, width,
and depth140. Therefore, muscle movements and valving may
occur at more than one level in the velopharyngeal tube. Many
times, the 4 different closure patterns are not distinct entities. In
fact, Walter examined 30 unrepaired cleft palate subjects with­
out their prosthesis, using nasoendoscopy, and described 10 dif­
ferent closure patterns67. Berry and others examined, with
nasoendoscopy, 5 adult cleft palate patients who had worn an
obturator prosthesis for more than 20 years141. They found that
lateral wall motion was variable but always below the torus
tubarius. Siegel-Sadewitz and Shprintzen reported that it was
not uncommon for children with large adenoids to have
velopharyngeal valving at more than 1 vertical and horizontal
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects 303

location both with different closure patterns142. Witzel and It appears that the palatopharyngeus contributes little to
Posnick reviewed 246 consecutive nasoendoscopic studies for the medial and posterior movement of the lateral pharyngeal
patients suspected of having velopharyngeal dysfunction72. walls. Its primary function is to mobilize the larynx and narrow
Velopharyngeal gaps were found in 181 of these patients; 121 the pharynx in speech and swallowing109. Dickson felt that, in
of the gaps were considered typical (i.e., they were centrally the adult, the fibers of the palatopharyngeus are so intertwined
located and due to hypoplasia of the musculus uvulae). In 28 with the superior constrictor that analysis of the function and
patients, the gaps were located laterally and, in 32 patients, the boundaries of the palatopharyngeus are difficult to delineate65.
gaps were attributed to the shape of the adenoids and/or to the The palatoglossus muscle, which forms the anterior tonsil­
anatomy or function of the posterior border of the soft palate. lar pillar, acts as an antagonist for the levator veli palatini by
Henningsson and Isberg compared the results of multiview elevating the tongue and lowering the soft palate, but plays no
videofluoroscopy and nasoendoscopy in 80 subjects with role in velopharyngeal closure. Since both the palatopharyn­
hypemasal speech60. They felt that multiview videofluoroscopy geus and the palatoglossus narrow and bulge in their central
provided more conclusive information regarding lateral wall portion during contraction, the imprint of both muscles can be
motion, while nasoendoscopy was best for viewing the levator noted during waxing procedures for construction of the obtura­
eminence and movements of the posterior pharyngeal wall. tor prosthesis for patients with extensive soft palate defects (Fig­
Because of these variations, it is best to employ multiple ure 7-14).
diagnostic procedures. Stringer and Witzel examined 25 sub­
jects with hypemasal speech, using multiview videofluoroscopic
projections (lateral, TOWNE, and base views) and
nasoendoscopic studies59. Each author separately rated the de­
gree of velopharyngeal closure (adequate, inadequate, or un­
certain) for each view with each type of evaluation. The TOWNE
view with videofluoroscopy and nasoendoscopy had the clos­
est agreement (Table 7-6).
The authors believe that velopharyngeal closure during
speech may have a 2-muscle model for most patients. Consid­
ering the multiple variations and the different patterns of
velopharyngeal closure employing varying levels of participa­
tion of the soft palate, lateral pharyngeal walls, and the poste­
rior pharyngeal wall, it is difficult to conceive that contraction
of the levator veli palatini alone could produce all these varia­
tions.
The salpingopharyngeus muscle, which has been given
some responsibility for lateral wall motion40143, does not con­
tribute to closure. Dickson45and Bluestone108found the salpin-
gophaiyngeus muscle to be extremely inconsistent or absent
and, when present, rarely of substantial size. Likewise, the sal­ Fig. 7-14. Patient with obturator prosthesis. Right arrow
pingopharyngeal fold was found to be primarily glandular in points to anterior tonsillar pillar, whereas left ar­
nature, not muscular. row indicates the posterior tonsillar pillar.

Table 7-6. Ratings of Velopharyngeal Closure in Subjects on Multiview Videofluoroscopy and Nasopharyngoscopy.

Closure
Adequate Inadequate Uncertain Total

Lateral view 12 13 0 25
TOWNE view 3 20 25
Basal view 2 13 7 22
Nasopharyngoscopy 2 21 2 25

Source: Stringer DA, Witzel MA. Comparison of multiview videofluoroscopy and nasopharyngoscopy in assessment of
velopharyngeal insufficiency. Cleft Palate J. 26:88;1989.
304 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Innervation Prosthodontic Rehabilitation

Modem texts describe the innervation of the velopharyngeal
mechanism as being derived from the pharyngeal plexus. Al­
though the innervation to it is not completely understood, most
researchers believe this plexus is supplied by the glossopharyn­
geal and vagus nerves. An exception is the tensor veli palatini
muscle, which is innervated by the trigeminal nerve. However,
studies by Nishio indicate that the facial nerve also innervates
this complex50-51. These studies may explain the differences in
velopharyngeal closure previously noted during swallowing and
speech. In Nishio’s studies, fibroscopic views of velopharyngeal
movements of the rhesus monkeys were observed following
electrical stimulation at the cortical level. The movement seen
when stimulating the vagus and glossopharyngeal nerves was
similar to that seen during swallowing in humans, whereas the
patterns of movement that occurred with stimulation of all 3
nerves resembled those seen during speech. Nishio reported that
the discrete and precise movements of the velopharyngeal com­
plex during speech may be attributed to the facial nerve, while
grosser movements are the responsibility of the vagus and glos­
sopharyngeal nerves.
Obturator is derived from the Latin verb, obturare, which
means “to close” or “to shut off”. This definition provides an
appropriate description of the objective Of obturation in patients
with velopharyngeal incompetence or insufficiency. A prosthe­
sis placed following resection of portions of the bony maxillae
and adjacent structures (see Chapter 6) is basically a covering
prosthesis to reestablish the oral-nasal partition. The extension
superiorly of the obturator into the defect provides the basis for
improved retention, stability, and support for the prosthesis.
There is very little movement of the tissues bordering these
defects. In contrast, obturators constructed for patients with soft
palate defects must function in concert with peripheral tissues
displaying considerable movement.
Obturator prostheses fabricated for patients with velopha­
ryngeal deficits vary with the location and nature of the defect
or deficiency (Table 7-7). Obviously, there are differences be­
tween obturator prostheses constructed for patients with devel­
opmental or congenital malformations of the soft palate, as com­
pared with those constructed for patients with acquired defects.
Yet, the objectives of obturation are identical (i.e., to provide

Table 7-7. Obturator Prostheses for Soft Palate and Other Palatopharyngeal Defects.

STRUCTURES INVOLVED CAUSE(S)

TOTAL SOFT PALATE The entire soft palate Surgical excision of neoplastic disease
DEFECTS Unoperated cleft palate
Surgically redivided cleft palate

POSTERIOR BORDER
DEFECTS
Median Posterior Posterior half of the palate Surgical excision of neoplastic disease
Border Defects Postsurgical cleft palate with insufficient
length
Lateral Posterior Lateral half of the soft palate Surgical excision of neoplastic disease
Border Defects and often the lateral
pharyngeal wall

SPECIAL OBTURATOR
PROSTHESES
Palatal Lift All structures intact Neurological diseases
• Posterior border of Postsurgical cleft palate with insufficient
the soft palate Length and movement

Meatal Hard and soft palate Unoperated cleft palate

Surgical excision of neoplastic disease
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects 305

the capability for the control of nasal emission during speech,
and to prevent the leakage of material into the nasal passage
during deglutition)144. While the habilitation of the cleft lip and
cleft palate patients is discussed in Chapter 8, the fabrication of
all types of obturator prostheses will be discussed in this chap­
ter.
Table 7-7 may imply that resections for control of neoplas­
tic disease of the soft palate can be categorized into homog­
enous groups, with a well-defined pattern of prosthetic treat­
ment for each category. However, resections for malignant neo­
plasms, confined solely to either a portion or all of the soft pal­
ate, are quite rare. Most resections that impact on the soft palate
originate in adjacent structures, such as the tonsillar pillars, ret-
romolar trigone, base of the tongue, or the oral or nasopharynx.
Therefore, most resections for neoplastic disease that involve
the soft palate also include other adjacent structures.
In a recent study, Zlotolow reviewed the medical and den­
tal records (from 1984 to 1993) of 234 patients at Memorial
Sloan-Kettering Cancer Center in which the soft palate was listed
as being included in the resection145. Of these 234 neoplasms,
only 66 (28%) were considered to be of soft palate origin, and
in only 43 (18%) was the resection confined to the soft palate.
Since most resections included adjacent structures, the deli­
cate functional balance of the velopharyngeal mechanism will
also be affected to varying degrees, depending on the extent of
the initial resection and the method of surgical closure. Most
raw surfaces of these surgical defects are lined and/or closed
primarily with various types of flaps or a skin graft. Therefore,
the prosthodontist may be asked to restore a velopharyngeal
defect which may, in part, be nonfunctional (Figure 7-15). If
the soft tissues peripheral to the defect do not display some
movement, rarely will speech be normal with either a prosthetic
obturator prosthesis or surgical reconstruction. Movement of
the lateral and posterior walls and movement of the residual
soft palate are essential for either method of rehabilitation.
Immediate and Delayed Surgical Obturation
If resection of the portions of the velopharyngeal mecha­
nism is contemplated for control of neoplastic disease, the place­
ment of an immediate or delayed surgical obturator may be in­
dicated. Immediate surgical obturation is most useful in dentu­
ious patients, where the entire soft palate is to be resected. In
the edentulous patients, or with patients with limited medial or
lateral posterior border resections, delayed obturation may be
the treatment of choice. The principle advantage of immediate
surgical obturators for soft palate defects is support and reten­
tion of the surgical packing.
There are differences between surgical obturators for pa­
tients with defects of the bony palate, as compared to defects of
the soft palate and contiguous structures. First, the drape of the
intact soft palate precludes the clinician from obtaining an im­
pression of the nasopharynx, where normal velopharyngeal clo­
sure occurs and where the surgical obturator should be located.
Second, functional movements of the velopharyngeal mecha­
nism cannot be recorded prosthodontically either prior to or
during surgery. Conscious control by the patient is necessary to
initiate velopharyngeal movements. Third, the pharyngeal tis­
sues peripheral to the defect will usually exhibit little move­
ment during function in the immediate postoperative period.
Fourth, the extent of tumors in this region are more difficult to
visualize; hence, it is more difficult to delineate the surgical
margins presurgically.

a b c
Fig. 7-15. Alteration of velopharyngeal function, a: Resection of right soft palate and right lateral pharyngeal wall. Defect lined
with myocutaneous flap. Right reconstructed lateral pharyngeal wall does not have movement potential. Obturator
prosthesis must be extended behind residual soft palate to engage posterior and left lateral pharyngeal walls.
Acceptable resonance balance was achieved with prosthesis, b: Soft palate and lateral and posterior pharyngeal
walls were resected and allowed to granulate and epithelize spontaneously. None of residual peripheral structures
displayed movement, so proper resonance balance could not be achieved with prosthesis, c: Entire velopharyngeal
mechanism was resected and rendered nonfunctional. Proper resonance balance could not be achieved with pros­
thesis.
306 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Immediate Surgical Obturation
Immediate surgical obturators, constructed presurgically,
are approximations with regard to the level of placement and
the contours of the lateral and posterior margins. The guess­
work can be minimized if an extended impression of the soft
palate is obtained.
After the cast is retrieved, it is altered to correspond to the
proposed defect (Figure 16 a,b,c). The superior-inferior level of
the obturator is detennined by the plane of the hard palate. The
cast is altered to extend the palatal plane to within 2 to 3 mm of
the estimated position of the posterior pharyngeal wall. The width
of the obturator is determined by the width of the soft palate.
These guidelines will usually produce a prosthesis that will not
be overextended. Adjustments at surgery may be necessary to
avoid excessive tissue contact or to provide space for a
nasogastric tube. Adaptation during the immediate postopera­
tive period need not be precise, as the surgical packing will
correct minor discrepancies. In addition, some patients will have
a tracheostomy tube placed at surgery, so speech will be com­
promised during the immediate postsurgical period. The imme­
diate surgical obturator is adjusted and retained in position as
described in Chapter 6.
Approximately 7 to 10 days postsurgically, the prosthesis
is removed along with the surgical packing (Figure 7-16d). The
lateral and posterior margins of the prosthesis are checked for
tissue contact. Appropriate corrections are made and tissue treat­
ment material* is added to the lateral margins of the prosthesis.
The patient is instructed to perform head and swallowing move­
ments to activate the velopharyngeal complex and mold the lin­
ing material. Often, patients are reluctant to activate the remain­
ing velopharyngeal musculature initially because of discom­
fort, edema, and possible neurologic deficits. Hence, speech in
the immediate postoperative period can be muffled, as lateral
pharyngeal wall movements are necessary to control nasal emis­
sions and establish proper resonance balance. As healing
progresses, and the peripheral tissues display a greater range of
movement, trimming and reapplication of a suitable liner will
be necessary (Figure 7-16 e,f). As the edema abates and move­
ment of these tissues increases, speech will also improve. The
patient is monitored with sequential appointments until the de­
finitive prosthesis can be constructed.

d e f

Fig. 7-16. Immediate surgical obturator, a: Adenoid cystic carcinoma of right lateral soft palate, b: Cast altered for prosthesis.
Tumor extended further anteriorly than it appeared in (a), c: Immediate surgical obturator on cast. Posterior exten­
sion should be short o f posterior pharyngeal wall, d: Defect 2 months postoperatively. e: Prosthesis with lining of
tissue-conditioning material, which accounts for dimensional changes, f: Prosthesis in position.

Trusoft orRimseal, Harry J. Bosworth Co., Chicago, IL.

 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects 307

| I ; . . - " Y

mi 4- ^$$0

a b c

Fig. 7-17. a: Patient with squamous cell carcinoma of anterior tonsillar pillar and soft palate, b: Defect 4 months postsurgically.
c: The delayed surgical obturator added to existing denture 10 days postsurgically. Tissue treatment material added
to both denture and obturator to enhance stability and retention of prosthesis, and to improve speech.

Delayed Surgical Obturation

Patients with smaller defects of the posterior or lateral bor­
der of the soft palate often are best served with delayed surgical
obturation. If the defect is limited, the postsuigical edema will
tend to mask the velopharyngeal defect during the initial post-
surgical period. As healing progresses, the patient can be con­
sidered for a delayed surgical prosthesis. In edentulous or par­
tially edentulous patients, consideration should be given to at­
taching the delayed surgical obturator to the existing maxillary
complete or partial denture (Figure 7-17).
Definitive Obturation
Patients exhibiting considerable movement of the residual
velopharyngeal complex during functionhave an excellent prog­
nosis for achieving normal speech with a prosthesis. Movement
of the lateral pharyngeal walls is essential for control of nasal
emission. Little or no movement of the remaining velopharyn­
geal mechanism makes it difficult, if not impossible, to achieve
normal speech with either surgical reconstruction or prosthetic
therapy.
The obturator is attached to a conventional prosthesis. If
the patient is dentulous, a removable partial denture framework
retains the obturator. The obturator should be rigid. Therefore,
it does not attempt to duplicate the movements of the soft pal­
ate. It is a fixed platform of acrylic resin which provides surface
contact for the remaining musculature of the velopharyngeal
mechanism during function. If the lateral and posterior pharyn­
geal walls exhibit normal movement, a space will exist between
these structures and the obturator when these tissues are at rest.
The surrounding space permits breathing through the nasal cavity
and the production of nasal consonant phonemes (Figure 7-18).

Fig. 7-18. a: Obturator prosthesis for a 27-year-old female with an unrepaired cleft palate.
The patient is saying “ah”. Note approximation of lateral and posterior pharyngeal
walls with obturator, b: Obturator prosthesis in position with tissues at rest. A space
now exists between obturator and lateral and posterior pharyngeal walls (arrows).
308 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

The level of optimal obturator placement in the nasophar­

ynx is determined by the position of movement of the residual
velopharyngeal mechanism126’144146’147,148. Passavant’s ridge and
the anterior tubercle of the atlas can vary in location in relation
to normal velopharyngeal closure95121,144. Therefore, definite
landmarks regarding obturator placement are somewhat diffi­
cult to delineate. As a general rule, the prosthodontist should
consider the following guidelines for location of the obturator
segment of the prosthesis.

1 The obturator for an adult patient should be located in the

nasopharynx at the level of normal velopharyngeal clo­
sure.
2 The inferior margin of the obturator should not extend be­
low the lower level of muscular activity exhibited by the
residual velopharyngeal complex.
3 The superior margin of the obturator should not extend
above the level of muscular activity.
4 The inferior extension of the obturator will usually be an
extension of the palatal plane, and extended to the poste­
rior pharyngeal wall.

Obturation of Total Soft Palate Defects

Methods o f fabrication Construction of obturators for soft

palate deficiencies begins with the fabrication of the conven­
tional prosthesis. In obtaining impressions for diagnostic casts,
the palatal portion of the stock tray should be extended with
wax so the defect will be recorded (Figure 7-19 a,b). The re­
sidual velopharyngeal musculature will contract when contact
is made with the impression material, resulting in some distor­
tion (Figure 7-19b). However, the cast will assist diagnostic
procedures and tray preparation, and it will aid in establishing
the appropriate design for the partial denture framework (Fig­
ure 7-19 c,d).
Partial denture designs for patients with defects or func­
tional deficiencies of the soft palate and contiguous tissues are
similar to partial denture designs for nonsurgical patients. How­
ever, the prosthodontist must also consider the long lever arm
created by the extension for the obturator. This extension is not
within the confines of the bony palate and teeth, and this addi­
c d
tional weight and length increases the effect of gravitational
forces and the potential for rotation around the fulcrum line. Fig. 7-19.
The effect of this extension will be most significant for patients a: Stock impression tray extended with baseplate wax. Ad­
requiring a Kennedy Class I or Class II partial denture and mini­ hesive was applied to both tray and wax prior to impression
mal for patients with Class HI or Class IV partial dentures. For­ procedures, b: Impression. Configuration of defect is prop­
tunately, the forces directed against the obturator are minimal. erly recorded, c: Partial denture framework in position for
If the obturator is positioned properly in the nasopharynx, it same cleft palate patient depicted in Figure 18. d: Patient
need not be bulky and weight and the effects of gravity can saying “ah.” Retention for obturator is located properly, slightly
thusly be reduced. above level o f palatal plane, and does not contact activated
For patients requiring Class I or Class II partial dentures, ve lo p h a ryn g e a l m usculature. N ote co n to u rs o f defect
multiple indirect retainers are suggested, which will tend to re- changed from rest (c) to attempted closure (d).
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects 309

sist the downward displacement of the obturator and increase
the stability of the prosthesis149. The clinician should also en­
hance stability and support for the basic prosthesis by covering
as much of the hard palate as feasible. In patients with an ante­
rior edentulous area, consideration should be given to the place­
ment of crowns on the adjacent abutment teeth with the attach­
ment of an anterior tissue bar. The bar will act as an indirect
retainer and provide excellent stability and retention for the
obturator extension (Figure 7-20).
In the patient depicted in Figure 21 (a,b,c), the defect is
extensive, so tray resin is added to the cast retention loops to
approximate the area of the defect, and the prosthesis is inserted.
The tray resin is adjusted so that contact does not occur with the
lateral and posterior walls as the patient says “ah” (Figure 7-
21d). Disclosing wax is quite valuable in checking these exten­
sions. Modeling plastic is added to the tray resin. We prefer to
start border molding at the anterior margins of the defect before
proceeding posterolaterally (Figure 7-2 le). After the warm
modeling plastic is placed in the mouth, the patient is instructed
to move his or her head in a circular manner from side to side,
to extend his or her head as far forward and backward as pos­
sible, and to speak and swallow. These movements activate the
remaining velopharyngeal musculature and mold the modeling
plastic (Figure 7-21 e,f). As described previously, velopharyngeal
closure varies with head position and activity (speech and swal­
lowing).
Walter122and Kamell69caution that swallowing should not
be used to develop the obturator bulb physiologically, since the
velopharyngeal musculature contracts more forcefully and this
contact extends over a greater area during swallowing, as com­
pared with speech. These authors believe that, if swallowing is
used, an underextended bulb will result, especially laterally,
where the potential for the most extensive velopharyngeal mo­
tion exists. In contrast, Beny suggests that underextension of
the prosthesis initially is preferred to overextension, particu­
larly where potential compensatory function may develop90.
Minsley and others warn that a soft palate obturator pros­
thesis may compromise nasal breathing in selected cleft palate
patients14. These investigators computed the nasal cross-sec­
tional area for 8 cleft palate patients with obturator prostheses
during both inspiration and expiration, using pressure airflow
recording equipment. Fifty percent of this sample had nasal
cross-sectional areas less than 0.40 cm2, with concomitant im­
pairment in nasal respiration. Patients with airways less than

Fig. 7-20. a: Patient with repaired bilateral cleft lip and cleft palate exhibiting palatal insufficiency. Cleft segments were stabi­
lized with crowns and a Dolder bar. Dolder bar provides excellent indirect retention for obturator extension, b:
Prosthesis. Thompson dowels provide retention and occlusal rests on second molars, enhance the stability of
prosthesis, and provide indirect retention for anterior edentulous area, c: Another patient with repaired unilateral
cleft of the lip and cleft of the palate. A hand-crafted bar was attached to crowns in this instance, d: Bar approxi­
mates tissues so replacement teeth may be positioned appropriately, e: Prosthesis.
310 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

m n o p

Fig. 7-21.
a: Large soft palate defect, b: Impression for partial denture framework with defect
also recorded, c: Partial denture framework on cast, d: Tray resin attached to frame­
work in preparation for altered cast impression, e: Forming the obturator with mod­
eling plastic, f: Molding process completed, g: Cut back in preparation for addition of
thermoplastic wax. h: Addition of thermoplastic wax. i: Completed waxup in mouth
with velopharyngeal tissues at rest. Tissues will approximate obturator bulb during
function, but space allows for normal breathing through nasal cavity with tissues at
rest, j: Completed waxup. Note convex contour of superior surface which directs
nasal secretions posteriorly. Contours will be refined after processing, k: Completed
waxup of inferior surface. Note concave contours for ample tongue space. I: Boxing
for pouring altered cast impression, m: Altered cast ready for processing in clear
acrylic resin, n: Completed prosthesis, o: Pressure indicating paste added to obtu­
rator. Only minimal adjustment usually is necessary at this time, p: Completed pros­
thesis with patient in process o f closure during function.
 Speech, Velopharyngeal Function, and Restoration of Soft Palate Defects
0.40 cm2are considered obligatory oral breathers. These inves­
tigators caution that the prosthodontist must consider the pa­
tency of the nasal airway.
A balance between oral and nasal resonance is always nec­
essary, and a speech pathologist can be particularly helpful in
this regard. In the past, the emphasis and challenge has been to
provide velopharyngeal obturation for sufficient oral pressure
for the oral components of speech and resonance. However,
nasal resonance must not be ignored; an adequate nasal airway
is always necessary fornasal phonemes, proper nasal resonance,
and nasal breathing.
Unfortunately, some patients present with anatomical and/
or postsurgical limitations which compromise the nasal airway
and subsequent speech production. Thus, an ideal oral-nasal
resonance balance may not be attainable with either surgical or
prosthetic rehabilitation. Any surgically-repaired cleft palate
patient, or any velar post-resection cancer patient, has the po­
tential for this type of resonance imbalance. Good lateral and/
or posterior pharyngeal wall movement is essential in order for
the patient to properly proportion oral-nasal airflow. If the re­
maining peripheral structures comprising the residual
velopharyngeal complex do not display some movement, the
prognosis for normal speech following either a pharyngeal flap
surgical reconstruction or prosthetic obturation will be com­
promised.
If the patency of the nasal airway is already compromised
at the level of the nasal valve, aggressive obturation at the level
of the velopharyngeal port will further compromisenasal breath­
ing. The range of tissue movement of the lateral and posterior
pharyngeal walls represents the potential space between the
obturator, or the pharyngeal flap, with these tissues at rest If
the obturator closely approximates immobile peripheral tissues,
or ifthe obturatorextends inferiorly or superiorly belowor above
the level of tissue movement, the prosthesis has the potential to
compromise the patency of the nasal airway. In this situation,
the prosthodontist must adjust the level of the obturator to cor­
respond to the level of peripheral tissue movement, followed
by a judicious reduction of the lateral obturator peripheries to
improve nasal resonance balance and nasal breathing. Meatal
obturators have this same potential, as this type of obturator is
positioned in an area where peripheral tissue movement does
not occur.
We prefer to include swallowing during the physiological
molding, but at the end of the sequence and especially during
molding with modeling plastic. The molding of the obturator
segment with modeling plastic is akin to an altered cast impres­
sion in that the modeling process is, in essence, refinement of
the extension of the tray. Since the velopharyngeal musculature
exhibits limited force during closure, finite functional contours
are actually perfected and recorded with a thermoplastic wax.
As molding proceeds, the prosthodontist may be able to
identify the indentations made by the anterior and posterior ton­
Impression Wax, Kerr Co., Emeryville, CA orAdaptol, Jelenko Co., Rochelle, NY.
311
sillar pillars, the tori tubari, Passavant’s ridge (if present), and
the anterior tubercle of the atlas. Shiny areas indicate the lack
of tissue contact. The activated pharyngeal musculature will
displace the excess modeling plastic superiorly and inferiorly,
and these excesses should be trimmed with a sharp scalpel.
Modeling plastic, displaced inferiorly, will disrupt swallowing
patterns, induce abnormal tongue movements, and precipitate
gagging. The modeling plastic should be as warm as the patient
can tolerate, as pharyngeal tissues do not contract forcefully,
except in swallowing. If deficiencies are evident, a lower fus­
ing modeling plastic may be used. When the molding process is
completed, the patient is asked to speak, swallow, and breathe
through the nostrils in order to test the effectiveness of the formed
obturator. If the position and contours of the obturator are satis­
factory, all extensions of the molding plastic are reduced ap­
proximately 1-2 mm with a sharp scalpel (Figure 7-21g).
A mouth temperature thermoplastic wax* is added to the
obturator, then the wax is heated and tempered, and the pros­
thesis is placed in the mouth. The functions activating the
velopharyngeal musculature, such as head and swallowing
movements, are repeated in order to reestablish the contours of
the obturator. Hie use of thermoplastic waxes ensures against
overextension of the obturator (Figure 7-21 h,ij,k), which may
be created with modeling plastic, especially anteriorly adjacent
to the anterior and posterior tonsillar pillars. Adequate areas of
contact demonstrate a dull, stippled appearance, while a shiny
surface indicates a lack of contact The obturator prosthesis is
left in the mouth for approximately 5 minutes, during which
time, the previously described functions are repeated several
times.
The prosthesis is removed and chilled withcold water. Gross
excesses of the thermoplastic wax are trimmed with a scalpel.
Overextended areas can be identifiedwherethe waxis displaced,
exposing the modeling plastic (Figure 7-22). These areas are
trimmed and additional wax is applied. The wax is flamed and
tempered, the prosthesis is reinserted, and functional movements
are repeated. When speech and swallowing are normal, and the
contour of the obturator appears adequate, the prosthesis is tem­
pered in a water bath and replaced in the mouth for an extended
period (1 to 3 hours). The patient is instructed to wear the pros­
thesis without removal and encouraged to speak, swallow, and
performthe circularhead movementspreviously described. Prior
to removal, the patient is given a glass of cold water and in­
structed to gargle to chill the thermoplastic wax. The prosthesis
is removed and further chilled in ice water. At this point, it is
unwise to trim the thermoplastic wax for it is easily distorted.
Contour modifications are safer to perform prior to delivery,
when the obturator has been converted into acrylic resin. The
altered cast impression is boxed and the master cast is com­
pleted (Figure 7-21 l,m).
The obturator is processed in a customary manner, with
either heat activated or autopolymerizing methyl methacrylate.
312 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 7-22. a: During functional molding of the obturator bulb, thermoplastic wax was displaced, so modeling plastic is visible,
indicating tissue displacement, b: Modeling plastic is cut back followed by reapplication of thermoplastic wax. c:
Functional formed obturator bulb. Note modeling plastic is no longer visible and the change in contours (indenta­
tion) in this area.
Following processing, gross excesses are removed. The supe­
rior surface should be convex and well-polished to facilitate
deflection of nasal secretions into the oropharynx (Figure 7-
21n). The tongue surface side of the prosthesis should be slightly
concave (Figure 7-21o). As previously mentioned, if the obtu­
rator bulb is bulky, and weight is a problem, the obturator should
be hollowed and a lid added, or an open top obturator can be
fabricated (Chapter 6). Also, the lateral margins of the obtura­
tor are lightly polished to improve hygiene and deflection of
secretions.
The final position and contour of the obturator is best de­
termined with the prosthesis positioned in the mouth. Pressure
mdicator paste is helpful in identifying areas of overextension
(Figure 7-21p). This material is placed on the lateral surfaces of
the obturator and the patient instructed to repeat the movements
used to fabricate the prosthesis. The contour and the level of
placement are reaffirmed, and areas of excessive pressure are
relieved. If the patient notices little discomfort, minimal adjust­
ments are suggested at the initial insertion. The obturator is pol­
ished and the patient is reappointed for subsequent adjustments.
Several clinicians have reported increased movement of the
velopharyngeal complex following obturation (Figure 7-23).
Indeed, many obturators for soft palate defects require reduc­
tion after delivery. If the patient complains of soreness, pres­
sure, stuffiness, hyponasal speech, or difficulty in breathing,
the obturator should be reduced accordingly.
If hyponasal speech and breathing difficulties persist, the
level of obturator placement in the nasopharynx should be evalu­
ated. A common error is extension of the obturator superiorly
above the level of muscular activity. Continuous contact of these
un-mobile tissues with the lateral border(s) of the obturator
does not permit the patient to control his or her nasal airflow,
creating hyponasality and breathing problems. Reducing the su­
perior surface has the added benefit of reducing the weight of
tbe prosthesis and the lever effect of this long extension upon
the abutment teeth or the complete denture base. If this maneu­
ver is unsuccessful, the lateral and posterolateral aspects are
reduced judiciously over 2 to 3 sequential visits. If these tissues
exhibit some mobility, they will often compensate with time by
extending their range of movement. At the same time, the nasal
airway is enlarged when these tissues are at rest. If the obturator
is extensive, consideration may be given to making it hollow
after resonance balance is perfected.
After the initial adjustment period is completed, cleft pal­
ate patients will benefit from the services of a speech patholo­
gist to assist them in utilizing their obturator prosthesis more
effectively. Some cleft palate patients may have faulty articula­
tory patterns along with various degrees of hypemasality. They
have never developed normal speech patterns. Providing im­
proved velopharyngeal competence by either surgical or pros­
thetic means does not automatically translate into improved or
normal speech. For example, Sell and Grunwall studied the
speech following late palatal surgery for 18 previously
unoperated Sri Lankan adolescents with cleft palates150. Speech
Fig. 7-23. a: Prosthesis fabricated in 1987. b: Replacement
prosthesis fabricated in 1994. Obturator was sig­
nificantly smaller in all dimensions, with consid­
erable contour changes of posterior pharyngeal
wall. We believe changes result from increased
motion of velopharyngeal complex, especially
posterior pharyngeal wall.
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects 313

was recorded prior to palatal surgery and at 8 and 12 months

postsurgically. Speech was very distorted prior to surgery, but
there was minimal spontaneous improvement postsurgically or
following a limited amount of speech therapy. Similar results
would be expected if these patients had been managed
prosthodontically. Ortiz-Monastero concluded that speech
therapy will help those youngsters operated on before 12 years,
but will have little effect with teenagers or adults with well-
ingrained and abnormal speech patterns151. In contrast, patients
with acquired defects will usually achieve acceptable speech
with insertion of the prosthesis if a functional portion of the
peripheral velopharyngeal complex remains essentially undis­
turbed by the surgical resection.

Size and position o f the obturator What are the ideal dimen­
sions of the obturator in the nasopharynx? It is our opinion that,
if the obturator is positioned correctly in the nasopharynx, the
superior extension need not be extensive. The lateral dimen­
sions of the obturator are determined by lateral and posterior
pharyngeal wall movement. However, the position and length
of the superior extension of the obturator are controlled by the
prosthodontist. If the obturator is positioned correctly at the level
of greatest lateral and posterior pharyngeal wall movement, a
superior extension of approximately 10 mm is adequate. The
most common errors noted with obturator prostheses constructed
by inexperienced clinicians seem to be related to position (too
low), superior extension (too extensive), and lateral extension
(underextended), especially the lateral-posterior aspect (Figure
7-24).
Several factors should be considered relative to the posi­
tion and superior extension of the obturator. As reported previ­
ously, several investigators have noted that, in normal patients,
closure of the soft palate against the posterior pharyngeal wall
extends approximately 5 to 7 millimeters in vertical height, with
closure at or above the level of the palatal plane64,95,99. There­
fore, the superior extension need not be extensive in order to
duplicate the normal contact area with the lateral and posterior
pharyngeal walls. Furthermore, the pharynx is a conical tube,
with its widest dimension superiorly in the nasopharynx, so fur­
ther superior extension of the obturator may add additional width
and extra weight (Figure 7-24c). As previously mentioned, ex­
tension and continuous tissue contact superior to the level of
pharyngeal wall movement will occlude the nasopharynx, re­ Fig. 7-24.
sulting in difficulty with nasal breathing and hyponasal speech. a: Obturator contoured inappropriately. Oral surface has con­
Conversely, if the obturator is placed too low into the orophar­ vex contour that may interfere with tongue function, and ob­
ynx, tongue function will be disrupted and gagging may be pre­ turator is underextended laterally, b: Properly contoured ob­
cipitated. turator for the same patient. Note concave contours of oral
Two studies seem relevant with regard to the position and surface for tongue, c: Obturator bulb molded with black gutta
size of the obturator. Mazaheri and Millard studied 10 young percha. Note displacement of material superiorly. Since phar­
adult, cleft palate patients with socially acceptable speech while ynx is a conical tube with its widest dimension superiorly,
using an obturator prosthesis146. The level of placement and extension above level of velopharyngeal motion (arrows) cre­
vertical extension of the obturators were studied with regard to ates continuous contact, predisposing to hyponasal speech.
314 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
their effect on speech. Three positions were tested with inter­
changeable obturators: high (above posterior pharyngeal wall
activity), medium (at pharyngeal wall activity), and low (below
pharyngeal wall activity). Each obturator was adjusted for 5
weeks before speech recordings were made. This investigation
disclosed that the middle position resulted in the best speech
for most patients. The inferior-superior dimension of the origi­
nal median obturator for these subjects varied from 13 to 19
mm, with a mean of 13.09 mm. Each obturator was reduced
inferiorly and/or superiorly to an average of only 3 mm in infe­
rior or superior extension, with no effect upon speech.
Subtelny and others studied the speech of 23 adult and ado­
lescent cleft palate speakers with obturator prostheses152. They
reported a wide variation in obturator position and size. The
position of the obturator varied from 20 mm below the palatal
plane to 6 mm above the plane. The vertical extension varied
from 11 to 35 mm. The best speech results were obtained with
the higher placement of the obturator. Where deficiencies were
noted clinically regarding tissue approximation, the lateral di­
mension was most commonly found to be deficient in exten­
sion.
Speech evaluation following obturator placement The pros­
thodontist may require the assistance of a speech pathologist to
evaluate articulation errors and inappropriate oral-nasal reso­
nance balance. Cleftpalate patients will invariably require speech
therapy in order to utilize their obturator prosthesis more effec­
tively, whereas patients with obturators for acquired defects of
the soft palate usually do not need this retraining. The articula­
tion test in Table 7-8 or the Iowa Pressure Articulation Test153
can be administered by the prosthodontist, but definitive judg­
ments concerning articulatory deficiencies should be reserved
for the speech pathologist. Patients with hypemasality often
exhibit facial grimaces to partially occlude the nostrils and the
nasal valve, or abnormal tongue postures as a compensatory
adjustment to reduce nasal emission. These compensations de­
velop over many years and may persist after improved obtura­
tion has reduced the amount of hypemasality. The presence of
abnormal speech patterns may preclude the production of nor­
mal speech, even in the presence of adequate obturation.
The obturator is adjusted to the point where the patient can
produce a clear “p” and a sustained “f ’ of “s” sound without
emission of air through the nose, as well as understandable na­
sal consonant sounds, such as “m”126. Several authors suggested
that the sustained pressure required for the “s” phoneme may
be a reliable method of evaluating the effectiveness of the obtu­
rator126154. Whereas greater intraoral pressure may be required
for stop-plosives, such as “p”, the sustained pressure required
for “s” mitigates the compensatory elevation of the tongue to
assist with closure. The tests discussed previously, such as
multiview videofluoroscopy, comparative oral and nasal air flow
measurements, and oral and nasal endoscopy, will aid in as­
sessing the perceived resonance balance. Nasal endoscopy, es­
pecially, can be very helpful, as this instrument does not inter­
fere with speech. Larger openings can be visualized through
the scope, while the bubbling of mucous may indicate smaller
openings that require correction69.
On occasion, the clinician will experience difficulty in
achieving appropriate resonance balance, especially if lateral
pharyngeal wall motion is minimal or absent. Nasal consonant
sounds will be hyponasal while other speech sounds will have a
hypemasal quality. Adjustments to the obturator may not prove
effective in establishing proper resonance balance. Studies by
Warren and coworkers32-58’77, and by Lubker155, seem to offer an
explanation for this paradox. These studies suggest that some
prosthetically managed speakers have larger velopharyngeal
openings for non-nasal phonemes than normal speakers, and
that these prosthetically managed speakers tend to have less
adequate nasal airways than normal speakers during the pro­
duction of nasal consonants. This problem with resonance bal­
ance has been noted with meatal obturator prostheses, obtura­
tor prostheses for patients with extensive acquired lateral pos­
terior border defects, and obturator prostheses for some cleft
palate patients. Timing, regulation, and control, along with other
compensatory phenomenon, may also be involved in oral and
nasal resonance imbalance54,57.
Obturation of Soft Palate Posterior Border Defects
Patients in this category have undergone surgical resec­
tions of the posterior portion of the soft palate for control of
neoplastic disease. They exhibit a variety of defects, but the
anterior portion of the soft palate remains intact, with attach­
ment to the posterior border of the palatine bones. The obtura­
tion of 2 prototype defects will be discussed. First, median pos­
terior border defects, which occur following the surgical resec­
tion of lesions of the uvula and the posterior soft palate. Sec­
ond, lateral posterior border defects, which occur following re­
section of lesions of the anterior tonsillar pillar and the retro-
molar trigone. In both instances, the velopharyngeal mecha­
nism may be compromised, and prosthetic obturation is usually
the treatment of choice.
The objectives for obturation of these defects is similar to
the obturation of total soft palate defects, which were previ­
ously described. However, the prosthetic approach differs, since
the remaining intact portion of the soft palate must be circum­
vented in order to place the obturator at the proper level in the
nasopharynx. Two approaches have been utilized to cross the
residual soft palate. One method is to record the soft palate at
rest. After the soft palate is circumvented, the obturator is ex­
tended superiorly behind the soft palate to the proper level for
obturation. This approach will be discussed in this section. A
second method is to displace the residual soft palate superiorly
with the soft palate extension in order to place the obturator in
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects
Table 7-8. Test sentences for evaluation of articulatory factors involved in consonant sounds.
Phoneme Contact
p, b, m Bilabial contact
K g, ng Linguo-velar contact
t, d, n Linguo-alveolar contact
f, v Labio-dental contact
th Linguo-dental contact
j, ch Linguo-palatal contact
1 Lateral lingual aperture
r Central lingual aperture
w Widening labial aperture
y Widening lingual aperture
s, z Linguo-alveolar contact
sh, zh Linguo-palatal contact and
wide air blade
Source: Chierici G, Lawson L. Clinical speech considerations in prosthodontics: Perspectives of the prosthodontist and speech
pathologist. J Prosthet Dent. 29:29;1973.
the proper area in the nasopharynx. Such a prosthesis is termed
a palatal lift prosthesis.
The characteristics of the remaining portion of the soft pal­
ate will determine the best approach for the patient. A short,
taut soft palate may be circumvented easily by the extension
from the basic prosthesis. Circumventing lengthy, immobile soft
palates can be difficult, and it also may create speech problems.
In this instance, if the soft palate is circumvented without dis­
placement, the prosthesis must extend across the soft palate into
the oral pharynx, which may interfere with tongue movements.
As described previously, several investigators have noted the
abnormal tongue contacts with the soft palate in patients with
inadequate velopharyngeal mechanisms. Subtelny, in a study
of 23 prosthetically managed cleft palate patients, reported that
patients with the poorest speech after prosthetic treatment were
those with long, immobile palates in which the soft palate was
circumvented without displacement152. The lengthy immobile
315
Test Sentence
Bobby popped my balloon.
Go get the coat and bring it back.
Tom did not do it.
Father found some coffee.
They thought there were three.
Jack jumped by the children.
The little lamp was lit in school.
Roy Rogers’ horse was Trigger.
Will you go with William?
You and your young sister will go
next year.
Six sisters saw the zebra in the zoo.
She will wash the dish in the garage.
soft palate compromised the superior extension of the obturator
into the nasopharynx, resulting in a lower position of the obtu­
rator relative to the position of the obturator for speakers who
achieved better speech. Therefore, patients with long or immo­
bile palates should be considered for palatal lift prostheses.
Median posterior border defects Neoplastic disease of the
uvula and posterior soft palate occur infrequently. Small, well-
localized lesions usually can be controlled with radiation therapy.
However, lesions failing to respond to radiation, or more exten­
sive lesions, may require surgical resection resulting in this type
of defect (Figure 7-25). Some cleft palate patients will exhibit
insufficient length or movement of the soft palate to effect
velopharyngeal closure and will benefit from prosthetic obtura­
tion (Figure 7-26). A few adult cleft palate patients will benefit
from redividing the residual soft palate, if further palatal sur­
gery is not contemplated.
316 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 7-25. Acquired median posterior border defects, a: Edentulous patient with median posterior border defect, b: Prosthesis
which must cross small remnant of soft palate, c: Another edentulous patient with median posterior border defect.
Tumor was extended laterally, so this aspect was reconstructed and lined with a myocutaneous flap. Median poste­
rior border defects are not necessarily confined to soft palate.

a b c

Fig. 7-26. Congenital median posterior border defects, a: Edentulous patient with short, immobile soft palate, b: Prosthesis.
Note extension across intact residual soft palate in order to position obturator properly in nasopharynx. Circum­
vented soft palate was included in altered cast impression and made quite thin, c: Prosthesis in position. Note slight
concave contour to inferior surface.

Methods o f fabrication The preliminary impression should
include the residual soft palate plus the defect posterior to the
soft palate. The diagnostic cast retrieved from this impression
will have distortions secondary to displacement and contrac­
tion of the soft palate during the impression procedure, but the
length of the residual soft palate will be approximately correct.
This cast serves diagnostic purposes and is useful for adapta­
tion of the wire loop extension for the obturator.
The basic prosthesis is completed as before. The presence
of teeth and/or implants enhances the prognosis with all types
of soft palate defects because improved retention permits accu­
rate positioning of the obturator. Obturators attached to com­
plete maxillary dentures may adversely affect retention because
of the additional weight and the long, cantilevered lever arm
necessary for obturator placement This additional weight is not
within the confines of the complete denture.
It is difficult to record the soft palate at rest accurately with
an irreversible hydrocolloid impression. To circumvent this dif­
ficulty, a wire loop is attached to the removable partial or com­
plete denture prosthesis to secure the obturator. A cast metal
meshwork is difficult to adjust for any displacement of the re­
sidual soft palate. In many instances, the wire loop will dis­
place the soft palate superiorly if the retentive loop was adapted
on the diagnostic cast. If this is the case, the loop should be
adjusted so that 1 mm of space exists between the wire reten­
tion and the soft palate at rest.
Tray resin, followed by border molding with modeling plas­
tic, is added to the wire loop commencing at the hard-soft pal­
atejunction and proceeding posteriorly, as previously described.
The extension across the intact palate need not be wide later­
ally, as it is only a vehicle for the velopharyngeal obturator.
Also, this extension should be kept as thin as possible to pre­
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects 317

elude interference with tongue function. Some clinicians prefer will contact velopharyngeal tissues. After the prosthesis is in­
a cast metal extension, which has the advantage of being thin. serted, the patient is instructed to repeat all head and swallow­
We prefer to construct this extension with a wire loop embed­ ing movements. Areas of displacement are noted and relieved.
ded in methyl methacrylate in order to facilitate future adjust­ Several trial insertions may be necessary until the prosthesis
ment and reline procedures. will seat comfortably. Disclosing wax can also be used for this
The factors determining the level of placement of the obtu­ purpose, but care must be taken to temperate it before insertion
rator are the same as in patients with a total soft palate defect. into the defect. If the level of normal velopharyngeal closure is
However, direct visualization of the area of normal velopha­ considerably above the posterior border of the soft palate, it is
ryngeal closure may not be possible, except with an oral or na­ advisable to reduce the inferior surface of the obturator. This
sal endoscope. A more lengthy superior extension will be nec­ bulk is not necessary for obturation and will provide more space
essary in order to reach the level of normal closure. for tongue function.
If the posterior border of the resected soft palate is scarred The patient is given instructions in the care of the prosthe­
and exhibits little motion, it may be feasible to extend the obtu­ sis and a sequence of recall visits is established. Most patients
rator across the nasal surface of the soft palate for a short dis­ adjust to the prosthesis quite readily.
tance. This extension provides some retention for the obturator
and is especially helpful for edentulous patients. To engage this
undercut, the margin of the soft palate must be slightly
displaceable and a compound path of insertion must be used.
This extension may contact nasal mucosa; consequently, it must
be molded carefully to avoid excessive tissue displacement, as
well as to permit residual palatal elevation.
After the extension across the soft palate has been recorded,
tray resin is added to the wire loop in the area of the defect. The
resin must be 3-4 mm short of the adjacent tissues at their maxi­
mum level of contraction. Modeling plastic is then added and
the patient is instructed to perform the head and swallowing
movements to mold the obturator, as previously described. Af­
ter molding procedures are completed, all tissue contacting sur­
faces of the modeling plastic are trimmed back approximately
1 mm with a sharp instrument. Thermoplastic wax* is added to
the obturator and the molding procedures are repeated. In pos­
terior border defects, overextension is most common at the pos­
terior margin and along the oral surface of the soft palate.
On occasion, the wire loop used to retain the obturator is
not in the most advantageous position. An ideal time to replace
the wire loop is after the prosthesis has been flasked, separated,
and cleansed of wax, prior to processing with resin (Figure 7-
27.) At this point, all structures will have been recorded in their
correct relationship, so the adaptation of a new wire loop is
facilitated. The new loop is attached to the conventional pros­
thesis and the obturator is processed with methyl methacrylate. c d
After processing and prior to insertion, the superior sur­
face of the obturator is trimmed and rounded slightly to form a Fig. 7-27. a: Dentuious patient with median posterior bor­
convex surface, and the extension of resin across the soft palate der defect. Soft palate was scarred and exhibited
is thinned as much as possible (Figure 7-27d). This extension limited motion, b: Existing cast loop was too short.
will be approximately 10 mm wide and 2 to 3 mm thick. Usu­ An ideal time to replace retention loop is after the
ally, this width will not interfere with tongue function, but ex­ altered cast impression is poured and cast re­
cessive thickness of resin can be bothersome. trieved. c: The new cast loop welded to the pos­
If the obturator was extended superiorly along the nasal terior palatal strap major connector, d: Prosthe­
surface of the soft palate, the length of this extension may re­ sis in the mouth. A metal extension is preferable
quire reduction to insert the prosthesis comfortably. Pressure if soft palate displays limited motion, as it is less
indicator paste is applied to the surfaces of the obturator which bulky.

Impression Wax, Kerr Co., Emeryville, CA orAdaptol, Jelenko Co., New Rochelle, NY.
318 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 7-28.
a: Right lateral posterior border defect with resection and defect confined to lateral
aspect of the soft palate. A rare defect with an excellent prognosis because of move­
ment of peripheral tissues, b: Left lateral posterior border defect with left lateral wall
restored with myocutaneous flap, c: Right lateral posterior border defect with re­
maining soft palate tethered to lateral pharyngeal wall, d: Right lateral posterior
border defect tethered with a tongue flap. Prosthetic prognosis is guarded due to
access, and limited peripheral motion.

Lateral posterior border defects These defects usually result
from the surgical resection of squamous cell carcinomas aris­
ing from the tonsillar tissues, retromolar trigone, or posterolat­
eral tongue regions (Figure 7-28). Invariably, the surgery in­
cludes a partial resection of the mandible and tongue, as well as
resection of the lateral oral pharynx and soft palate in continu­
ity with a radical neck dissection. Flaps are often used to close
the lateral portions of the surgical defect, leading to an immo­
bile lateral pharyngeal wall (Figure 7-28b). In some patients,
the residual soft palate is tethered to the pharyngeal wall, com­
promising its elevation (Figure 7-28c). In tonsillar resections, a
tongue flap occasionally is sutured to the anterior and/or poste­
rior tonsillar pillar. As the wound contracts, the soft palate is
pulled downward and forward, preventing normal soft palate
elevation and compromising access to the velopharyngeal area
(Figure 7-28d). Therefore, resurfacing these areas with
myocutaneous or free flaps is preferred. Whatever the method
of closure, the prosthesis must engage the opposite and still
functional lateral pharyngeal wall behind the residual soft pal­
ate in order to achieve velopharyngeal closure (Figure 7-29). In
patients with severe tongue dysfunction associated with the
tongue-mandibular-tonsillar resection, the velopharyngeal defi­
cits appear inconsequential, yet these patients will derive con­
siderable benefit from obturation. Two to 6 months are often
necessary to determine the nature of the possible velopharyngeal
incompetence or insufficiency. In some patients, such a deter­
mination is obvious from the beginning, but, in others, local
accommodation and loosening of scar contracture may eventu­
ally permit adequate velopharyngeal function without obtura­
tion.

Fig. 7-29. a: Right lateral posterior border defect with right lateral margin restored with a myocutaneous flap. Peripheral mo­
tion was very good, b: Prosthesis with obturator extending behind the residual soft palate to the still-functional left
lateral pharyngeal wall.
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects
Residual speech deficits may remain following placement
of the definitive obturator prosthesis. These deficiencies can be
associated with the oral-nasal resonance balance, as established
by the obturator, but they are more often caused by errors in
articulation predisposed by a misshapen oral cavity and com­
promised by the partial loss of motor and sensory innervation
of the tongue. However, the prosthesis will usually improve
speech and eliminate the regurgitation of particulate matter and
liquids into the nasal cavity.
Methods o f fabrication As with all types of soft palate
defects, a complete or partial prosthesis must be constructed
before the obturator can be fabricated. The retention for the ob­
turator is best provided by a retentive loop attached to the con­
ventional prosthesis. An exception would be where the residual
soft palate exhibits little or no motion. In this situation, a cast
meshwork may be constructed as a component of the partial
denture framework. After the conventional prosthesis is fabri­
cated and adjusted, the retention for the obturator is adjusted
following the guidelines previously described.
The clinician should observe the configuration of the de­
fect, and the degree and the direction of movement of the tis­
sues bordering the defect, prior to molding the obturator. In con­
trast to defects confined to the soft palate, the movements ex­
hibited by the tissues bordering lateral defects can be quite vari­
able. In most instances, the residual soft palate and lateral pha­
ryngeal wall on the defect side will display little movement.
Often, the residual soft palate does not exhibit normal elevation
on the unresected side because the soft palate is tethered on the
defect side. This condition leads to VPI behind the soft palate
and medial to the oral defect. Consequently, to effect
velopharyngeal closure, the prosthesis must extend from the
defect side superiorly behind the soft palate along the posterior
pharyngeal wall to the opposite lateral pharyngeal wall.
The obturator is fabricated, as previously described, using
modeling plastic and thermoplastic wax. The objective is to
record the tissues bordering the defect during functional move­
ments. There must be adequate movement of the residual
velopharyngeal mechanism in order to control nasal air flow. In
defects with limited mobility during velopharyngeal function,
continuous contact is maintained between these tissues and the
obturator, both at rest and during function. This results in occlu­
sion of the nasal airway and hyponasal speech in these patients.
It may be necessary to reduce the size of the obturator in order
to permit nasal breathing. However, in doing so, speech may
become hypemasal. It is best to affect these adjustments after
the obturator has been fabricated. Generally, the lateral exten­
sions of the obturator are reduced gradually until nasal breath­
ing is acceptable. Sequential monitoring appointments are es­
sential following delivery of these prostheses.
319
Implant Retained and Supported Obturator Prostheses
Obturators restoring soft palate and pharyngeal wall de­
fects should be accurately positioned in the nasopharynx and
effectively retained if speech and swallowing are to be restored.
This may be difficult when the residual maxillae are edentu­
lous, because the defect, whether it be congenital or acquired,
may alter the posterior palatal seal area, making it difficult to
obtain and maintain a peripheral seal. Retention may also be
compromised, as previously described, due to the posterior ex­
tension of the obturator into the nasopharynx.
In patients with soft palate defects, osseointegrated implants
enable the design and fabrication of complete overlay dentures
with retentive capacities similar to prostheses for dentuious pa­
tients with partial denture frameworks. If the soft palate defect
has not resulted in the compromise of die posterior palatal seal
area, and the residual palatal structures are favorable, 2 implants,
placed into the premaxillary segment in the region of the cus­
pids, will be a sufficient supplement to the retention, stability,
and support derived from the residual structures (Figure 7-30).
However, if the defect has compromised the posterior palatal
seal area, and/or the residual palatal structures provide insuffi­
cient stability and support for the prosthesis, 4 or more implants
should be placed (Figure 7-31). The retention provided by the
implants will be enhanced if the implants can be positioned to
maximize the anterior-posterior (A-P) spread (Figure 7-31 b,c).
The design of the retentive apparatus in these patients will de­
pend upon a number of factors, such as the opposing dentition,
number and length of the implants, the quality of the bone into
which the implants were inserted, the A-P spread of the im­
plants, and the size of the defect. In most patients, the number
and distribution of implants will require that occlusal forces be
Fig. 7-30. Implant retained and supported prosthesis. Im­
plants were placed in each cuspid area to support
the complete denture, with an attached obturator
for a limited lateral posterior border defect. Be­
cause posterior palatal seal area was intact and
the defect was small, 2 implants were sufficient.
320 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 7-31.
a: Large right lateral posterior border de­
fect that extends anteriorly into the right
lateral hard palate. Remaining tooth was
overlaid and used as a rest, b: Four im­
plants and bar positioned in premaxillary
segment, c: Altered cast impression of the
defect, d: Prosthesis with clips.

shared between the implants anteriorly and the traditional den-
ture-bearing surfaces posteriorly, and attachments which per­
mit the prosthesis to rotate around a predictable axis (Figure 7-
32).
Special Obturator Prostheses
The palatal lift and the meatal obturator prostheses are useful
in selected situations. The palatal lift prosthesis, as its name
implies, displaces the soft palate superiorly and posteriorly in
order to assist the soft palate to affect closure with the periph­
eral pharyngeal tissues. The meatal obturator establishes obtu­
ration with nasal structures diagonally above the hard palate
terminus, and controls nasal airflow in this position, not in the
area of normal velopharyngeal closure.
Palatal Lift Prostheses
The popularity of the palatal lift prosthesis has increased
since it was first advocated by Gibbons and Bloomer136. This
type of prosthesis is especially useful for patients with velopha­
ryngeal incompetence who exhibit compromised motor control
of the soft palate and related musculature. Examples can be
seen following myasthenia gravis, cerebrovascular accidents,
traumatic brain injuries, bulbar poliomyelitis, cerebral palsy, or
injury to the soft palate (as sequelae following adenoidectomy,
tonsillectomy, or maxillary resections), or with cleft palate pa­
tients with palatal insufficiency and submucous cleft palate. The
objective of a palatal lift prosthesis is to displace the soft palate
to the level of normal palatal elevation, enabling closure by pha­
ryngeal wall action (Figure 7-33). If the length of the soft palate

Fig. 7-32. a and b: In this design, the attachments (Hader bar in anterior segment and ERA attachments posteriorly) allow the
prosthesis to rotate around a predictable axis, permitting the residual denture bearing surfaces to aid in support of
occlusal loads, c: Clinical view of a bar and attachments using this concept.
 Speech, Velopharyngeal Function, and Restoration of Soft Palate Defects
— pp
PP
b tion that cannot be treated as effectively with palatal surgery or
Fig. 7-33. a: Anatomically normal but paralyzed soft palate,
b: Palatal lift prosthesis in position, elevating the
soft palate to produce velopharyngeal closure (pp
= palatal plane, ta = median tubercle of the at­
las). (Source: Gonzales BJ, Aranson AE. Palatal
lift prosthesis for treatment of anatomic and neu­
rologic palatopharyngeal insufficiency. Cleft Pal­
ate J. 7:91;1970.)
a dontically demonstrated improved speech. Hardy felt that the
PP
b maintained.
Fig. 7-34. a: Congenital anatomic insufficiency of the velo­
pharyngeal region, b: Palatal lift plus obturator in
position, elevating the soft palate and obturating
the velopharyngeal space (pp = palatal plane, ta
= median tubercle of the atlas). (Source: Gonzales
BJ, Aranson AE. Palatal lift prosthesis for treat­
ment of anatom ic and neurologic palato­
pharyngeal insufficiency. Cleft Palate J.
7:91 ;1970.)
321
is insufficient to effect closure after maximal displacement, the
addition of an obturator may be necessary behind the displaced
soft palate (Figure 7-34). Adequate lateral pharyngeal wall
movement is necessary for the lift to be effective. A space for
breathing should be present laterally between the displaced soft
palate and the pharyngeal walls at rest
The advantages of a palatal lift prosthesis are as follows:
(1) the gag response is minimized due to the superior position
and the sustained pressure of the lift portion of the prosthesis
against the soft palate, (2) the physiology of the tongue is not
compromised due to the more superior position of the palatal
extension, (3) the access to the nasopharynx for the obturator
(if necessary) is facilitated, (4) the lift portion may be devel­
oped sequentially to aid patient adaptation to the prosthesis, and
(5) the lift principle has application to a diverse patient popula­
other types of obturator prostheses.
A palatal lift prosthesis is contraindicated if: (1) adequate
retention is not available for the basic prosthesis, (2) the palate
is not displaceable, or (3) the patient is uncooperative. The
displaceability of the soft palate can be checked by the me­
chanical elevation of the soft palate with a mouth mirror.
The literature substantiates the effectiveness of palatal lift
prostheses for the neurologically handicapped patient. Lang
advocated the use of lift prostheses for this group of patients
but cautioned that concomitant speech therapy may be neces­
sary for best results157. Hardy compared the surgical and pros­
thetic management of 17 children with cerebral palsy, inadequate
velopharyngeal closure, and defective speech158. Six children
received pharyngeal flaps and 11 were treated with palatal lift
prostheses. Only 3 of the 6 surgical patients demonstrated im­
proved speech while 10 of the 11 patients treated prostho-
hyperactive gag reflex of the neuromuscularly handicapped child
with an upper motor neuron lesion contraindicates the use of a
conventional obturator prosthesis. In his view, lift prostheses
minimized the gag response and therefore were the treatment
of choice. Surprisingly, Hardy found that these patients demon­
strated sufficient lateral pharyngeal wall motion to achieve clo­
sure with the displaced soft palate and yet nasal breathing was
Gonzales and Aranson, in a comprehensive study of 35
patients with palatal lift prostheses, reported speech improve­
ment with and tolerance of the prosthesis for all but 3 patients159.
The best results were obtainedfor patients where the neurologic
disorder was confined to the soft palate. Patients with severe
muscularparalysis of the lips, tongue, larynx, or respiratory mus­
culature had residual articulatory defects following placement of
the lift prosthesis. Gonzales reported that several patients re­
ported that less effort was involved in speaking. Also, the pros­
thesis stimulated soft palate and pharyngeal wall motion, per­
mitting sequential reduction of the lift portion of the prosthesis.
322 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Table 7-9. Number of patients and results with palatal lift prostheses*.

O p tim u m S u c c e s s fu l D esirable U n sa tisfa ctory Total

Initial se s sio n .7 5 20 8 40
L a st s e s s io n 14 7 19 4 44

* Prostheses were made initially prior to 1972 for 4 of the 44 patients.

Graph of palatopharyngeal port areas obtained while a patient was counting w ithout a palatal lift prosthesis,
after the prosthesis vyas first constructed, and after the last modification of the prosthesis.

Source: La Velle WE, Hardy JD. Palatal lift prostheses for treatment of palatopharyngeal incompetence. J Prosthet Dent. 42:308;1970.

Mazaheri and Mazaheri concurred with these observations,
and they suggested myofunctional therapy in addition to speech
therapy following delivery of the prosthesis160. They reported
that it has been possible to stimulate the soft palate and contigu­
ous tissues to the point where, in some patients, the prosthesis
could be eliminated. Neither hard or soft palate irritation, nor
adverse tooth movement, was reported using palatal lift pros­
theses.
LaVelle and Hardy studied 44 neurologically handicapped
children and adults with intact but nonfunctional soft palates
treated with palatal lift prostheses between 1972 and 197991.
The molding process was monitored with oral-nasal airflow
measurements, and the velopharyngeal port area was determined
prior to, during, and after treatment (Table 7-9). The authors
caution that ideal treatment was not always possible. Every ef­
fort was made to mold the lift in 1 session, but some patients
required additional sessions to reduce the velopharyngeal por­
tal. Turner and Williams described the use of both multiview
videofluoroscopy and nasoendoscopy for the design, placement,
and modification of a palatal lift prosthesis70.
Wolfaardt monitored 32 patients with palatal lift prosthe­
ses with nasoendoscopy, oral-nasal airflow measurements
(Perci), and a nasometer prior to, during, and after treatment94.
It was possible to eliminate the prosthesis in 14 of the 32 pa­
tients due to improved velar function.
Method o f fabrication In patients where the prospect of im­
provement may be difficult to predict, it may be advisable to
fabricate a provisional palatal lift prosthesis. The clinician may
then proceed with die definitive prosthesis if it appears that mean­
ingful improvement in speech can be achieved (Figure 7-35a).
Construction of a palatal lift prosthesis begins with an impres­
sion procedure intended to record and displace the soft palate
superiorly. To achieve this objective, the custom tray is extended
with baseplate wax, as previously described. A suitable partial
denture framework is fabricated and verified (Figure 7-35b).
The retentive meshwork or wire loop is extended to cover the
anterior two-thirds of the length of the soft palate. If the degree
of displaceability of the soft palate is in doubt, the wire loop
form of retention is suggested as it is more adaptable. Modeling
plastic is added to the retentive meshwork until the appropriate
displacement of the soft palate is achieved. In order to achieve
appropriate displacement of the soft palate, these prostheses are
necessarily quite broad posteriorly and shaped like a beaver tail
(Figure 7-35 c,d,e). Speech should be monitored for appropri­
ate nasal resonance during the waxing sequence. A thermoplas­
tic wax is used to record tissue detail. The obturator can be
extended behind the deficient soft palate if displacement does
not achieve adequate obturation (Figure 7-36). The lift may be
extended posteriorly gradually by sequential additions over sev­
eral appointments if adaptation to the prosthesis is difficult for
die patient.
Often, due to problems associated with retention of the max­
illary complete denture, palatal lift prosthesis are either con­
traindicated or of limited value for completely edentulous pa­
tients. Displacement is caused by the combination of the long
lever arm, created by the lift extension, and the downward dis­
lodging force, developed by any residual tonicity of the soft
palate. Some edentulous patients will manage a palatal lift pros­
thesis quite well by using the dorsum of the tongue to augment
the retention of the prosthesis. At other times, the desired lifting
force must be reduced in order to be compatible with the amount
of retention exhibited by the complete denture. Sato suggested
that the lift extension be of an open meshwork design to reduce
weight, and the attachment of the lift portion to the complete
denture be made with Ni-Ti (nickel-titanium) orthodontic wire161.
The authors felt that the flexibility of the wire counteracted some
of the displacing force from the elevated soft palate.
Patients with palatal lift prostheses should be monitored
closely to insure that the lifting force does not create soreness,
and that the force of the displaced soft palate does not have an
adverse effect on the supporting dentition. As Gonzales and
Aranson159, Mazaheri and Mazaheri160, and Wolfaardt94 sug­
gested, increased soft palate and pharyngeal wall motion may
require post-insertion reduction of the prosthesis.
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects 323

Fig. 7-35.
Palatal lift prosthesis, a: Provisional prosthesis, b: Partial denture casting with
retentive extension for palatal lift, c: Altered cast for palatal lift extension, d:
Completed prosthesis, e: Completed prosthesis in mouth. Note indications of
stretching of anterior tonsillar pillars.

Meatal Obturator Prostheses

A meatal obturator prosthesis was first described by

Schalit162, and later advocated by Sharry163. A meatal obturator
establishes closure with nasal structures at a level posterior and
superior to the posterior terminus of the hard palate (Figure 37).
The obturator extends superiorly and slightly posteriorly from
the hard palate border, separating the nasopharynx and nasal
cavities at the level of the posterior choanae164. There are no
movable tissues in this area and closure is established against
the turbinates, the residual vomer (if present), and the roof of
the nasal cavity. The palatal defect must be as wide as the area
to be obturated, or the rigid meatal obturator cannot be consid­
ered. Meatal obturators are used infrequently, but they can be
indicated for patients with extensive defects of the soft palate
who exhibit a very active gag reflex. Indeed, they may be the
obturator of choice for edentulous patients when retention is a
problem. The meatal extension is not as lengthy as the more
conventional obturators previously described, and it may be quite
thin in its anterior-posterior dimension, as contact with mobile
tissues is not a consideration. Thus, less weight is added to the
maxillary complete denture. Also, the downward displacement b
force from the obturator extension is closer to the supporting Fig. 7-36. Palatal lift with obturator prosthesis, a: Patient with
tissues of the parent prosthesis. partial maxillectomy defect. After obturation with
The disadvantages of this design are obvious. First, the ob­ a silicone bulb, speech remained hypernasal due
turator does not enable the patient to control nasal air emission to the loss of innervation to remaining soft palate,
because it is positioned in an area devoid of muscle function. b: Palatal lift with obturator bulb added. Speech
Nasal air flow is created by a drilling hole(s) in the obturator or returned to normal.
324 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Method o f fabrication As with all types of obturator prosthe­

onventional obturator
Fig. 7-37. Schematic drawing depicting position of meatal
obturator in relation to palatal plane and position
of conventional obturator.
by reducing its lateral extensions. Consequently, the nasal pas­
sage is either obstructed, leading to hyponasal speech and im­
paired nasal respiration, or open, predisposing to excessive na­
sal emission. Therefore, speech therapy is usually not indicated
or effective in refining speech after obturator placement. Sec­
ond, distortions in nasal resonance are evident because the oral
cavity and the oropharynx and nasopharynx are increased in
size and the nasal cavity is reduced proportionately. Third, the
anterior surface of the meatal obturator may act as a dam by
hindering normal postnasal drainage patterns, leading to the ac­
cumulation of mucous secretions anterior to the prosthesis. Thus,
frequent removal of the prosthesis is necessary for cleaning164.
Despite these difficulties, meatal obturator prostheses will im­
prove speech, and they can be adjusted to permit nasal breathing.
ses, the definitive maxillary prosthesis is constructed prior to
developing the obturator portion. After the definitive prosthesis
is adjusted, a wire loop is attached to the palatal terminus of the
prosthesis. Tray resin and modeling plastic are added sequen­
tially to the wire loop in order to mold the obturator. As the
obturator is formed, the clinician will be able to identify the
indentations formed by the inferior and middle turbinates and
the residual vomer. Head, speech, and swallowing movements
are unnecessary, as there are no movable tissues in this area.
After the obturator is formed, it is reduced approximately 1 mm
with a scalpel, and thermoplastic wax is added to it. Care must
be exercised to avoid overextension, as nasal mucosa will not
withstand displacement. After processing, the anterior-poste­
rior dimension of the obturator is reduced to approximately 5
mm in thickness. If the position and angulation of the meatal
obturator is correct, most of this reduction will be at the ex­
pense of the posterior surface. The lateral margins which con­
tact nasal structures should not be disturbed at this time (Figure
7-38). The obturator need not be wide antero-posteriorly, as tis­
sue movement is not a consideration. At this juncture, the pa­
tient will exhibit hyponasality, and nasal breathing will be diffi­
cult. To compensate for these difficulties, Sharry suggested plac­
ing a hole or vent (approximately 5 mm in diameter) through
the obturator to permit nasal breathing163. An alternate method
is to place 2 smaller holes through the obturator to correspond
with the nasal compartments, or to reduce the lateral dimen­
sions of the obturator until nasal breathing is restored. Taylor
and Desjardins suggested that the vent or openings be placed in
the superior third of the anterior surface and angled downward
(at a 45° angulation) to minimize the regurgitation of fluids
during swallowing164.

a b c

Fig. 7-38. a: Patient with extensive unrepaired cleft of hard and soft palate. Patient reported 3 unsuccessful attempts at
obturation at level of palatal plane. Meatal obturator prosthesis. Lateral margins of prosthesis were reduced slightly
to permit nasal breathing, b and c: Prosthesis in mouth. Because of the position of the meatal obturator, its position
in nasopharynx cannot be seen.
 Speech, Velopharyngeal Function, and Restoration o f Soft Palate Defects
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161 Sato Y, Sato M, Yoshida K, Tsuryu H: Palatal cleft prostheses
for edentulous patients. J Prosthet Dent. 58:206; 1987.
162 Schalit A: Obturator of choice for congenital cleft palate. Amer
JOrthod. (Oral Surg. Sect) 32:688; 1946.
163 Sharry J: Meatus obturator in particular and pharyngeal
impressions in general. J Prosthet Dent. 8:893; 1958.
164 Taylor TD, Desjardins RP: Construction of the meatus-type
obturator: Its advantages and disadvantages. J Prosthet Dent.
49:80; 1983.
Chapter 8
Cleft Lip and Palate
Arun B. Sharma and Thomas A. Ciirtis
Cleft lip and palate is one of the most common congenital
anomalies, but prevention of this malformation remains, elu­
sive. Treatment, which is dictated by the severity of the malady,
is unique in that it begins at birth and is usually not completed
until the end of the second decade. Multidisciplinary manage­
ment, with interaction among the various specialists of the cleft
palate team, is essential in order to achieve optimum results.
An international review of the multidisciplinary team ap­
proach in the management of the cleft lip and palate patient
illustrates the diversity of treatment strategies and techniques1.
The treatment philosophy at the Craniofacial Anomalies Cen­
ter, University of California, San Francisco will form the back­
ground for this chapter. Other treatment philosophies and their
controversies will be discussed with reference to the UCSF
model.
Historical Background
The role of the prosthodontist in the management of the
cleft lip and palate patient has changed significantly in the past
40 years2. Definitive prosthodontic treatment is usually one of
the final therapies instituted, and it must attempt to mitigate any
anatomical and/or functional deficiencies that may remain after
the gamut of other treatment is essentially completed. In the
past, large, bulky removable prostheses were often necessary to
replace missing teeth, correct horizontal or vertical growth dis­
crepancies, or provide an obturator extension for oral-nasal reso­
nance balance (Figures 8-1 and 8-2). Fortunately, the need for
these all-inclusive removable prosthesis has diminished signifi­
cantly in more recent years due to effective treatment stem­
ming from a better understanding of the problems unique to the
cleft individual (Figures 8-3, 8-4, and 8-5). Where these ad­
vances can be implemented, the need for these large fixed or
fixed-removable prostheses has also diminished. Presently, if
the maxillary arch can be united by bone grafting the alveolar
cleft, osseointegrated implant(s) and selective crown and/or
porcelain veneer placement may be the only prosthetic treat­
ment required.
From the prosthodontic perspective, younger readers may
not realize that some maxillofacial clinics and/or programs be­
gan as cleft palate clinics, especially at University based hospi­
tals. However, as multidisciplinary treatment improved for the
cleft patient, the need for removable prosthodontics, in particu­
lar, diminished. The maxillofacial prosthodontist began to treat
more and more adult patients with acquired defects, whereas
cleft patients required less specialized and more routine
prosthodontic care. At the same time, the cleft palate team be­
gan to examine and treat more children with other craniofacial
anomalies. This mix of older and younger patients, with differ­
ent defects and somewhat different treatment objectives, led to
an amicable division into the Craniofacial Anomalies Treat­
m ent Centers and Maxillofacial Prosthetic Clinics at most in­
stitutions in the mid 1960’s.
Palatal Development and Classification of Clefts
Palatal Development
Palatogenesis begins in the fifth week and is complete by
the twelfth week in utero. The palate develops from 2 primor-
dia; namely, the primary and secondary palates. The primary
palate is also called the median palatine (nasal) process. It forms
the premaxilla which includes the incisor teeth and that portion
of the hard palate anterior to the incisive foramen. The primary
palate develops at the end of the fifth week from the innermost
portion of the intermaxillary segment of the maxilla. This seg­
ment, formed by the merging of the medial nasal prominences,
forms a wedge-shaped mass of mesoderm between the internal
332 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 8-1. Removable prosthodontics— complete dentures, a: Edentulous patient with cleft lip and palate, b: Only lip was closed
surgically, but never revised. Note obvious scar and linear and superior contraction of lip. c: Maxillary complete
denture fabricated in 1962.

Fig. 8-2.
Removable partial dentures, a: Patient presented in 1968 with collapsed maxilla;
flat, heavily-scarred, and short hard and soft palates; right bicuspid rotated 180
degrees, and anterior and lingual to cuspid; and hypernasal speech. Oral hygiene
was very good, b: Maxillary removable partial denture that restores lip support and
esthetics. Prior to prosthetic treatment, malpositioned bicuspid was extracted and
soft palate redivided so obturator prosthesis could be positioned in correct location
in nasopharynx, c and d: Esthetics, e: Obturator prosthesis, f: Patient in 1991. g:
Prosthesis.
9
 Cleft Lip and Palate 333

Fig. 8-3.
Fixed, removable prosthodontics. a: Diagnostic casts for 20-year-old patient in 1972 after
completion of orthodontic treatment. Note anterior maxillary discrepancy. Maxillary
advancement procedures for cleft patients were uncommon during this era. b: Fixed
component. The cleft segments were united with porcelain fused to metal crowns and hand
crafted bar. Note Thompson dowels for retention o f removable partial denture, c: Completed
restorations. A completely fixed restoration was not indicated because of need for additional
upper lip support, d: Prosthesis. Note thickness o f labial flange, e: Esthetics. Note only 3
incisors were used, but midline alignment with mandible was maintained.

Fig. 8-4. Fixed prosthodontics. a and b: Twenty-one-year-old patient with bilateral cleft lip and palate following third period of
orthodontic treatment in 1968. Note gingival irritation, lack of attached gingivae, and approximation of cuspids and
central incisors. Plastic crowns had previously been placed. Note heavy scarring of lip and nasal discrepancies, c:
Gingival health was restored, diagnostic wax-up was completed and 6 unit porcelain fused to metal fixed partial
denture was fabricated. If a bone graft is not contemplated, 2 teeth in each segment must be used to retain both the
fixed partial denture and arch alignment, d: Same patient 9 years later. Note improved gingival health.
334 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

a b c d

Fig. 8-5. a: Patient with repaired bilateral cleft lip and palate at approximately 10 years of age. Note lip and nasal
discrepancies, b: Same patient at 22, after 10 supernumerary and other poorly developed teeth were removed.
Diagnostic wax-up was completed to give patient and parents an idea of what could be accomplished. Note anterior
open bite and position of bicuspids, c: Pontic length was a concern, so a provisional removable prosthesis was
fabricated with a thin veneer over the bicuspids, d: Completed 10 unit fixed partial denture. Note improvement in
facial esthetics between (a) and (d). Small scar below lower lip is from Abbe flap lip switch surgical procedure, where
tissue from lower lip is rotated into upper lip to improve contour and bulk.

surfaces of the maxillary prominences of the developing max­

illa.
The secondary palate gives rise to the hard palate (from the
incisive foramen posteriorly) and the soft palate. The hard and
soft palates develop from 2 horizontal mesodermal projections
called lateralpalatine (nasal) processes or palatine shelves (Fig­
ure 8-6). Initially, these processes project interiorly towards the
tongue, but, as development occurs, the tongue moves down­
ward, and the palatine shelves become elongated superiorly to
the tongue and shift to a more horizontal position (7th week).
As development proceeds, the palatine shelves fuse with each
other in the midline, the primary palate, and the nasal septum.
The fusion begins with the nasal septum anteriorly (9th week)
and is completed by the twelfth week in the region of the uvula.
The posterior portion of the palatine shelves does not become
ossified and forms the soft palate and uvula. The palatine raphe
permanently indicates the line of fusion of the lateral palatine
processes. The incisive foramen remains the embryologic bor­
der between the primary and secondary palate3.
Fig. 8-6. Embryological development of face. Lack of fusion
Classification o f Clefts of embryological processes leads to formation of
clefts. Median nasal process (A), Lateral nasal
A number of different classification systems have been pro­ process (B), Maxillary process (C).
posed over the years. However, we prefer a simple classifica­
tion based upon embryology which divides cleft lip and palate
patients into 3 categories: (1) Cleft lip and alveolus (primary posterior clefts are different; anterior clefts are caused by de­
palate), (2) cleft of the hard and soft palate (secondary palate), fective development of the primary palate due to a mesenchy­
and (3) a combination of (1) and (2) (primary and secondary mal deficiency, whereas posterior clefts result from defective
palate) (Figures 8-7 and 8-8). In addition, clefts can be unilat­ development of the secondary palate due to growth disturbances
eral or bilateral. Thus, patients can present with a number of which interfere with the fusion of the palatine shelves. Anterior
combinations (Figure 8-9). clefts include cleft lip with or without a cleft of the alveolus.
The incisive foramen serves to separate the anterior from Posterior clefts involve the soft and/or hard palate up to the
posterior cleft malformations. Embryologically, anterior and incisive foramen.
 Cleft U p and Palate 335

Fig. 8-7. a: Left unilateral cleft lip and palate prior to lip. closure, b: Six months later and prior to closure of hard and soft
palates, c: Dentition and occlusion at 4 years. Note missing left deciduous lateral incisor and non-vital adjacent
central incisor. Also note crossbite on cleft side, d: Facial view at same age.

Incidence and Etiology

The incidence of clefting varies in relation to the popula­
tion studied. Vanderas has reported the highest rates in Ameri­
can Indians (1 in 278 live births), followed by the Japanese,
Maoris, Chinese, Caucasians and African-Americans (1 in 3,330
live births)6. The generally-accepted incident rate shows that 1
in every 700 infants bom has some form of clefting7. Left-sided
clefts (70% of unilateral clefts) are more common than bilateral
a clefts of the lip and palate, and the right-sided clefts are the
least common8.

Cleft Lip

Clefts of the upper lip, with or without cleft palate, occur

Fig. 8-8. a: Bilateral cleft lip and palate with protruding
premaxilla (prolabium), b: Lip closure 18 months
later. Several revisions of lip and nose will be
necessary during formative years.
Cleft patients may also present with other anomalies.
Syndromic forms of clefts are those with a medically or surgi­
cally relevant abnormality of an organ system outside the ana­
tomical cleft region and include mental retardation. The major­
ity (85%) of patients with clefts have the nonsyndromic form4.
The London Dysmorphology Database (1987) lists 215 non-
chromosomal syndromes that can include cleft lip, cleft palate,
or bifid uvula5.
approximately once in 1,000 births, with varying frequency
among ethnic groups9. Males are affected twice as frequently as
are females. The cleft of the primary palate can be unilateral or
bilateral, and it is most commonly found on the left side in pa­
tients with unilateral cleft Ups.
In a unilateral cleft lip, the maxillary prominence on the
affected side fails to unite with the merged medial nasal promi­
nences. If the mesenchymal masses do not proliferate and merge,
the overlying lip epithelium is not forced out, and a labial groove
will develop and persist As the epithelium in the labial groove
becomes stretched, it ruptures and thus divides the lip into me­
dial and lateral components. With a bilateral cleft lip, the mes­
enchymal masses of the maxillary processes do not merge with
the mesenchymal masses of the median nasal process. The epi­
thelium in both of the labial grooves stretches and breaks down,
resulting in a bilateral cleft. The degree of clefting can vary on
the 2 sides. When the cleft is complete bilaterally and involves
the alveolus, the premaxillary segment is free and protrudes
anteriorly. The resulting deformity is significant due to the lack
of continuity of the orbicularis oris muscle, which is essential
for mouth closure.
336 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Incisive papilla

a Hard palate
A
Soft palate
Uvula

Nasal

Nasal septum
D
Primary palate

Site of
incisive
foramen

Secondary palate

Fig. 8-9. Drawings of various types of cleft lip and palate, a: Normal lip and palate, b: Cleft uvula, c: Unilateral cleft of posterior
or secondary palate, d: Bilateral cleft of secondary palate, e: Complete unilateral cleft of lip and alveolar process with
a unilateral cleft of primary palate, f: Complete bilateral cleft of lip and alveolar process with bilateral cleft of the
primary palate, g: Complete bilateral cleft of lip and alveolar process with bilateral cleft of the primary palate and
unilateral cleft of secondary palate, h: Complete bilateral cleft of lip and alveolar process with complete bilateral cleft
of primary and secondary palate. (Adapted from: Moore K. The Developing Human: Clinically Oriented Embryology.
Philadelphia; W.B. Saunders.)

The failure of the median nasal process to develop and
merge results in a rare cleft, the median cleft lip (Figure 8-10).
This, a characteristic of Mohr syndrome, is transmitted as an
autosomal recessive trait10.
Flg. 8-10. Median cleft lip. A rare form of cleft.
Cleft Palate
Cleft palate, with or without cleft lip, occurs about once in
2,500 births. Isolated cleft palate is more common in females.
The fact that the palatine processes fuse about 1 week later in
females than in males may explain why isolated clefts of the
palate only are more common in females".
The embryological basis of cleft palate is the failure of the
mesenchymal masses of the lateral palatine processes to meet
and fuse with each other, the nasal septum, and/or the posterior
margin of the primary palate. This could result in a cleft of the
primary palate, cleft of the primary and secondary palates, or
cleft of the secondary palate only. Clefts of the secondary pal­
ate may involve both the hard and soft palates or may be lim­
ited to just the soft palate.
Causes of Clefts
Clefts can be caused by a number of factors that affect the
mother early in the first trimester. These factors include infec­
tions and toxicity, poor diet, hormonal imbalances, and genetic
factors. Most clefts are caused by multiple genetic and
nongenetic factors. The amount of neural crest mesenchyme
that migrates into the facial primordia is affected. If this defi­
ciency results in insufficient mesenchyme, clefts of the lip and/
or palate occur as part of syndromes that are determined by
single mutant genes, or as part of chromosomal syndromes, such
as trisomy 13. Teratogenic agents have also been associated
with causing clefts (Table 8-1).
Cleft Lip and Palate 337
Evaluation of twins indicates that genetic factors play a
greater role in cleft lip, with or without cleft palate, as com­
pared with clefts of the palate only. Complete clefts involving
the lip, alveolus, and palate are usually transmitted through a
male-sex-linked gene. When the parents of a cleft child are not
affected, the risk to a subsequent sibling is around 4 %9. Table
8-2 (A and B) shows the risk of clefting, depending upon the
family history of clefts.
Treatment and Sequence
Early lYeatment and Evaluation
Early Intervention and Counseling
When a child is bom with a cleft defect, the nurse from a
cleft palate team is notified. If the infant is in a hospital with a
cleft team, then the team nurse is able to perform an initial as­
sessment to determine the severity of the cleft and the possibil­
ity of other congenital deformities. The nurse then contacts the
parents to ascertain their level of understanding of the defect
and to clarify the information given to the parents. At this point,
the parents are grief stricken and are usually not prepared for
detailed information. It is important that the team members as­
sist with the emotional and social adjustment of the family. The
nurse should demonstrate an accepting attitude toward the in­
fant and emphasize the positive aspects of the child’s appear­
ance. Pre- and postoperative photographs of patients with simi­
lar defects may help considerably in reassuring the parents.
Before leaving the hospital, the parents should be able to
feed the infant and to examine and clean the cleft. Appoint­
ments should be made for evaluation by the complete team and
follow-up telephone calls should be made by the nurse and/or
the social worker to address any problems that may have devel­
oped.
Feeding
An infant with a cleft requires special nursing consider­
ations during feeding. Maintaining nutrition is a priority, as nour­
ishment is necessary for growth and development. Adequate
nutrition and hydration are essential for the infant and for the
infant’s preparation for the first surgery. It is important for the
pediatrician to closely monitor the infant’s development.
Depending on the type and severity of the cleft, a variety
of feeding devices are available. Infants with an isolated cleft
lip most often feed normally with a bottle or breast. A broad
base nipple will work well with a regular bottle to provide a
seal. The feeding problem is more significant with a cleft palate
with or without a cleft lip. Cleft palate infants generate a nega­
tive pressure when sucking and tire easily, resulting in unfin-
338 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Table 8-1. Teratogenic Agents Associated with Clefts.*

Agent C L±C P CP O ther Abnorm alities

Drug and Chemical Agents

Ethanol ? + +
Vitamin A congeners ? - + +
Folate antagonists- - + +
Alkylating agents - + +
Phenytoin + + +
Trimethadione - + +
Valproic acid + - +
Barbiturates ? ? +
Benzodiazepines 9 -
Meprobamate - ? ?
Physical agents
Fetal constraint ?
Amniotic bands + + +
Maternal health conditions
Diabetes mellitus + + +
Myotonic dystrophy - + +
Vitamin deficiency ? - +

Where + = associated with this agent, - = not known to be associated, ? = possibly associated but
data insufficient to warrant conclusion.

* Adapted from: Hanson JW, Murray JC. Genetic aspects of cleft lip and palate. In: Multidisciplinary Management
of Cleft Lip and Palate. Bardach J, Morris HL, eds. Philadelphia, 1990; W.B. Saunders.

Table 8-2 A. Empiric risk of nonsyndromic cleft lip with or Table 8-2 B. Empiric recurrence risks of nonsyndromic cleft
without cleft palate in Caucasians.** palate in Caucasians.**

A ffected Individual/ % at Risk Number Affected Individual/ % a t R isk Number

A t Risk Individual Individuals a t Risk A t R isk Individual Individuals at Risk
w ith CL + CP S tudied w ith CP S tudied

Parent/Child 2.9 1290 Parent/Child 3.8 585

S ibling/S ibling 4.0 5751 S ibling/S ibling 2.6 2067

Uncle o r A unt/ Uncle o r A u n t/

Nephew o r Niece 0.7 8794 Nephew o r Niece 0.4 4638

F irst co usin / F irst co u sin /

firs t C ousin 0.2 3941 firs t C ousin 0.2 8191

G randparent/ G randparent/
G randchild 0.3 365 G randchild 0.1 705

** Source: Williams W. Segregation analysis of cleft lip and palate. Thesis. University of Hawaii, 1981.

ished feedings. A feeding device that can deliver formula into
the mouth is necessary to conserve the infant’s energy.
Soft, premature nipples conform better to the palatal de­
fect than do regular hard nipples, which can improve sucking.
Cross cut nipples allow for easier flow of formula, thus de­
creasing the strain on the child. Longer nipples are more suc­
cessful, as they can be positioned posterior to the defect. The
squeeze bottle (Figure 8-11) has helped significantly to decrease
the effort required from the infant, as it allows the parent to
squeeze and control the flow of formula into the mouth. This is
especially helpful when the sucking reflex is weak. A bulb sy­
ringe can also be used to deliver formula without requiring ef­
fort from the child.
After a feeding technique has been selected, several modi­
fications may be required to suit the individual situation. Feed­
ing in a semi-upright position reduces nasal regurgitation. For
an infant with a cleft palate, feeding usually requires more time
and it should be unhurried. As the parent and child adjust to the
technique, the time required for feeding will usually decrease.
If feeding routinely requires more than 45 minutes, then the
child may be working too hard and the technique may need to
be reevaluated. On completion of feeding, a wet oral swab should
be used to clean mucous and formula from the cleft.
If the mother desires to breast feed her child, the attempt
should be made. A child with an isolated cleft lip should not
Fig. 8-11. Feeding aids.
Cleft Lip and Palate 339
have any problem. There may be some leakage of milk when
the child is sucking due to the inability to form a seal on the
breast. The seal can be improved by placing a finger over the
lip defect as the child nurses, or by using the areola to fill the lip
defect. If there is a unilateral cleft of the alveolus, the nipple
should be pointed toward the unaffected side.
When there is a cleft of the palate, breast feeding is more
difficult. This is due to the inability to generate and maintain
the necessary vacuum. The mother should position the nipple
toward the side of the cleft and support the breast with her fin­
gers so as to assist the child to grasp the nipple and prevent loss
of suction. Chin support for the infant will help to stabilize the
mandible and press the nipple and areola between the gums.
Breast feeding alone will usually not be adequate, so signifi­
cant augmentation with formula will be required to ensure ad­
equate nutrition.
Parents should practice feeding their baby while in the hos­
pital and before being sent home. Adequate nutrition is essen­
tial for growth and development so as not to delay the required
surgery. The first surgery for the lip is usually performed at
around 3 months. At UCSF, the “rule of ten” (10 weeks old, 10
pounds in weight, and a hemoglobin count of 10) is used as a
rough guideline for surgery.
340 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Genetic Evaluation
Genetic evaluation of an infant with a cleft of the lip and/or
palate should begin during the first visit as part of the team
evaluation (see next section). The evaluation includes an accu­
rate prenatal history with exposure to known teratogens, family
history with known relatives with a cleft, lip pits (Figure 8-12),
mental retardation, congenital heart disease, limb and ocular
abnormalities, bone dysplasia, and other birth defects known to
occur with cleft syndromes.
It is important that patients with a cleft are evaluated for
the possibility of a syndromic condition. The presence of a car­
diac anomaly or chromosome disorders could increase the risk
level of surgery. A complete physical examination is essential
with particular emphasis on cardiac evaluation and abnormali­
ties associated with the extremities, such as polydactyly, syn­
dactyly, and dwarfing. An examination of the parents and sib­
lings should also be performed, looking for lip pits, submucous
clefts, and so forth, as these conditions may indicate that Men-
delian disorders are segregating in the family. Trisomy 13, tri­
somy 18p-, and trisomy 4p- are common chromosomal disor­
ders with clefting. Chromosomal analysis is essential, especially
if other major organ systems are involved. The family should
also be informed of the long-term prognosis prior to surgical
intervention.
A genetic evaluation is not complete until all medical
records are obtained for family members with potential disor­
ders. The examination is completed on the patient with refer­
rals to the cardiology, ophthalmology, or other services, if re­
quired. Once all the information has been evaluated, a diagno­
sis of a syndromic or nonsyndromic cleft is made. If the diag­
nosis of a syndromic cleft is made, the parents will require coun­
seling concerning the etiology, incidence, risk to future offspring,
and the long-term prognosis.
Distinguishing syndromic from nonsyndromic clefts is
important from the prognostic aspect and for determining the
risk of recurrence in future generations. Clefts can also be present
with a range of severity. It is important for parents to under­
stand that severely affected children do not necessarily imply
severe defects for future children, or that mild defects signify
that future children will have a mild disorder. Counseling is
very important for the parents, especially with regard to the risk
to future generations (please refer back to Tables 8-2, A and B).
Fig. 8-12.
Lip pits on lower lip
(Van d e r W oude’s
syndrome).
Team Evaluation
At the UCSF Craniofacial Anomalies Center, a patient is
initially evaluated by the team. The team members represent
the various specialties that will be involved in the care of the
patient from birth to adulthood. The team is comprised of an
audiologist, geneticist, genetic counselor, nurse coordinator, oral
and maxillofacial surgeon, orthodontist, otolaryngologist, pe­
diatrician, pedodontist, plastic surgeon, prosthodontist, speech
pathologist, and social worker. Each patient is initially evalu­
ated by the entire team and, if required, additional referrals are
made for completion of the diagnostic workup. Following the
initial evaluation, a treatment plan is outlined and discussed with
the family. On recall visits, the team members involved in the
current active phase of treatment evaluate the patient. As treat­
ment progresses, modifications are made as necessary to the
previously outlined treatment sequence (Figure 8-13). Recall
visits are scheduled at least once a year until early adulthood.
Surgical lYeatment
Reconstruction of any defect, especially a congenital
defect, requires a thorough understanding of the anatomy and
embryology of the area. It is also necessary to understand the
anatomical and functional relationship of cleft-altered structures
to adjacent normal structures.
Lip repair
Anatomy The reconstruction of a cleft lip requires that the
faulty formation of the lip components, as well as their defec­
tive development, be corrected. It is also important to under­
stand the functional relationships between the lip, the adjacent
muscles of facial expression, and the nose. The upper and lower
lips are similar structurally; the major difference being the pres­
ence of the philtrum in the upper lip, which originates from the
fused medial nasal processes.
The lip can be divided into 3 zones; namely, the external
surface covered with skin, a transition zone with the vermillion
border, and the internal aspect of the lip covered by mucous
membrane. The vermillion zone is covered by thin, non-kerati-
nized epithelium, and it appears red due to the abundance of
capillaries and increased translucency of the epithelial layers.
The central philtrum, with its raised adjacent structures (the cris-
tae) and the medial tubercle, forms a curve at the vermillion
border. This curve is referred to as the Cupid’s bow of the lip.
The lip has many sweat and mucous glands. The vermillion
zone does not have any glands, but mucous glands are present
in the mucous membrane lining of the inner surface of the lip.
The orbicularis oris muscle, which structurally makes up
most of the lip, is firmly attached to both the external skin and
internal mucous membrane. The muscle originates from the
 Cleft Lip and Palate 341

Fig. 8-13.
a: A 4-year-old patient with bilateral cleft lip and palate, as presented in 1977 to
Center for Craniofacial Anomalies at UCSF. b: Dentition, as presented in 1977.
Note malformed deciduous central incisor and anterior open bite, c: Patient in
1980. d: Patient in 1983. Note increasing maxillo-mandibular discrepancy, e: Pa­
tient in 1987. Note midface retrusion. f: Panoramic radiograph following maxillary
advancement and alveolar cleft bone grafting in 1990. Note poor root develop­
ment of maxillary central incisors, g: Note occlusion following completion of orth­
odontic treatment and orthognathic surgery. At this stage, the treatment plan called
for a bone graft to the anterior maxilla, skin graft vestibuloplasty, and implant
placement, h: Provisional prosthesis in 1991, i: Autogenous iliac crest marrow
bone graft to premaxilla, j: Reconstructed anterior alveolar ridge 3 weeks post
operatively, k: Skin graft. I: Panoramic radiograph with 2 implants in anterior max­
illa. m and n: Completed porcelain fused to metal prosthesis, using UCLA abut­
ment. o and p: Patient in 1993 with completed prosthetic treatment. Compare
profile with (e). Minor revision surgery may still be required for lip and nose.
342 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
second branchial arch, which differentiates during the fifth week
when the facial nerve penetrates this mesenchymal mass. Dur­
ing the second month of normal embryonic development, the
orbicularis oris muscle, in its primitive form, reaches the mid­
line of the lip and joins with its companion muscle on the oppo­
site side. The muscle consists of an external and an internal
layer and is not covered by fascia. The external layer originates
from the periosteum of the maxilla and mandible in the region
of the anterior teeth. The muscles of facial expression insert
into this external layer (Figure 8-14). The external layer of the
orbicularis oris muscle is responsible for opening of the mouth
as well as for the facial expressions associated with both the
upper and lower lips. The internal layer passes between both
comers of the mouth so it can perform its primary function of
constriction of the lips.
The main artery of the upper lip is the superior labial ar­
tery, a branch of the external maxillary artery. The arteries on
both sides meet and anastomose in the midline. The superior
labial artery branches off the external maxillary artery just be­
low the comer of the mouth. The external maxillary artery then
proceeds superiorly toward the nasolabial crease where it di­
vides into 2 branches at the nasal ala. The lateral nasal artery
supplies the nasal ala and tip while the angularis artery joins the
dorsal nasal artery, a terminal branch of the ophthalmic artery.
The superior labial artery in the philtrum produces a small branch
that supplies the frontal part of the nasal septum.
The theories of the pathogenesis of a cleft lip deformity
include tissue deficiency, malposition of the maxillary segments,
failure of fusion of the facial processes, and failure of mesoder­
mal penetration of the epithelial layer. Originally, it was be­
lieved that the cleft lip resulted from a failure of the fusion of
the lateral maxillary processes and the fronto-nasal process. This
implied that the deformity was due to a lack of fusion only, but
all the tissue components were present. However, it is now ac-
Caninus
Triangularis
Fig. 8-14. Diagram representing muscle fibres in the lip. Note
position of nasolabialis muscle, elevating the cen­
tral part of lip.
cepted that the cleft is a result of failure of mesodermal penetra­
tion of the epithelial layer, which results in a tissue deficiency
in the cleft area. The lack of tissue is an important consideration
for the surgeon during the repair, as a simple rearrangement of
the tissues will not provide a satisfactory result. Studies on the
changes in the orbicularis oris muscle in the cleft patient dem­
onstrate that the facial nerve and arteries of the lip follow the
course of the muscle bundles12.
In the cleft patient, the muscle stumps of the orbicularis
oris do not grow in a lateral to medial direction in order to meet
in the midline. Thus, this mutual insertion with the companion
orbicularis muscle is missing. As the stumps do not meet in the
central line of the lip, they seek attachment to firm points in the
area. As a result of these atypical insertions, the muscle is not
functional, and its development is incomplete. In complete bi­
lateral clefts, the prolabium does not have any muscle fibers.
Therefore, to achieve proper lip function following surgery, the
surgeon must detach the orbicularis oris from its atypical inser­
tions and bring the muscle bundles together (end to end) or en­
courage them to grow into the prOlabium. This will enhance
proper function and foster further growth and development.
It is not the purpose of this chapter to discuss surgical tech­
niques for lip repair (Figure 8-15). We have outlined the patho­
genesis of the cleft lip and the goals for surgery. In order to
enhance proper function of the lip following surgery, it is es­
sential that the surgical repair include isolating the orbicularis
oris muscle bundles, releasing them from their atypical inser­
tions, and reorienting them in a lateral to medial direction. De­
pending upon the tissue deficiency in the area, the bundles could
be placed end to raid or allowed to grow into the prolabium.
The surgical technique will vary with the severity of the cleft.
Thus, the greater the tissue deficiency, the more difficult the
surgical procedure. In cases with significant tissue deficiencies,
multiple procedures may be necessary. The surgical procedure
is also complicated by the degree of involvement of the nose.
Adjunctive Surgical Procedures
We will mention a few of the commonly used surgical pro­
cedures often performed after lip and palatal closure and con­
tinued as the child matures.
Lip adhesion The lip adhesion operation has been used for
many years. According to Randall, lip adhesion converts a wide
and difficult to close cleft lip into a much less difficult incom­
plete cleft13. Johanson and coworkers were the first to perform
a lip adhesion procedure14. Their protocol suggests a prelimi­
nary operation to close the lip and alveolus prior to the primary
bone grafting procedure. A second operation is then performed
to insert autogenous bone in the alveolar cleft along with a more
definitive lip repair. When Randall followed this protocol, he
found that, during the second procedure, there was frequently

Fig. 8-15. Modified Le Mesurier surgical technique for lip closure, a: Development of flaps, b: Flaps pre­
pared for closure, c: Lip closure. Note conservation of lip tissue and relaxing incision around cleft
nostril.
little or no space remaining to insert bone in the alveolar cleft,
but the lip repair was easier and the alveolus had been reposi­
tioned nicely.
Lip adhesions are most beneficial for patients with a bilat­
eral cleft lip and palate and a protruding premaxilla. The lip
adhesion operation helps to reposition the protruding premax­
illa posteriorly. It provides for more underlying bone and re­
duces tension during lip repair. In bilateral clefts, where the pro­
labium is small, lip adhesions act as a skin expander, stretching
the prolabium and making the definitive lip repair easier to per­
form. Lip adhesions are usually combined with the closure of
the soft palate. This combined procedure leads to a significant
narrowing of the hard palate cleft Definitive lip repair can then
be done with greater ease, better landmarks, and lesser tension.
A number of modifications to the lip adhesion procedure have
been reported, most notably by Millard15 and by Walker and
Collito16.
Associated nasal deformities Some degree of nasal deformity
is associated with all clefts of the lip. The nose develops in con­
junction with the primary palate, which contributes not only the
premaxilla but the columella and the anterior nasal septum as
well. Though the exact process of formation of this region is
not completely understood, at least 2 factors are involved in the
development of the cleft lip and nose. There is agenesis of tis­
sues in the region of the cleft, due to deficiencies of mesoderm
and ectoderm, which induces a mechanical stress to the devel­
oping nose from the progressive separation of the cleft. Meso­
dermal deficiencies are seen in the lack of bony development at
the piriform margin in the floor of the cleft nostril, in the defi­
ciency of septal cartilage, and, occasionally, in the anterior na­
sal spine. The ala nasi is always thinner on the cleft side. The
ectodermal deficiency is manifested in the underlying dental
abnormalities discussed later in this chapter.
Cleft Lip and Palate 343
The alar cartilage is the focal point of the cleft lip-nasal
deformity. Normally, these cartilages are high in the nasal tip,
and the alar dome is at the level of the junction of the middle
and lower thirds of the nasal bridge. On the cleft side, the alar
cartilage is spread and rotated downward, while the alar dome
is displaced downward, backward, and laterally. This produces
a drooping of the nostril rim on the cleft side. A shortening of
the columella occurs as the alar dome is deflected away from
the nasal tip. The arch of the nostril is flattened and the ala joins
the columella at an oblique angle. The columella is tilted away
from the midline towards the noncleft side. The tip of the nose
is irregular, broad, and less prominent, as the alar dome is dis­
placed backward, laterally, and downward. In complete clefts,
the width of the nose is greater than normal. In bilateral clefts,
the nasal tip is flat and broad, and the nostril rims may droop
and curve downward. The columella appears to be shortened,
or nonexistent, and joined directly to the tip of the nose. The
septum is usually in the midline, but the premaxilla can be twisted
and/or deviated, especially if the cleft is incomplete on one side.
The goal of cleft lip and nose repair is a multilayered, ana­
tomical closure of the cleft with restoration of lip function by
realigning the displaced lip and nasal anatomy while preserv­
ing as much tissue as is possible. Complete clefts are more dif­
ficult. The margins of the cleft lip are lengthened and aligned
without loss of tissue in a transverse dimension, and the nasal
dome, ala, and alar base must be aligned atraumatically, with­
out causing skin webbing, folds, or vestibular stenosis.
Repair of the cleft lip will improve nasal appearance. The
degree to which surgeons address nasal reconstruction at the
time of initial lip repair will vary. Excellent results can be
achieved by either repairing the nose at the time of initial lip
repair, or by delaying the nose repair to a later date. Even if the
nose is repaired at the initial lip repair, it most often will require
some revision surgery, as growth occurs and the underlying
344 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 8-16 .
a: Bilateral cleft lip and palate patient in 1974. b: Patient in 1979. Note nasal and lip deforma­
tion. c and d: Patient in 1994 following multiple lip and nasal surgical procedures and maxillary
advancement.
supporting bony skeleton is repositioned surgically or
orthodontically (Figure 8-16).
Revision surgery The ideal timing for surgery to correct the
remaining deformities is a complex strategy. Optimal timing
for surgery is dependent upon the nature of the deformity, the
amount of scar formation, and the prolonged effects of surgical
trauma on facial growth. Surgery for simple problems, such as
lip scars and muscle bulging, can be carried out as early as 12
months following the initial repair. Structural deformities, such
as long, tight, or short lips, and nasal deformities are related to
growth of the facial skeleton. Definitive repair of these struc­
tural deformities is best performed once the dental, orthognathic,
and maxillary components have been successfully treated. Un­
treated skeletal and dental asymmetry for both unilateral and
bilateral clefts will adversely affect lip repair. Dental and
orthognathic bony manipulation can delay lip repair until a sat­
isfactory orthodontic goal is achieved. It is unrealistic to ac­
complish all these goals with a single surgical procedure, and
the decision for suigical correction should be made to achieve
the most favorable long-term result.
Palatal Repair
The principle objectives of cleft palate repair are enhance
normal speech development, provide anatomical palatal clo­
sure, and minimize maxillary growth inhibition and dentoal-
veolar deformities. The different muscles, their innervation, and
their function have been discussed in Chapter 7.
The main consideration regarding palatal closure is that
the surgery on the palatal shelves should not be performed too
early. As the child grows, the palatal shelves continue to grow
and the cleft narrows, especially if lip continuity has been re­
stored. The timing for palatal surgery varies from 12 months to
4 years, depending upon the philosophy of the team and the
width of the cleft. If the cleft is very wide, then there may not be
sufficient tissue available to permit closure with adequate length
and function. In this situation, it is better to delay closure.
Due to the variability in the extent of the cleft, availability
of tissue, and experience of the cleft team, evidence is not avail­
able to definitively support either the timing or any particular
surgical procedure for palatal closure. Proponents of delayed
palatal closure (Zurich approach) feel that delayed palatal sur­
gery will limit the inhibition of maxillary growth, minimizing
the need for surgery to advance and/or widen the maxilla. Op­
ponents of this approach feel that delayed closure of the palate
will lead to the development of compensatory speech and swal­
lowing patterns, which are not easily corrected.
The decision to use a prosthesis during the first few years
of life are dictated by the experience of the team and the recom­
mendation of the speech pathologist. At the Center for Cranio­
facial Anomalies, we rarely fabricate a prosthesis for an infant.
For most patients, the soft palate is closed at around 12 months
of age. The only exceptions are for very wide clefts and for
patients with Robin sequence (Pierre Robin syndrome). For
patients with Robin sequence, the mandible is small and retruded
so that the tongue is in a more posterior and superior position.
Closing the soft palate cleft may lead to an inability to breathe
through the nose, as the retrusive tongue may close the nasophar­
ynx. The decision as to when to close the cleft must be made
individually for these patients. The surgeon must be sure that
the mandible has grown sufficiently to allow the tongue to oc­
cupy a more normal anterior position.
While it is not the purpose of this chapter to discuss surgi­
cal techniques, we will briefly discuss 2 of the commonly used
procedures; namely, the Von Langenback technique, first de­
scribed in 1861, and a 2-stage palatoplasty (Zurich approach).
The Von Langenback technique consists of the following
steps: incising the edges of the cleft, dividing the palatal mus­
culature, detaching the mucoperiosteal flaps of the palate, and
applying sutures. Most surgeons essentially carry out these same
steps today. Opponents of this technique point out that this pro­
cedure results in significant scar contracture which tends to pull
the soft palate forward, creating palatal insufficiency and pre­
venting velopharyngeal closure. The low rate of fistula occur­
rence made this procedure widely acceptable; however, dissat­

isfaction with the functional results have led many surgeons to
modify the original procedure by reconstructing an active muscle
sling for velopharyngeal closure and for appropriate function
of the eustachian tube. In order to improve function, the need to
reconstruct the displaced halves of the levator veli palatini
muscles become apparent. Today, the levator sling reconstruc­
tion is frequently combined with the Von Langenback proce­
dure.
The 2-stage palatoplasty procedure has been used in Zurich
since 1969. The procedure is based on interaction and coopera­
tion between maxillary orthopedic treatment and surgery. Or­
thopedic guidance is initiated at birth and continued until the
child is 16 months of age. The main objective of orthopedic
guidance is to restrict the tongue from the cleft, normalize feed­
ing, and allow spontaneous narrowing of the cleft, thus facili­
tating subsequent soft palate closure and providing more tissue
for velar length. The soft palate is closed around 18 months of
age, and the hard palate is closed when the child is 4 to 5 years
of age. Individual variations are based on development of the
child, particularly of speech. The Zurich approach was devel­
oped as the team found deficiencies in the procedures that were
previously used. This group found that the Von Langenback
technique, together with its various modifications, resulted in
maxillary hypoplasia and poor speech. The group then adopted
the 2-stage procedure, as described by Slaughter and Brodie17,
but this procedure was abandoned because of poor speech re­
sults. A single-stage procedure was then used, but many residual
fistulae and poor development of the maxilla resulted in aban­
doning this procedure as well. It was then that the Zurich 2-
stage palatoplasty approach was adopted.
Growth and Development, and Orthodontic Treatment*
In assessing craniofacial jaw proportions and relationships
in a growing child with a cleft condition, it is important to know
that jaw growth and dentoalveolar development may not fol­
low normal patterns. Knowledge about growth expectations is
particularly important in treatment planning. The extent to which
Fig. 8-17. a: Unilateral cleft. Note medial displacement of posterior segment on cleft side, b: Bilateral cleft. Note medial dis­
placement of both posterior segments, c: Presence of supernumerary teeth maintain a more normal arch form.
The section on growth and development, and orthodontic treatment contributed by Karin Vargervik.
Cleft Lip and Palate 345
growth is inhibited or aberrant depends on many factors, in­
cluding the degree of intrinsic tissue deficiency and the quality,
amount, and location of scar formation consequent of surgical
intervention.
Early presurgical manipulation of maxillary segments is
advocated in some centers for the purpose of facilitating surgi­
cal repair and, purportedly, creating an environment for normal
tongue position and function as well. The expectation is that
normal function would follow. However, this has not been clearly
documented. At the Craniofacial Center, presurgical orthope­
dic treatment is generally not initiated in unilateral clefts. It is
often necessary, however, to mold a prominent premaxilla back
into a position that facilitates lip repair in bilateral clefts.
Following lip and palate repair, there will be molding of
the anterior alveolar process due to pressure from the lip, and
narrowing of the maxillary arch as a consequence of scar tissue
following palate repair. The usual finding in a 3-year-old with a
repaired unilateral cleft is medial collapse of the cleft segment
with crossbite of the cuspid, with or without crossbite of the
molars (Figure 8-17a). In bilateral clefts both lateral segments
may be in a medial position (Figure 8-17b). The cleft margins
of the segments usually contact each other by age 4 to 5. This
contact counteracts further medial movement of the segments
unless the teeth on the cleft margin are lost and the surrounding
alveolar bone is resorbed. The degree of maxillary width reduc­
tion is closely related to the development of the alveolar pro­
cess; this, in turn, is determined to a large extent by the number,
position, size, and shape of the teeth in the area (Figure 8-17c).
Therefore, premature loss or removal of teeth on the cleft mar­
gin is undesirable.
Growth During Primary and Mixed Dentition Stage
During the primary dentition stage, jaw relationships, oc­
clusion, and position of individual teeth usually remain stable,
unless there is severe tooth decay and loss. There may be a su­
pernumerary tooth present, usually situated on the palatal aspect
of the lateral cleft margin. Often, the lateral incisor is missing.
346 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Studies on skeletal morphology and size in unilateral cleft
lip and palate have shown few differences from average values
for normals in the late primary and early mixed dentition
stages18,1^ 0. As part of a study of orthodontic treatment effects
on subjects with unilateral cleft lip and palate at the Craniofa­
cial Center, pretreatment cephalometric head films of 8 girls
and 8 boys with unilateral cleft lip and palate (UCLP) were
studied. The mean age was 8 years, 1 month for the girls, and 7
years, 2 months for the boys. The mean values for both groups
did not differ significantly from the control values for any of
the measurements which were selected to determine unit sizes
of the maxilla and mandible and jaw relationship21.
In bilateral cleft lip and palate (BCLP), the premaxilla is
usually protrusive at birth, and it remains protrusive during the
first years of life if surgical intervention in this area is limited to
lip closure22.
The transition from the primary to mixed dentition is char­
acterized by an increased discrepancy between maxillary and
mandibular sizes and dental arches. The permanent lateral inci­
sor on the side of the cleft is frequently missing, and there is a
high incidence of congenital absence of bicuspids. The central
incisor on the cleft side averages 10% narrower than the other
central incisor, and its shape is often abnormal. The path of
eruption of the central incisors is lingual and towards the cleft;
these teeth are usually severely rotated as well. Further medial
displacement of the alveolar process on the cleft side, and an
increased anterior crossbite, usually occur during this stage.
When the maxillary segments are displaced medially, the
tongue cannot be accommodated in its normal position in the
palate. The position that the tongue acquires becomes decisive
for the pattern of further development of the maxilla as well as
the mandible. If nasal respiration is adequate, the tongue may
be positioned below and in contact with the occlusal surfaces of
the maxillary teeth duringrest. When this occurs, alveolarheight
is inhibited—even in the absence of restrictive scar tissue. If
nasal respiration is impeded, the tongue may assume a low pos­
ture in order to facilitate oral respiration. If the tongue in this
low position does not rest under the occlusal surfaces of the
maxillary teeth, the alveolar height will increase, resulting in a
progressive lowering of the mandible, a more open gonial angle,
and a more retruded position of the chin.
Growth and Development in the Adolescent
Progressive retrusiveness of the maxilla may occur during
later growth. In noncleft children, mandibular length measured
from condyle to pogonion increases by average yearly incre­
ments of 2.5 mm2'. The corresponding figure for the maxilla is
1.5 mm. Adjustments for this difference in growth in length of
the jaws takes place in the alveolar processes, and primarily by
downward and forward development of the maxillary alveolar
process. In a child with cleft lip and palate, this adjustment
mechanism is often impeded and becomes an important cause
ofjaw disproportions during active growth periods, particularly
during adolescent growth.
A tight, scarred lip and scar tissue bands in the palate can
impede the forward growth of the entire maxilla as well as the
alveolar process. The retrusiveness of the maxilla and maxil­
lary alveolar process generally becomes more pronounced dur­
ing this stage.
In a study on 16 individuals with unilateral clefts who had
received orthodontic treatment and 8 who had only received
surgical treatment, we reported that the average downward and
forward growth, and translation of die maxilla, was not only
significantly less in the untreated group than in the treated, but
also significantly less in the treated group than in the noncleft
control group21.
In a study on bilateral clefts, we reported that the premax-
illaiy region stayed more protrusive than normal up to age 12,
but, after 12, it became gradually more retruded as the man­
dible continuedto grow at a normal rate22.The premaxilla started
out as excessively protrusive, but came forward at an average
rate of 1.0mm per year, versus the normal increment of 1.5 mm
per year from age 6 to 16 years. Therefore, in planning treat­
ment for a child with a repaired bilateral cleft, it is important to
accept early prominence of the premaxilla, taking into account
that the forward growth in this area will be less than normal.
Principles of Orthodontic Treatment
Expand the maxilla to correct segmentposition and crossbite
In order to achieve lateral movement of the cleft segment, a
palatal rather than a labial appliance must be utilized. Several
appliance types are available for this purpose, such as a plain
lingual wire with auxiliary springs (typically used at UCSF) or
a quadhelix appliance (also commonly used). This treatment
(Figure 8-18) is usually started at around age 7, at the time of
eruption of the permanent maxillary incisors and after eruption
of the first permanent molars. As the permanent incisors are
almost always malpositioned, they need to be straightened. This
is done in conjunction with maxillary expansion. When adequate
maxillary width has been achieved and the incisors aligned, the
expansion is retained by bonding a simple lingual arch wire
onto the lingual surfaces of these teeth.
Monitor eruption of teeth Ectopic position of toothbuds and
ectopic eruption is not uncommon in the cuspid and bicuspid
area, and exfoliation of the primary teeth may not proceed nor­
mally. It is, therefore, importantto obtain radiographs on a regu­
lar basis and extract primary teeth as necessary to facilitate erup­
tion of succedaneous teeth.
Other treatment considerations It is very important to decide
if a missing permanent lateral incisor space should be kept open

a b
Fig. 8-18. a and b: Patient with unilateral cleft lip and palate immediately after placement of maxillary expansion appliance, c
and d: One year following expansion of maxilla.
for prosthetic replacement or closed by mesial eruption and
movement of the cuspid (Figure 8-19). If the size of the maxilla
is judged to be borderline small and/or the cuspid appears to be
too large compared to the other lateral, the lateral space may
preferably be kept open for later implant placement. If, how­
ever, it is decided that the cuspid should come forward, bone
grafting of the alveolar cleft should be done early, after expan­
sion but before the cuspid crown has moved down into the bony
defect.
Full orthodontic treatment is begun after eruption of the
bicuspids and cuspids. Standard orthodontic treatment is done
in the permanent dentition. Long-term retention is necessary, as
there will be a tendency for loss of both maxillary width and
incisor position.
If occlusal and esthetic objectives cannot be achieved by
orthodontic treatment, orthognathic surgery must be considered.
Almost always, the cause of the jaw size discrepancy is a hypo­
plastic maxilla. The amount of advancement versus lowering
of the maxilla must be determined primarily on the basis of
tooth display and other clinical measures of facial balance and
esthetics.
Fig. 8-19.
Patient with mesial movement o f left
cuspid into missing lateral incisor’s po­
sition.
Cleft Lip and Palate 347
e d
Pharyngeal Flaps and Obturator Prostheses
While the anatomical and physiological basis for obturator
fabrication and placement is discussed in Chapter 7, a brief dis­
cussion of obturators for pediatric cleft palate patients seems
appropriate in this chapter. Most velopharyngeal discrepancies
for cleft patients are managed surgically, usually with a combi­
nation of a push back and palatal closure procedure initially (9
to 12 months), followed by a superiorly based pharyngeal flap
procedure (about 3 to 7 years), if necessary. After surgical treat­
ment has improved the functional aspects of the velopharyn­
geal mechanism, intensive speech therapy is usually required
to refine speech production. The success of these combined
therapies has improved the speech of most cleft palate patients
to the point of acceptability.
However, there are 2 types of cleft lip and palate patients
that may require obturator prosthesis. A small number of pa­
tients, primarily patients with clefts confined to the secondary
palate, are best managed prosthodontically without surgery (Fig­
ure 8-20). These patients characteristically have an unusually
wide posterior bimaxillary width, a paucity of residual palatal
tissues, or are poor anesthetic risks. Again, this is a very small
group. The second group includes those patients with
hypemasality and inadequate speech following push-back and
pharyngeal flap suigical procedures and, thus, prosthodontic
intervention is indicated.
When velopharyngeal deficiencies and hypemasality are
evident, usually due to inadequate length or movement of the
soft palate, closure of this sphincteric valve is compromised.
Air escapes into the nasopharynx and nasal cavities, and oral
pressure is not adequate for proper articulation and oral reso­
nance. To reduce the size of the velopharyngeal orifice, a verti­
cal flap is raised along the midline of the posterior pharyngeal
wall, rotated forward, and attached into the nasal surface of the
soft palate to reduce orifice size, leaving 2 small openings later­
ally for nasal breathing. During closure, the lateral pharyngeal
walls move medially to contact the flap and close these lateral
openings (Figure 8-21).
There are 2 types of pharyngeal flaps, a high attached and
a low attached flap, based on the location of flap attachment to
348 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 8-20. a: Provisional prosthesis with obturator extension in the process of being developed with modeling plastic. The
team advised a trial period with a prosthesis prior to considering a pharyngeal flap. Note Adams retainers, b: Provi­
sional prosthesis in mouth, c: Fluid wax added and formed functionally after modeling plastic was reduced about 1
mm in all dimensions, d: Finished prosthesis adjusted with pressure indicating paste. Patient did well with prosthe­
sis so pharyngeal flap was not necessary. Obturator bulb reduced in vertical extension to correspond with area of
greatest motion.

Fig. 8-21. a: Palatal closure and push-back procedure. Flaps are raised in hard palate area and then rotated posteriorly to
increase length of reconstructed palate. Denuded areas are allowed to granulate in. b: High-based pharyngeal flap.
Soft palate is redivided for access to posterior pharyngeal wall. Flaps are raised on the nasal surface of soft palate
and from the posterior pharyngeal wall. Pharyngeal flap is rotated into soft palate, and oral surface lined with nasal
flaps, so both surfaces of pharyngeal flap have mucosal covering. As organization and contraction occurs, soft
palate is pulled toward area of normal closure, c: Pharyngeal flap-soft palate during closure.
 Cleft Lip and Palate 349

the posterior phaiyngeal wall. Fortunately, high attached pha-
ryngeal flaps are preferred by most surgeons. With healing, these
flaps tend to organize and contract, thus pulling the soft palate
toward the area of flap attachment. Therefore, a high-based flap
will tend to elevate and pull the soft palate toward the area of
normal closure in the nasopharynx, whereas the low-based flap
will tether the soft palate and restrict palatal elevation.
Prosthesis for these patients are usually fabricated with
acrylic resin with adapted wire retainers. Adams or interproxi-
mal ball clasps are effective and require minimal tooth prepara­
tion. If retention is or becomes a problem, orthodontic bands
with buccal lugs or bonded brackets will provide excellent re­
tention. One of the problems we have experienced in fabricat­
ing obturators for this small group of patients is access to the
area of normal closure in the nasopharynx. Access was excel­
lent for the patient depicted in Figure 8-22, as a portion of the
flap broke down on the patient’s right side, whereas access was
restricted for the patient in Figure 8-23. The low-based pharyn­
geal flap used in this instance required that both of the 2 small
obturators must extend superiorly for a considerable distance to
reach the area of optimal tissue motion. In this process, it is
very difficult to avoid contact with immobile phaiyngeal tis­
sues below the level of optimum motion. This constant contact
will create hyponasality and restrict nasal breathing. These pros­
theses may stimulate additional peripheral motion, so periodic
adjustments may be required23.

Fig. 8-22. a: High-based pharyngeal flap. Right side of flap broke down, leading to hypernasality. Team recommended trial
period with prosthesis. Access is now available to nasopharynx and area of normal velopharyngeal closure, b:
Provisional prosthesis, c: Provisional prosthesis in mouth.

Fig. 8-23. a: Low-based pharyngeal flap with soft palate tethered inferiorly. Openings laterally were larger than anticipated,
with subsequent hypemasality. A tria l period with provisional prosthesis was recommended, b: Prosthesis, c: Provi­
sional prosthesis in mouth. Because soft palate is tethered inferiorly, it was difficult to extend these small obturators
superiorly to the area of tissue movement without creating constant contact with inferior immobile pharyngeal tis­
sues, thus creating hyponasality. After this trial period, further pharyngeal surgery was recommended.
350 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Bone Grafting the Alveolar Cleft*
The goals for grafting the alveolar cleft are: (1) to separate
the oral and nasal cavities, (2) to stabilize the maxillary seg­
ments with a bony union, (3) to provide normal quality of bone
in the alveolus for orthodontic movement and support for the
teeth, and (4) to provide adequate 3-dimensional bone volume
for placement of an osseointegrated implant or implants when
this procedure is indicated.
The timing for surgical closure of the alveolar cleft, which
can be divided into 3 categories, remains controversial. The clo­
sure of the oronasal fistula, with or without placementof a bone
graft in the alveolar cleft, at the time of lip closure (less than 1
year of age) is classified as “early” closure. Secondary closure
applies to those patients who have a fistula closed and bone
grafting to the alveolar cleft during the mixed dentition stage
when the maxillary canine root is one-half to two-thirds devel­
oped. The third group of patients are those who have the alveo­
lar cleft grafted after growth is essentially completed. For these
patients, the fistula and alveolar cleft are often repaired in com­
bination with a LeFort I osteotomy to correct midfacial retru-
sion. The surgical technique for closure of oro-nasal fistula is
demonstrated in Figures 8-24 and 8-25.
Ross investigated treatment variables affecting facial
growth in unilateral lip and palate patients24. Fifteen centers from
around the world contributed 1,600 cephalograms of 538 Cau­
casian males with unilateral complete cleft lip and palate. Ross
compared 213 subjects who had various types of alveolar clo­
sure with 226 subjects with no alveolar surgical repair. The re­
sults demonstrated that surgical manipulation of the alveolus in
unilateral cleft lip and palate prior to completion of growth re­
sulted in a deficiency of vertical growth of the anterior maxilla.
If a bone graft or periosteoplasty were used, the vertical growth
deficiency of the maxilla increased. There was also a slight an­
teroposterior maxillary deficiency following bone grafting in
comparison with those patients who were not bone grafted. The
Ross data is clinically significant regarding the timing and type
of operation. The effect of bone grafting an alveolar cleft in
infancy is different from that of bone grafting in the late mixed
dentition. Those patients treated after age 9 showed little growth
inhibition24.
Friede and Johanson reported severe maxillary retrognathia,
and a vertical deficiency that worsened with age, in patients
who had alveolar cleft bone grafting in infancy25. Similar re­
sults were reported by Robertson and Jolleys26. Rosenstein, in
contrast, believed that early alveolar cleft repair and bone graft­
ing does not significantly retard maxillary growth27. The cur­
rent consensus is to close the oronasal fistula and bone graft the
alveolar cleft with iliac cancellous bone and marrow during the
late mixed dentition28. By this age, the maxilla should have
achieved its appropriate width either spontaneously, or through
orthodontic treatment. The canine root should be one-half to
Section on bone grafting the alveolar cleft contributed by Leonard B. Kaban.
two-thirds developed. The majority of maxillary canines will
spontaneously erupt into the cleft when it is grafted with iliac
cancellous bone29’30,3132. If the canine does not erupt spontane­
ously, it can be exposed and orthodontically aligned in the arch.
Finally, if a midfacial deficiency develops, the maxilla can be
moved forward and downward as a single unit with a LeFort I
osteotomy to restore midfacial harmony.
In patients with bilateral cleft lip and palate, the position of
the premaxilla and its relationship to the lip and nose must be
considered. Vargervik studied 63 patients with bilateral com­
plete cleft lip and palate who had no premaxillary surgery22.
The premaxilla was protrusive throughout the deciduous and
mixed dentition periods. By age 12, however, the premaxilla
became relatively more retrusive as mandibular growth pro­
ceeded more normally. At the end of growth, none of these pa­
tients had an excessively protrusive premaxilla. Therefore, it is
advantageous to maintain the premaxilla in its protrusive posi­
tion during these formative years to avoid midface retrusion as
the child approaches maturity. In 12 subjects who had premax­
illary surgery in infancy, or in early mixed dentition, to set back
the premaxilla, or stabilize it to the posterior segments, forward
growth of the premaxilla was decreased, as compared to
nontreated individuals. All 12patients developed severe midface
retrusion. Surgical procedures that reduce the prominence of
the premaxilla should, therefore, be avoided in growing patients,
except in extreme cases of premaxillary protrusion where the
position of the premaxilla will interfere significantly with the
proposed lip and nose surgery.
The use of osseointegrated implants to restore the missing
dentition in noncleft patients is well documented33,34,35. Patients
with cleft lip and palate are frequently missing the lateral inci­
sor on the cleft side. If the treatment plan includes prosthetic
replacement of the missing lateral incisor, the surgeon must plan
for the placement of an implant by overcorrecting the width
and height of the alveolar ridge. In addition, the timing of im­
plant placement is critical. Perrott reported that, after 3 months,
there may be significant resorption, which rapidly reduces the
width and height of the reconstructed alveolar ridge36. There­
fore, they recommend placement of endosseous implants in
grafted alveolar clefts within 3 to 6 months of the grafting pro­
cedure.
Restoring the Missing Dentition
Most cleft lip and palate patients will require more special­
ized and continuing prosthodontic services, as compared to
noncleft patients. There are several reasons for this additional
care. If the cleft involves the primary palate, invariably the lat­
eral incisor in the area of the alveolar cleft will be missing or
significantly malformed. However, the deciduous lateral inci­
sor is usually present with relatively normal morphological de­
velopment. The maxillary central incisor adjacent to the cleft is
 Cleft Lip and Palate 351

Fig. 8-24. Diagrammatic representation of closure of oronasai fistula, a: The cleft is incised (dashed
line) at its margin, b: Medial and lateral flaps are elevated fo r nasal lining (upper dia­
gram). Palatal flaps are mobilized for closure. Iliac cancellous bone and marrow in al­
veolar cleft, c: Alveolar ridge covered with buccal rotation flap, d: Alveolar ridge covered
with flap of alveolar mucosa and gingiva. (Source: Kaban L. Pediatric Oral and Maxillo­
facial Surgery. Philadelphia, 1990; W.B. Saunders.)

Fig. 8-25 . a: Radiograph of a 30-year-old female with repaired bilateral cleft lip and palate, but unrepaired alveolar cleft and
presence of oronasai fistula. Note fractured tissue bar adjacent to right cuspid, b: Alveolar cleft prior to bone graft,
c: Autogenous iliac crest bone grafted to alveolar cleft, d: Panoramic radiograph 3 months following surgery. Eden­
tulous space restored with removable partial denture.
352 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

a b c d

Fig. 8-26. a: Right maxillary lateral incisor is missing. Note smaller size, hyperplastic enamel and composite restoration of
adjacent central incisor, and slight anterior open bite in cleft region. Excessive space exists for replacement lateral
incisor, b: Left maxillary lateral incisor missing. Inadequate space exists for replacement tooth. Note more normal
ovoid contour of larger right cleft segment, but a linear contour of smaller left cleft segment, c: Lateral incisor and 1
bicuspid missing. Note cuspid position is distal to remaining bicuspid, d: Right lateral incisor present. Note size of
lateral and central incisor and slight open bite in cleft area.

often smaller than the companion central incisor (in a unilateral
cleft), and the teeth on either side of the cleft will characteristi­
cally display hypoplastic enamel formation in varying degrees
(Figure 8-26). The teeth in the premaxilla usually have shorter
and poorly developed roots. In addition, cleft lip and palate pa­
tients are more likely to have supernumerary or other missing
teeth. A substantially higher incidence of congenitally missing
teeth in both maxillary and mandibular arches has been reported
in cleft children37. Twenty-four percent of patients with cleft Up
and palate were congenitally missing premolars, compared with
6.6% in the general population38. Mackey reported that 49.6 %
of cleft patients had 1 or more congenitally missing teeth39.
Mackey also found that 21% of patients with cleft lip and palate
had 1 or more supernumerary teeth. Thus, with the potential for
missing and/or malformed teeth and abnormal growth and erup­
tive patterns, most cleft patients will require more prosthodontic
care during their lifetime as compared to noncleft patients.
The jaws of cleft individuals tend to be smaller, especially
the maxilla. Due to lack of downward and forward growth of
the maxillae and the subsequent underdevelopment of the
midface, it is not uncommon for the dental arches to be of in­
sufficient length to accommodate a full complement of suc-
cedaneous teeth. The dentition may be crowded with an irregu­
lar alignment because of this lack of space. The maxillary cus­
pid frequently erupts into the cleft in a diagonal direction and at
a level superior to the gingival margin. Occasionally, the canine
is impacted horizontally in the palate, or only the cusp tip will
be visible in the alveolar cleft. Oral hygiene can be compro­
mised because of these alignment and eruptive patterns. Scar­
ring and inflexibility of the upper lip may complicate hygiene
in the anterior maxilla. The teeth in the premaxilla may be more
prone to caries due to malformation, malalignment, and hypo­
plastic enamel development. Adequately attached gingivae is
often scanty or missing around these maxillary anterior teeth.
Therefore, cleft lip and palate patients are likely to require
prosthodontic services to replace missing teeth, improve esthet­
ics, or possibly provide an obturator prosthesis if palatal sur­
gery is unsuccessful or contraindicated. However, definitive
prosthodontic care is customarily one of the final treatment
modalities in the progression of treatment from birth to early
adulthood.
Early Care
Early dental care is usually provided by the pedodontist
and orthodontist. The objective of this primary care is to estab­
lish a good oral hygiene regimen, maintain the dentition during
these formative years, and improve alignment and stimulate
growth orthodontically during this period. Even malposed,
malformed, and supernumerary teeth preserve bone and help
maintain arch alignment and occlusal relationships. For example,
it is important to maintain the teeth in the premaxillary seg­
ment These teeth can then be used as an aid in the early expan­
sion of the maxillae, and to correct anterior or posterior crossbite
tendencies. If the alignment of the deciduous teeth can be cor­
rected, they will help to guide the permanent teeth into this im­
proved alignment. Maintaining alveolar bone during growth and
development may enhance future prosthodontic care. For ex­
ample, adequate alveolar bone may be available in the premax­
illa as possible site(s) for implant placement or to provide sta­
bility and support for a removable prosthesis in later years.
Prosthodontic care during the preadolescent years is mini­
mal. A missing tooth or teeth, such as a missing lateral incisor
or incisors, is often incorporated into the orthodontic retainer

(Figure 8-27). Early prosthodontic treatment may be indicated
if there are lingering speech problems that are not amenable to
surgical intervention (see Chapter 7) or if there are esthetic prob­
lems. However, definitive care is usually indicated during ado­
lescent growth and development, when tooth maturation is es­
sentially completed.
Definitive Prosthodontic Treatment
Definitive prosthodontic care for cleft patients is usually
indicated sometime after early adolescence, when the gamut of
treatment during the formative years has essentially been com­
pleted. If there are missing, malposed, or unesthetic anterior
teeth, the motivating factor for referral is customarily esthetics.
It is not uncommon for the replacement tooth or teeth attached
to the orthodontic retainer to be less than optimal from the per­
spective of the maturing patient and his or her family, and the
orthodontist often makes the referral. Also, there may be es­
thetic concerns with the remaining teeth in the premaxilla, so
the patient and parents are looking for direction and guidance.
Mounted diagnostic casts and appropriate radiographs are es­
sential for establishing a diagnosis and for the development of a
long-range treatment plan. Prior to the next consultation ap­
pointment, the clinician should consult with the patient’s other
health care providers, such as the plastic surgeon, orthodontist,
and the family intemist-pediatrician, regarding their thoughts
and suggestions for future treatment.
As previously discussed, bone grafting the alveolar cleft of
the primary palate exerts a very significant and positive influ­
ence on the treatment plan. A consolidated and mature bone
graft unites and stabilizes the cleft segments, simplifying future
treatment. If a maxillary alveolar bone graft is contemplated,
the prosthodontist should alter and delay his or her definitive
treatment plan accordingly. If the ultimate treatment plan in­
cludes selected porcelain fused to metal or porcelain veneer res­
torations, in addition to the possible placement of osseointegrated
implants in the grafted cleft, then a diagnostic wax-up is re­
quired.
Fig. 8-27. a: Patient with bilateral cleft lip and palate in 1980, with anterior crossbite and in need of maxillary expansion, b:
Expander in place in 1980. c: In 1986, following orthognathic surgery and completion of orthodontic treatment, d:
P atent in retention phase with missing left central and lateral incisor attached to orthodontic retainer.
Cleft Lip and Palate 353
Indeed, a diagnostic wax-up can be invaluable as orthodon­
tic realignment is nearing completion. A wax-up will permit
both the orthodontist and the prosthodontist to visualize the
potential esthetic arrangement, and will allow the orthodontist
to make final refinements that will enhance future prosthodontic
care. Spacing and relative tooth size can vary. If the lateral
incisor(s) are missing, the space for the lateral incisor may be
either wider or narrower mesiodistally than a normal maxillary
lateral, while the adjacent central incisor will usually have a
smaller than normal mesiodistal width. A diagnostic wax-up
will help the prosthodontist proportion the anterior space ap­
propriately, is an excellent educational tool for the patient and
parents, and can serve as a template for the future provisional
restorations. With this information, the clinician can provide
the family with some idea of the sequence of the proposed treat­
ment and how this treatment might interact with treatment by
other health care providers.
Often, the initial prosthodontic care is the fabrication of a
well-fitting interim removable partial denture to replace any
missing teeth. This type of partial denture is especially appro­
priate if a bone graft is scheduled in the future. Ideally, most
prosthodontists would prefer to fabricate all anterior fixed units
at the same time, including any implant-supported crowns. The
ideal time to perform this definitive treatment is around 25 years
of age, when the alveolar cleft bone grafts are mature and well-
consolidated. The proposed treatment will be very similar to
the treatment for a noncleft patient. At this age, more esthetic
restorations can be fabricated for the natural teeth, since these
teeth can be prepared so that there is an adequate thickness avail­
able for both the porcelain and metal, thus permitting more ideal
crown contours. Therefore, an interim removable partial den­
ture will fill this void until definitive treatment is indicated.
Modem restorative dentistry offers other alternatives at an
earlier age for the cleft patient who has received a successful
alveolar cleft bone graft or grafts. Since implants may serve as
anchors for the replacement of missing teeth in the premaxil­
lary segment (or possibly in other areas as well), bonding and/
or porcelain veneer restorations are viable options to correct
354 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
size, space, or esthetic deficiencies associated with the remain­
ing maxillary anterior teeth. The size of the pulp chamber is not
such a limiting factor, so restorative treatment may be accom­
plished at an earlier age. As previously mentioned, the remain­
ing teeth in the premaxillary segment may have short and poorly
developed root systems. Therefore, implants, bonding, porce­
lain veneers, or, possibly, a Maryland bridge can be viable al­
ternatives.
If the decision is for an interim removable partial denture,
the clinician should consult with the orthodontist and the plas­
tic surgeon, informing them of the proposed short and long­
term treatment plans. The orthodontist may have concerns re­
garding possible relapse of the realigned maxillary cleft seg­
ments, especially if a bone graft has not been performed. If graft­
ing has been accomplished, the proposed partial denture design
often will be akin to the design for a noncleft patient. If orth­
odontic treatment was completed quite recently, the orthodon­
tist is usually concerned about a collapse of the maxillary arch
in a lingual direction. In this scenario, the partial denture frame­
work must also act as a lingual retainer, with contact of the
framework with most maxillary teeth (Figure 8-28). A remov­
able partial denture could even be the treatment of choice if a
residual alveolar cleft remains after bone grafting. A long re­
placement tooth or pontic can be an esthetic liability. Replace­
ment tooth length can be controlled more easily with a remov­
able prosthesis, as pink acrylic resin can be added gingivally to
maintain a consistent level of the gingival margin with adjacent
teeth. The upper lip of many cleft patients may display limited
mobility superiorly, so the smile line should always be checked
during the diagnostic process and prior to treatment.
If there are no arch retaining requirements, we prefer to
fabricate a rather simple cast chrome removable partial denture
framework, requiring minimal tooth preparation, considering
the age of the patient (11 to 25 years). The major connector
Fig. 8-28. a: Fifteen-year-old patient after completion of orthodontic treatment, b: Prosthesis also acts as orthodontic retainer.
Note lingual contact of all teeth with major connector, c: Prosthesis in position.
should be kept well away from non-abutment teeth and gingiva
to make the prosthesis as self-cleansing as is possible. Adoles­
cents adapt to these prostheses quite well in spite of minimal
retention. If a lateral incisor or incisors require replacement, the
adjacent teeth may exhibit enamel hypoplasia. If bonding or
porcelain veneers are not indicated at this time, the acrylic resin
replacement tooth or teeth can be stained with resin stains to
match the adjacent hypoplastic teeth, which will improve es­
thetics and enhance patient acceptance of the prosthesis.
Fixed Partial Dentures If the patient is functioning quite well
with their removable partial denture, further definitive care may
not be necessary. However, most cleft patients will prefer some
form of fixed replacement(s). If a bone graft has been performed,
a single implant-supported tooth replacement may be all that is
required. As previously mentioned, if the missing lateral inci­
sors are replaced in this manner, bonding or porcelain veneers
are esthetic options for the adjacent teeth.
If the other adjacent teeth require porcelain fused to metal
(PFM) crowns, and if the arch has been stabilized with a bone
graft, consideration may be given to fabricating a fixed partial
denture with a lateral incisor pontic. A review of the diagnostic
wax-up may help the patient to understand the options. If the
patient has not had a bone graft, a fixed partial denture can still
be fabricated, but at least 2 abutments in each of the cleft seg­
ments must be utilized. These extensive fixed partial dentures
are not recommended, especially at a young age, as any move­
ment of the cleft segments will tend to rupture the luting bond
for the crowns in the more stable segment. Amore conservative
option is bone grafting and the subsequent placement of an im­
plant and crown, a Maryland bridge, or a simple fixed partial
denture. Many times, the crowns and/or fixed partial dentures
will be enhanced with some modest intrinsic staining of the
porcelain.

On occasion, we have found it difficult to match the cen­
tral incisor abutment of a 3-unit fixed partial denture with the
adjacent central incisor. Sometimes, esthetics, spacing, and
crown contours can be improved by including both central inci­
sors in the fixed partial denture, or placement of a porcelain
veneer on the contralateral central incisor. For example, it is not
uncommon in the edentulous space for the missing lateral inci­
sor to be wider than the ideal replacement lateral incisor. As
noted earlier, one central incisor adjacent to the cleft may be
smaller than the other adjacent central incisor, but the overall
width of the 4 units and the relative sizes of the individual teeth
(i.e., maxillary cuspid, lateral incisor, and 2 central incisors)
might be enhanced by including both central incisors so that
shade, size, match, and contours are improved.
On occasion, we have experienced some minor problems
associated with obtaining profound local anesthesia of the teeth
in the premaxillary segment. The scarring in the labial vesti­
bule makes the anesthetic more painful to administer and diffu­
sion of the anesthetic may be less effective.
The advent of adhesive dentistry has had a significant im­
pact in the care of the cleft patient, who has missing, malformed,
or discolored dentition. As previously discussed, this group of
patients has a higher incidence of size discrepancies, especially
with anterior teeth, along with hypoplastic enamel. In the past,
porcelain fused to metal restorations were utilized to address
these esthetic concerns. Today, however, with significant im­
provement in composite resins, dentin bonding, and porcelain
veneers, the use of porcelain fused to metal restorations is de­
creasing. Size and color deficiencies can be easily corrected by
using bonded composite resin restorations or porcelain veneers.
Missing teeth may be replaced with a bonded Maryland bridge,
Cleft Lip and Palate 355
provided that the alveolar cleft has been grafted to stabilize the
maxillary segments. A Maryland bridge can also be used if an
osseointegrated implant is contraindicated. When adhesive den­
tistry is the treatment of choice to restore these deficiencies, it is
still necessary to have mounted diagnostic casts and a full diag­
nostic wax-up prior to completion of the orthodontic treatment.
This will allow for ideal tooth position, with an equitable distri­
bution of spaces between the anterior teeth that will be receiv­
ing restorative treatment. The esthetic results with composite
resin and porcelain veneers have been very encouraging. How­
ever, the clinician must inform the patient and the parents of the
possible discoloration of the composite resin with time, as well
as the risk of fracture of the porcelain veneers. We believe that
the use of adhesive dentistry in this group of patients is less
invasive than porcelain fused to metal restorations and more
economical.
Very often patients present with hyperplastic gingival tis­
sue and lack of attached gingivae in the premaxillary segment.
A periodontal evaluation may also necessary prior to any de­
finitive restorative treatment. If the observed oral hygiene is
marginal or poor, hygiene procedures should be reviewed with
the patient and definitive prosthodontic treatment postponed until
both patient motivation and gingival health improve.
Removable Partial Dentures For patients with repaired cleft
lip and palate, removable partial dentures have similar design
and functional requirements as do partial dentures for noncleft
patients. The exception is for patients with velopharyngeal de­
ficiencies, when the conventional prosthesis must support a pala­
tal lift and/or obturator prosthesis (Figure 8-29). As discussed
in Chapter 7, the prosthodontist must consider the long lever
Fig. 8-29.
Large removable partial denture with obtura­
tor. a: Unilateral cleft lip repaired without clo­
sure of the palatal cleft. Note notching of lip
and anterior partial overdenture abutment, b:
Tissue surface of partial denture with obtura­
tor. c: Mirror view of cleft maxilla with alveolar
and soft palate openings, d: Tissue surface of
prosthesis with obturator.
356 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

arm created by this extension. This is especially true for pa­
tients requiring a Kennedy Class I or Class II partial denture.
Adequate indirect retention is very helpful in this situation, but
effective indirect retention can be difficult to obtain for Class I
patients if only anterior teeth remain, and especially for patients
with a square arch form.
Two additional precautions should be considered for cleft
patients that would not be a consideration for noncleft patients.
First, if the primary palate has not been bone grafted, tortuous,
fistula-like openings may exist in the alveolar cleft area, which
are sometimes difficult to detect as overt openings during ex­
amination. A gentle stream of air will aid in the examination
process. These potential openings are of little or no consequence
with regard to speech, but they should be considered during
impression making. When an irreversible hydrocolloid impres­
sion is made, the impression material may be forced up into
these openings. When the impression is removed, the impres­
sion material will fracture and remain in the opening. On occa­
sion, the clinician will find the impression material difficult to
remove. Usually with patience, this material can be teased out
with the aid of cotton pliers. On occasion, slightly larger alveo­
lar and/or palatal openings can be utilized to enhance retention
of complete dentures with extension into the defect with acrylic
resin or soft silicone materials (Figures 8-30 and 8-31).
Therefore, to avoid the problem of small openings extend­
ing up into the nasal cavity, the alveolar cleft area should be
blocked out with a gauze strip lubricated with patroleum jelly
prior to impression making. If the gauze protrudes slighdy from
the cleft, the gauze will be incorporated into the impression
material and will be removed with the impression. If the open­
ing is larger than a fistula, and is contiguous with the nasal cav­
ity, this aspect of the partial denture should be processed in acrylic
resin, with the potential for adjustments and reline (Figure 8-
32).

Fig. 8-30.
a: Small opening in labial reflex, b: Acrylic
resin extension into opening to improve
retention and to obturate defect. Resin
extension must be seated initially, then
denture is rotated up into position.

Fig. 8-31. a: Premaxillary segment was resected during infancy to enhance lip closure for bilateral cleft lip and palate patient.
b: Silicone obturator was used to engage undercuts more completely. Further adjustment is often necessary after
delivery, as obturator must interface with nasal mucosa, c: Tissue surface of overdenture supported by 2 endodon­
tically treated molars with gold copings. Teeth were recontoured to improve gingival health.
 Cleft Lip and Palate 357

a c

Fig. 8-32. a: Palatal view of repaired cleft of hard and soft palates with low attached pharyngeal flap and unusual anterior
palatal defect. There were no missing teeth, b: Master cast, c: Framework on master cast. Note framework de­
signed so defect areas can be processed in acrylic resin, d: Corrected cast impression, e: Framework on corrected
cast, f: Completed prosthesis. Clear acrylic resin permits visualization of possible areas of pressure. (Courtesy:
Eleni Roumanas).

Second, the repair of a palatal cleft is a soft tissue closure viously explained, the dentate cleft maxillae tend to be con­
which will display various degrees of scarring and can be quite siderably smaller proportionally, as compared to the more
unyielding. During the fabrication of removable partial den­ normal-sized mandible. This is due to their lack of down­
tures, most laboratory technicians will bead the peripheral mar­ ward and forward growth. With complete edentulism, this
gins of the tissue surface of the major and minor connectors. arch disparity becomes even greater (Figure 8-33).
The technician should be instructed to follow these ridges of
scar tissue, rather than cross them, if possible, and to bead the
cast only minimally. This situation is analogous to following
rather than crossing rugae with the beaded margins of an ante­
rior palatal strap major connector.

Complete dentures

Treatment concepts— challenges and difficulties Com­

plete dentures for patients with clefts of both the primary and
secondary palates are challenging for the clinician to fabricate
and for the patient to utilize effectively. The following reasons
for this situation are important to recognize.
• The reduced size o f the cleft maxilla In conventional
Complete denture prosthodontics, the edentulous maxillae
tend to become both smaller and narrower in all dimen­
sions in comparison with the edentulous mandible. As pre­
Fig. 8-33. Maxillary complete denture with silicone obtu­
rator for hard palate defect. The soft silicone can en­
gage undercuts more completely. Note thickness of la­
bial flange and reduced size of maxillary arch for poten­
tial prosthetic support. Also note unusual configuration
of posterior palatal seal area due to excessive scarring
and desire to follow— rather than cross— scar bands.
358 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
• Excessive inter-arch space Due to reduced downward
and forward growth of the maxillae, cleft patients often
have an excessive amount of interocclusal distance. If the
patient is edentulous, this disparity is even more signifi­
cant This means that denture teeth must be positioned a
considerable distance both laterally and inferiorly from the
maxillary foundation area, and a Class HI tooth relation­
ship is not uncommon.
• Lack o f a bony palate In a noncleft patient, the bony
palate and alveolar ridge add to the support and stability
for the complete denture, especially in square and ovoid
arches. These attributes are reduced because of the lack of
a bony palate in cleft palate patients. In addition, it may be
more difficult to develop an effective posterior palatal seal
because of the scarring and varying resiliencies of the re­
sidual soft palate. Plus, landmarks, such as the vibrating
line or the fovea palatini, may be indistinct.
• Poor alveolar ridge development and shallow depth o f
the palate Due primarily to the lack of vertical growth,
the edentulous maxillary alveolar ridges are usually not
well developed and the palatal vault may be rather shal­
low. These conditions will compromise both stability and
support for the maxillary complete denture for the edentu­
lous cleft palate patient
• Scarring from Up closure At times, surgical closure of
the lip in infancy predisposes the patient to significant and
unyielding scar bands in various configurations in the la­
bial vestibule. This scarring, in turn, reduces the effective
depth of the labial vestibule and reduces the amount of
stability available for the denture.
Therefore, many of the steps necessary for fabrication of
complete dentures for edentulous cleft palate patients are made
more difficult for the clinician and, ultimately, more difficult
for the patient in adapting to their new prosthesis.
Fabrication o f Complete Dentures
Consultation appointment Prior to commencing
prosthodontic treatment, it is imperative that the prosthodontist
discuss the myriad of factors related to the treatment to be ren­
dered and the prognosis for the new dentures. Most patients
with a cleft of the lip and palate will realize that they have a
problem, as they have been living with their condition for all
their years. Yet, their expectations can easily become unrealis­
tic, so the prosthodontist should explain the limitations in a re­
alistic manner.
As in conventional prosthodontics, the patients’ previous
experience with removable prosthesis can be revealing. A fa­
vorable history of complete denture use is very encouraging,
whereas the opposite scenario is discouraging for both the pa­
tient and the clinician. Cleft patients recently rendered edentu­
lous in the maxilla have a very guarded prognosis, especially if
opposed by essentially a complete complement of natural man­
dibular teeth. A complete history and careful oral examination
should be performed. Aspects that would be a negative factor
for a noncleft patient take on added significance for cleft pa­
tients. If the patient requires an obturator bulb, the added length
and weight for this extension may adversely effect retention,
since this additional weight is not centered within the confines
of the complete denture.
A word of caution seems in order regarding speech. If the
cleft patient is an inexperienced denture wearer, speech may
deteriorate modesdy with the initial placement of new dentures.
Within 2 to 3 weeks, the patient should begin to adapt to these
new contours and speech should gradually return to pretreat­
ment levels. Rarely will articulation improve with the place­
ment of new dentures.
Impressions The clinician may use his or her cus­
tomary denture impression technique for cleft lip and palate
patients with only a few exceptions. The need to block out small,
bony openings has already been discussed. For the same rea­
son, metallic oxide and plaster wash impression materials should
not be used. These materials become hard and friable after they
set. Thus, a piece of hard impression material could become
lodged in a small, unobserved opening. Since alternative and
flexible wash materials are available, we suggest their use.
We prefer a standard technique that includes the fabrica­
tion of a custom tray, border molding the tray with modeling
plastic, followed with a wash of light body rubber base impres­
sion material. Rubber base material rarely fractures and tends
to withdraw completely from small bony defects.
Two areas require special consideration during border
molding. First, care must be taken to avoid over extension in
the maxillary labial reflex, especially in relation to the scar bands
resulting from lip closure. The modeling compound should be
as warm as the patient can comfortably tolerate, and the cleft lip
should be hand manipulated in a downward, forward, and lat­
eral direction several times. Secondly, the posterior palatal seal
should be developed during border molding. The movements
of the soft palate should be observed as the patient says “ah”.
There may not be a sharp delineation between the immobile
and mobile areas of the soft palate. Philosophically, we prefer
not to establish the posterior palatal seal across heavily scarred
tissue but to follow the creases or folds of scar tissue in the
palate. Therefore, the posterior palatal seal will have an irregu­
lar sweep across the palate. However, if the posterior margin
terminates in a crease, it will be less obtrusive to the tongue.
To establish the posterior palatal seal, the impression tray
is cut back to the desired terminus, and the molding process is
completed in a customary manner. After the impression is com­
pleted, the wash material is cut back to the posterior margin of
the modeling plastic, and the cast is completed in a standard
manner. It is helpful to scribe the posterior palatal seal in the

cast with the patient present, as the resiliency of the palatal tis­
sues will vary considerably. A posterior bead feathered slightly
anteriorly is used instead of the more standard butterfly pattern.
Scar tissue has the capacity to rebound if displaced and can be a
negative influence on retention.
Vertical dimension o f occlusion Establishing an ap­
propriate vertical dimension of occlusion (VDO) is critical for
many edentulous cleft lip and palate patients. Unfortunately, it
is difficult to give definitive guidelines for establishing the cor­
rect VDO, as clinical judgment plays an important role. The
clinician is faced with a dilemma in performing this task. The
maximum VDO will likely create the best esthetic arrangement,
but the maxillary replacement teeth will be further from their
foundation area. We prefer to locate the occlusal platform at the
appropriate level for the mandibular teeth and arch, and vary
the vertical position of the maxillary replacement teeth and arch
based on the level of retention, stability, and support available
from maxillary structures. For example, if the maxillary struc­
tures have limited potential for retention, stability, and support,
the VDO is closed 2 to 4 mm at the incisor point, but at the
expense of esthetics. Input from the patient should be included
in the decision-making process.
The facebow record is made and the maxillary cast is
mounted on the articulator with the aid of the facebow. The
final adjustments are made to the wax rims and a centric rela­
tion record is made. The flexibility of the upper lip should be
considered in contouring the maxillary wax rim, as lip flexibil­
ity will vary.
Try in If esthetics is a major concern, the clinician
should consider arranging the 12 anterior denture teeth in the
operatory with the patient present. This will give both the den­
tist and the patient a glimpse at the potential esthetic result. If
this tooth arrangement is not satisfactory for either party, con­
sideration should be given to increasing the VDO slightly. If
this is done, it is best to make a new centric relation record and
remount the mandibular cast. A second try-in appointment should
be scheduled to verify esthetics, centric relation, and to make a
protrusive record.
The second try-in appointment is an opportune time to make
subtle adjustments in the anterior tooth arrangement related to
repair of the cleft lip. The lips tend to frame the anterior ar­
rangement so, if abnormalities in the upper lip are apparent,
subtle changes in the tooth arrangement or denture base con­
tours may enhance esthetic harmony. Since clefts of the lip cor­
respond to the maxillary lateral incisors, most of these adjust­
ments will be related to the replacement lateral incisors or the
denture base in this area. If the denture teeth are set to a rela­
tively even or flat occlusal plane, this arrangement will accen­
tuate slight lip discrepancies. Sometimes, scar contracture oc­
curs linearly along the line of the lip scar, so contracture will
produce a slight notch in the lip opposite of the lateral incisor. If
the lateral incisor(s) is raised slightly above the occlusal plane
Cleft Up and Palate 359
(not an unusual position for the lateral incisor), the irregularity
in the lip may be less noticeable.
On occasion, the protruding scar of the upper lip can be
made less conspicuous by removing wax from the future den­
ture base. Sometimes, moving the lateral incisor slightly lin-
gually will also help. Most of these adjustments will be related
to the replacement of maxillary lateral incisors or the denture
base in this area, especially for patients with a repaired unilat­
eral cleft lip. Adjustments to the future denture base may im­
prove smile harmony. While these changes are minor, they do
improve patient acceptance of the prosthesis, especially if the
patient is involved in the decision-making process.
Because of the smaller maxillary edentulous arch, the po­
tential maxillo-mandibular discrepancies, and the need for rather
bulky wax rims, the clinician is often forced to manage 2 un­
stable record bases during the recording of VDO and centric
relation. Consequently, it is sometimes advisable to scribe the
posterior palatal seal and process the permanent maxillary record
base(s) prior to the appointment for jaw relation records. This
will give the clinician the advantage of a more stable record
base during this important step. The denture teeth are then pro­
cessed to these bases with cold cure resin.
Delivery and adjustment The complete dentures are
processed and delivered in the customary manner, employing
both a laboratory and clinical remount to finalize the occlusion.
Thin projections of acrylic resin that extend up into the residual
cleft are removed and smoothed. Rarely will leakage occur as a
result of this maneuver. We have found that disclosing wax is
more diagnostic in relieving the denture base in the labial reflex
to accommodate the scar band. Prior to dismissal of the patient,
it is advisable to discuss the limitations and expectations for the
dentures again. The patient is also apprised of subsequent recall
appointments.
If an obturator is to be attached to the maxillary complete
or partial denture, it may be done at 2 different times. If the
patient has never used an obturator, we prefer to delay its fabri­
cation until the patient has accommodated to the denture (about
4 to 6 weeks). If the patient has an existing obturator, the new
obturator must be completed prior to delivery of the prosthesis.
A wire loop for retention of the obturator segment is attached
with wax and checked for position at the second try-in appoint­
ment. After the completed dentures are adjusted and the occlu­
sion is refined, the obturator is developed with modeling plastic
and fluid wax. The dentures are then delivered at a subsequent
appointment. As discussed in Chapter 7, rarely will speech be
markedly improved with the addition of an obturator for adult
patients. Nasal resonance and fluid leakage will be reduced, but
long-standing articulatory errors will remain.
Single maxillary complete dentures Due to the reduced size
of the edentulous maxilla and the difficulty in establishing a
reasonable occlusion with the proportionally much larger man­
360 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

dible, single maxillary complete dentures for cleft patients will
be a challenge for both the dentist and the patient. Maxillary
teeth have often been lost at various times, sometimes without
replacement Therefore, the opposing mandibular teeth will of­
ten exhibit varying degrees of extrusion and realignment. We
have found that the modified Meyer technique40 for a single
maxillary denture is excellent for establishing a functional oc­
clusion with irregularly positioned mandibular teeth. A bilat­
eral posterior crossbite is not uncommon.
Maxillary overdentures As previously mentioned, while man­
dibular growth is essentially normal in cleft patients, maxillary
growth is restricted in a downward and forward vector when
the cleft involves both the primary and secondary palates. There­
fore, some adult cleft lip and palate patients will exhibit a re­
stricted maxillary arch with an anterior open bite, especially if
orthodontic treatment was either not instituted or unsuccessful
and/or the anterior teeth in the premaxilla were lost at a rela­
tively early age. Because of these growth deficiencies, some
adult cleft lip and palate patients are candidates for various forms
of overdentures that may be supported by either the remaining
teeth (Figures 8-34 and 8-35), a combination of remaining teeth
and implants (Figure 8-36), or implants alone (Figure 8-37).

a b c
Fig. 8-34. a: Bilateral cleft lip and palate with excellent oral hygiene and reduced vertical dimension of occlusion, b: Overdenture
with retainers and internal chrome cobalt framework. Note thickness of labial flange, c: Completed prosthesis.

d e

Fig. 8-35. a: Mirror view with 2 remaining teeth prepared for coping crowns. Note palatal openings and flatness of repaired
hard and soft palate, b: Master cast with coping crowns, c: Casts mounted on articulator. Note lack of tooth-to-tooth
contacts, d and e: Preparation for wax try-in. f: Completed prosthesis.
 Cleft Lip and Palate 361

Fig. 8-36. a: Maxillary arch immediately after placement of 3 implants on right side and 1 implant on left side, b: Three implants
splinted with a Hader bar, but not connected to either crowns or to single implant on the left side, as alveolar cleft
has not been bone grafted, c: Partial overdenture with obturator.

Fig. 8-37.
a: Facial view without prosthesis. Note
lack of midfacial support, b: Implant
surgical stent, c: Implants immediately
following exposure and revision of soft
tissues. Note flatness of hard and soft
palates, d: Implants on diagnostic cast.
Unfortunately, im plants on left side
failed, e: Hader bar and 2 ERA attach­
ments. f: Tissue surface of overdenture g
with Hader clip. Note thickness of
labial flange, g: Occlusion of maxillary
overdenture functioning with existing mandibular partial denture, h: Facial view with prosthesis. Compare (a) and (h). (Cour­
tesy: Eleni Roumanas.)
362 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

There is 1 type of overdenture, or, more appropriately, a
partial overdenture, that is not uncommon and reflects this vec­
tor of deficient downward and forward growth and develop­
ment. In contrast to noncleft patients, when few teeth remain in
the adult maxillae, they are usually posterior teeth. The occlu­
sion may be limitedto posterior molar contact Ifthe interocclusal
distance seems excessive, and if the vertical dimension of oc­
clusion (VDO) is over-closed, an improved VDO can be estab­
lished with selected crown placement on the molar teeth in oc­
clusal contact. In addition, solid occlusal stops are created, and
crown contours should be ideal for the partial overdenture, which
will cover the remaining maxillary teeth and reestablish occlusal
contact with the mandibular teeth. If interocclusal space poste­
riorly is limited, gold occlusals on the partial overdenture may
be considered. A clinical remount is required. Obviously, good
oral hygiene and patient compliance are essential, and periodic
recall visits must be stressed.
Osseointegrated implants At the Center for Craniofacial
Anomalies at UCSF, we have in progress a 5-year prospective
study on the success of endosseous implants placed in the al­
veolar cleft following a bone graft. A patient with an alveolar
cleft is usually missing the permanent lateral incisor on the side
of the cleft. During orthodontic treatment, a decision is made
regarding whether the lateral space should be restored prostheti-
cally (Figure 8-38a) or the space should be closed. If the space
is to remain, the prosthetic options include a removable partial
denture, a fixed partial denture, a Maryland bridge, or an im­
plant-supported single crown.
An implant-supported restoration to replace the missing
lateral incisor offers the following advantages: (1) abutment tooth
preparation is not required with the decreased possibility of
damage to the dental pulp, (2) increased loading of the abut­
ment teeth is avoided, and (3) the implant in the alveolar cleft
may transfer functional forces to the graft, which could decrease
resorption of the graft. These potential advantages precipitated
this investigation.
Currently, the investigation is in its third year. Eleven im­
plants have been placed successfully in 10 patients with grafted
alveolar clefts. The average follow-up after implant placement
is 24 (6-25) months and, since restoration, 17 (6-22) months.
The average interval between alveolar cleft bone grafting and
implant placement is 16 (3-36) months. Once placed, there have
been no implant failures. Figure 8-38 shows one of the patients
enrolled in the study.

Fig. 8-38. a: Fifteen-year-old male patient with a unilateral cleft of lip and palate. Orthodontic treatment completed intending to
restore missing lateral incisor with implant-supported crown, b: Periapical radiograph following alveolar cleft graft­
ing. c: Placement of plasma-sprayed, 4.0 mm implant, d: Provisional implant-supported crown after second-stage
surgery, e: Periapical radiograph of implant-supported restoration, f: Final prosthesis.
 Cleft Lip and Palate 363

Other Related Anomalies Submucous Cleft Palate and Occult Submucous Cleft Palate

In 1976, there were fewer than 150 recognized syndromes
associated with clefting, while more than 400 have been identi­
fied today. As an example of this expanded interest, the Ameri­
can Cleft Palate Association has become the American Cleft
Palate-Craniofacial Association, their journal is now the Cleft
Palate-Craniofacial Journal, and most cleft palate centers are
craniofacial centers. Two other conditions warrant a brief dis­
cussion primarily because of their relationship to cleft palate,
and because they are representative of the growing interest in
craniofacial anomalies.
The conditions we will discuss are (1) submucous cleft
palate and a variant, related condition, occult submucous cleft
palate, and (2) Robin sequence (Pierre Robin syndrome). Pa­
tients with submucous cleft palate and occult submucous cleft
palate have cleft-like symptoms, such as hypemasality, without
overt clefts of the palate, whereas infants with Robin sequence
have an interesting triad of anomalies that include a cleft of the
hard and soft palate. The primary treatment of choice for both
patient groups is surgery, so there are limited indications for
prosthetic treatment for either group.
Submucous cleft palate (SMCP) and occult submucous cleft
palate (OSMCP) are conditions which are related both to each
other and to cleft lip and palate41, but without overt clefting of
the palate per se. Patients with submucous cleft palate are iden­
tified by the triad of a bifid uvula, midline muscular diastasis
(zonapellucida), and a notch or other alterations in the contour
of the posterior margin of the hard palate42 (Figure 8-39). The
bifid uvula can be detected as the SMCP patient says “ah”, and
the contour changes of the posterior margin of the hard palate
can be detected by palpation.
Patients with occult submucous cleft palate exhibit only
muscular diastasis of the levator veli palatini or hypoplasia of
the m usculus uvulae, w hich is responsible for the
hypemasality43’44’45,46. A careful oral examination will usually
reveal the possibility of SMCP, whereas the same examination
process may not detect any anatomical limitations of the appar­
ently intact hard and soft palate for patients with OSMCP.
Rarely can muscular diastasis of the levator veli palatini be
detected by oral examination, and certainly hypoplasia of the
musculus uvulae cannot be detected orally. Multiview

Posterior nasal spine

Notch of hard palate

Hamulus Hamulus

Pterygoid bone
Midline muscular diastasis

Tensor veli palatini Tensor veli palatini

Abnormal insertion
of levator veli palatini

Fig. 8-39. Submucous cleft palate, a: Normal anatomical contours of soft palate. Note levator sling formed by the anastomosis
o f levator veli palatini muscles, b: Triad of anatomical abnormalities associated with submucous cleft palate (i.e.
bifid uvula, midline muscular diastasis of soft palate due to abnormal insertion of levator veli palatini, and notch of
hard palate). Several anatomical variations o f the levator muscles are possible with partial insertion into hard palate
and/or partial anastomosis across the palate.
364 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
videofluoroscopy and/or nasal endoscopy examination are nec­
essary to confirm hypoplasia of the musculus uvulae, as these
paired muscles occupy the central portion of the nasal surface
of the soft palate. On occasion, when the levator veli palatini
are aberrantly attached to the posterior margin of the hard pal­
ate, and do not anastomose and form the levator sling, the clini­
cian may note a pale, bluish cast to the midline of the soft palate
due to the lack of normal musculature beneath the oral mucosa
(Figure 8-40). This clinical sign, plus the presence of a bifid
uvula and hard palate notch, should lead the clinician to strongly
suspect submucous cleft palate.
The primary motivating factor for the parents to seek con­
sultation and treatment for their child is the development of
hypemasal speech due to velopharyngeal dysfunction, result­
ing from muscular diastasis of the levator veli palatini or hypo­
plasia of the musculus uvulae. Therefore, it is not uncommon
for either of these conditions to go undetected until a child be­
gins speaking. Normally, the levator veli palatini will insert and
anastomose with its counterpart across the medial aponeurosis
of the soft palate and posterior to the hard palate border and
form the so-called “levator sling”. As the normal levators con­
tract, they elevate and retract the central one-third of the soft
palate and, simultaneously, move the lateral pharyngeal walls
medially to facilitate velopharyngeal closure, creating the typi­
cal “knee” appearance of the soft palate seen in lateral radio-
graphic projection during closure. With diastasis of the levator
veli palatini muscles, at least a portion of each levator muscle
inserts instead into the posterior border of the hard palate lateral
to the midline. As a consequence, the levator sling either does
not form, or is incompletely formed, and velopharyngeal dys­
function and hypemasal speech results.
As discussed in Chapter 7, we now realize that the muscu­
lus uvulae contribute to velopharyngeal closure, especially with
circular closure patterns44,45. With hypoplasia of the musculus
uvulae and the subsequent lack of development of the “velar
eminence” on the nasal surface of the soft palate, hypemasal
speech will also result for patients with OSMCP.
a b
Fig. 8-40. Submucous cleft palate, a: Muscular diastasis of central soft palate. Note bluish cast, b: Levator veli palatini during
contraction. Note insertion into hard palate instead of forming levator sling, c: Bifid uvula. (Courtesy: Karin Vargervik).
Bifid uvula and changes in the bony configuration of
the posterior margin of the hard palate have only a limited in­
fluence on speech problems associated with SMCP. Wharton
and Mowrer examined 709 elementary school children for bi­
fid uvula47. They found that 16 (2.26%) had a bifid uvula. How­
ever, only 2 (0.3%) of the children had a full-length uvular cleft,
and none of the 16 children with bifid uvulae exhibited
hypemasality.
The role of the contour changes associated with the poste­
rior border of the hard palate (palatine bones) is indeterminate
at the present time. As previously stated, the midline notch and/
or the absence of the posterior nasal spine can often be pal­
pated. On occasion, the posterior margin of the hard palate will
exhibit more of a “U”-shaped contour, as compared with the
standard butterfly pattern of the palatine bones. This change in
contour would tend to shorten the overall length of the hard
palate and, thus, possibly indirectly shorten the velum because
of its more anterior attachment to the shortened hard palate.
Kaplan noted this tendency for a shortened hard palate during
suigical treatment for OSMCP43.
The reader should also be aware that there is a broad spec­
trum in the severity of the stigmata associated with both SMCP
and OSMCP. The critical assessment is the degree of
hypemasality during speech production. If speech is normal or
near normal, rarely is surgical treatment indicated. Unfortunately,
the opposite scenario is also true. If the degree of hypemasality
is pervasive, rarely will maturity or intensive speech therapy
improve speech or hypemasality.
Some children with SMCP or OSMCP will display other
symptoms that mimic symptoms seen by patients with cleft lip
and palate, such as middle ear infections and subsequent hear­
ing loss, short hard or soft palate or deep nasopharynx, and a
generalized maxillary hypoplasia. Kaplan suggests that clefts
of the secondary palate, submucous cleft palate, and occult sub­
mucous cleft palate are “variations of the same embryologic
disorder” in a “continuous spectrum of muscle malformation
and actual clefting”43. Trier suggests that over 90% of patients
e

with velopharyngeal incompetency and without an overt cleft
of the palate have a microform of cleft palate46.
A study by Kono and others41offers some support for these
theories. They examined 71 patients with clefts confined to the
primary palate (lip and alveolus) for SMCP and OSMCP. Inter­
estingly, these investigators found that 13% of them also exhib­
ited the triad of stigmata associated with submucous cleft pal­
ate. In addition, these patients exhibited other symptoms asso­
ciated with cleft palate, such as hypemasality, middle ear dis­
ease, and so forth. These authors suggest that any patient with a
cleft confined to the primary palate should always receive a
thorough examination for SMCP or OSMCP.
What is the incidence of SMCP and OSMCP? This ques­
tion is impossible to answer at the present time, since only symp­
tomatic patients with hypemasal speech are referred to cranio­
facial centers for diagnosis and treatment. Kaplan examined 240
patients with velopharyngeal incompetence without cleft lip and
palate43. He found 41 with classic overt submucous cleft palate
and 23 with occult submucous cleft palate among this group of
patients. Lewin examined 131 patients without cleft lip and
palate but with velopharyngeal insufficiency with a nasal endo­
scope45. Of the 131, 57 were diagnosed with submucous cleft
palate, 24 with other neurological or functional disabilities, and
29 with occult submucous cleft palate due to hypoplasia of the
musculus uvulae. Please see Chapter 7, Tables 7-2 and 7-3, for
more details regarding this study.
Symptomatic patients with obvious hypemasality should
be treated surgically with a combination of procedures, includ­
ing a palatal push-back, a levator muscle reconstruction to rees­
tablish the levator sling, and a superiorly-based pharyngeal flap
which is inserted into the raw surface of the nasal surface of the
soft palate. Kaplan reports significant speech improvement post-
operatively with this approach43. However, McWilliams cau­
tions that surgery is indicated only with demonstrable
hypernasality48. In a group of 130 noncleft patients at the Pitts­
burgh Cleft Palate-Craniofacial Center, 44% remained asymp­
tomatic into early adulthood and never required surgery. She
cautions that submucous cleft palate patients should not be re­
paired surgically in infancy unless there are significant feeding
problems or unremitting ear disease. Surgery should never be
performed on an infant based on the theoretical possibility of
the potential effect on speech.
Rarely is prosthodontic treatment indicated for patients with
SMCP or OSMCP, unless there are also motor or sensory defi­
cits associated with the soft palate. Under these circumstances,
a palatal lift prosthesis (see Chapter 7) would be indicated be­
cause of the length and position of the anatomically normal-
appearing palate.
On occasion, persistent hypemasality and either SMCP or
OSMCP is diagnosed following a routine tonsillectomy or ad-
enoidectomy for a “normal” patient. The adenoids masked the
problem, as the intact but compromised soft palate was able to
Cleft Lip and Palate 365
close against the protruding adenoidal pads. Many times, a care­
ful history will reveal feeding problems, or persistent middle
ear infections and hearing loss, during infancy. Therefore,
Shprintzen and others caution that any patient with a bifid uvula
or any other marker should be carefully examined for SMCP or
OSMCP to avoid the potential for unexpected future problems49.
Robin Sequence (Pierre Robin Syndrome)
Robin sequence was named after the French stomatolo­
gist, Pierre Robin, who first described the triad of anomalies
consisting of micrognathia, U-shaped cleft palate, and upper
airway obstruction in newborns in 1923 and 193450. Presently,
the preferred term is Robin sequence, since a sequence is de­
fined dysmorphologically as an individual with multiple anoma­
lies where some or all of these anomalies are caused by one of
the primary anomalies. In contrast, a syndrome is caused by a
single pathogenesis. In Robin sequence, the mandibular micro­
gnathia secondarily precipitates the development of both the
U-shaped cleft palate and the upper airway obstruction, but the
mandibular abnormalities may have multiple etiologies50,51(Fig­
ure 8-41). Hence, the term Robin sequence is more apropos.
The interrelationships between micrognathic-retrognathic
mandible, cleft palate, and upper airway obstruction are inter­
esting. Embryologically, it is postulated that the micrognathic
mandible forces the embryonic tongue into a superior and more
retruded position which, in turn, interferes with the midline fu­
sion of the developing palatal shelves (described earlier) during
the 7th to 11th week of gestation. The retruded mandible is also
indirecdy responsible for obstruction of the upper airway be­
cause of the more posterior attachment of the tongue to the
retrognathic mandible. The tongue tends to retrude back into
the oral pharynx, blocking the airway with its contact with the
posterior and lateral pharyngeal walls. This retropositioning of
Genetic Chromosomal Teratogenic
Syndromes - . Syndromes Influences
Mechanically- Multifactoral
Induced Factors C ontributions
, Cleft P alate* Upper Airway Obstruction
Fig. 8-41. Schematic representation of multiple etiologies of
micrognathia that secondarily lead to cleft palate,
upper airway obstruction, and Robin sequence.
(Adapted from: Shprintzen RJ. The implications
of the diagnosis of Robin Sequence. Cleft Pal-
CraniofJ. 29: 205;1992.)
366 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
the tongue is called glossoptosis. However, not all newborns
with micrognathia will exhibit upper airway obstruction, and
the degree of compromise can be quite variable. A thorough
pediatric examination is always indicated under these circum­
stances, as a correct diagnosis leads to proper treatment, since
there are other causes for infant airway obstruction52,53. A naso­
endoscopic examination is useful to verify the degree of upper
airway obstruction.
Not only is this triad of anomalies interrelated by cause
and effect, Robin sequence is also related to other primary
syndromic conditions (Table 8-3). Shprintzen examined and
reviewed the records of 100 consecutive children with Robin
sequence based on the presence of micrognathia, U-shaped cleft
palate, and upper airway obstruction50. Only 17 of them could
be diagnosed as nonsyndromic Robin sequence (without other
anomalies). Therefore, 83 patients had associated anomalies
other than the Robin triad. Stickler syndrome, which occurred
in 34 patients of this sample, was by far the most commonly
associated syndrome. In addition to the Robin sequence triad,
Stickler syndrome is characterized by myopia, retinal detach­
ment, flat midface, prominent joints with a tendency towards
degenerative joint disease, and other abnormalities.
Airway maintenance is the primary concern in newborns
with Robin sequence, as these stigmata have the potential to be
fatal for them. Therefore, the infant must be monitored continu­
ously during the first few days and weeks. If the obstructive
apnea is not life threatening, less invasive techniques, such as
prone positioning of the infant, and nasopharyngeal and endot­
Table 8-3. Primary Syndromic Diagnoses in a Sample of 100 Consecutive Children with Robin Sequence Based on the
Presence of Micrognathia, U-Shaped palate, and Upper Airway Obstruction.*
Primary Diagnosis
Stickler syndrome
Velocardiofacial syndrome ••
Fetal alcohol syndrome
Provisionally unique pattern syndromes
Treacher Collins syndrome
Bilateral femoral dysgenesis syndrome
Distal arthrogryposis
Larsen syndrome
Miller-Dieker syndrome
Spondyloepiphyseal dysplasia syndrome
Diastrophic dysplasia syndrome
Popliteal pterygium syndrome
ADAM sequence (amnion rupture sequence)
Beckwith-Wiederman syndrome
Nager syndrome
Isolated (nonsyndromic) Robin sequence
* Source: Shprintzen RJ. The implications of the diagnosis of Robin Sequence.
racheal tubes, are employed initially. The tubes will temporarily
maintain the patency of the airway. If the apnea is or becomes
life threatening, then a glossopexy surgical procedure is per­
formed to open the airway which repositions the tongue for­
ward by surgically attaching the tongue tip to the anterior al­
veolar ridge and lower lip. Many times, the attachment of the
genioglossus and/or lingual frenulum is released simultaneously
to aid this forward positioning of the tongue54. A tracheotomy is
the final option, which was necessary in only 9 of 53 patients
reviewed by Sher52 (Tables 8-4 and 8-5). This treatment phi­
losophy is based on supporting the infant until mandibular
growth and development will correct the upper airway obstruc­
tion. If the airway and feeding problems are mitigated, often
the tongue is released at the same time as the palatal cleft is
closed (about 9-12 months). LeBlanc andGolding-Kushner did
-not find any long-term speech pathology in later years, after the
tongue was released55.
Treatment during the first year is complicated by the feed­
ing problems associated with both the cleft palate and the upper
airway obstruction. As previously discussed, most infants with
a cleft palate will have difficulty nursing due to the palatal open­
ing. Airway obstruction further complicates nursing, as the in­
fant may be a mandatory oral breather due to the posterior air­
way obstruction. Therefore, the newborn must pause to breathe,
which prolongs feeding time and exhausts the infant. The deci­
sion regarding tube placement or surgical intervention is often
made on the basis that the infant is not thriving.
Number
34
11
10
10
5
2
2
2
1
1
- 1
1
1
1
1
1.
Cleft Pal-Craniofac J. 29:205; 1992.
 Cleft Lip and Palate 367

Table 8-4. Treatment and Outcome in Robin Sequence.*

Number o f infants Required Additional

Treatment (n = 53) Treatment

Temporary naso-pharyngeal tubes W0 B , 28

Glossopexy 0

Tracheotomy 9 o

Note: Report o f 53 consecutive infants, ages ranging 1 day to 9 months.

* Source: Sher AE. Airway obstruction in Robin sequence. Cleft Palate-Craniofacial J. 29:224;1992.

Table 8-5. Treatment Results by Age in Robin Sequence.**

Treatment— ,'
Number of p m Nasopharyngeal' Endotracheal GlosSopexy Ip lrp je o to m y
infants Tube Tube '
(n = 53) (Definitive)'

HI

1 ' #■s 1
>needed after removal of tubo

** Source: Sher AE. Airway obstruction in Robin sequence. Cleft Palate-Craniofacial J. 29:224;1992.

A question remains regarding the progression of mandibu­
lar growth as the newborn ages. Many times, parents are in­
formed that their child’s mandible will “catch up” and have a
relatively normal dimension within 2 years. Shprintzen cau­
tions that, if the mandible is intrinsically normal, and the micro­
gnathia was due to positional constriction in utero, then the
mandible will have the potential for “catch up” and be rela­
tively normal at 2 years50. However, in most instances, the mi­
crognathia is due to the Robin sequence, so the mandible will
remain relatively small as the child continues to grow50,51 (Fig­
ure 8-42). If the child is receiving adequate nourishment, some
growth does occur and the patency of the airway improves pro­
portionally.
In contrast, Figueroa and coworkers found that there was
a “partial catching up” of mandibular growth56. These authors
conducted a longitudinal cephalometric study during the first 2
years of life of 17 infants with Robin sequence only, 26 matched
infants with isolated cleft palate only, and 26 normal infants.
They reported that patients with Robin sequence initially had a
shorter mandible, narrower airway, smaller and shorter tongue,
and the hyoid position was more posterior and inferior, as com­
pared with normals. They reported that mandibular growth was
greater proportionally for infants with Robin sequence during
the first 2 years of life, as compared to the other 2 groups. Most
of the growth occurred early, but the mandible continued to be
smaller, as compared with the mandibles of the normal group.
Thus, there appears to be a “partial catching up” for patients
with Robin sequence.
What is the incidence of Robin sequence? This is a diffi­
cult question to answer, as the degree of micrognathia and up­
368 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
per airway obstruction may vary; the criteria for inclusion in
any study are important considerations. For example, infants
with micrognathia, cleft palate, and borderline upper airway
obstruction might not be included in the study unless the infant
“failed to thrive”. Bush and Williams conducted a carefully
controlled study and reported an incidence of 1:8,500 live
births57. Therefore, Robin sequence is not as uncommon as ear­
lier studies indicated.
b
Fig. 8-42. a: Patient with Robin sequence at 1 year of age.
Note retrognathic mandible, b: Palate after clo­
sure at 2 years and 6 months.
Other Craniofacial Anomalies
A prosthodontist in a craniofacial anomalies center is often
involved in the treatment of patients with other craniofacial
anomalies that have restorative and/or prosthodontic require­
ments. There are a number of craniofacial anomalies that have
congenitally missing dentition (partial or complete anodontia)
or malformed teeth. It is not our purpose to discuss every con­
dition that potentially could require prosthodontic services, but
we would like to briefly discuss 2 conditions not related to cleft
lip and palate, but have high incidence rates and may require
special prosthodontic considerations: hemifacial microsomia and
ectodermal dysplasia.
* Section on hemifacial microsomia contributed by Leonard B. Kaban.
Hemifacial Microsomia*
Hemifacial microsomia is a variable, progressive, and asym­
metrical craniofacial deformity. It involves both the skeletal and
soft tissues along with neuromuscular components of the first
branchial arches. After cleft lip and palate, it is the most com­
mon (1 in 5600 live births) congenital facial anomaly58,59. The
mechanism of development in humans is unknown, but
Poswillo60has described an animal phenocopy in mice. A he­
matoma in the area of the first and second brachial arches is
produced by hemorrhage of the developing stapedial artery. The
size of the hematoma and resultant tissue destruction explains
the morphology and variability of hemifacial microsomia in the
experimental model.
Like cleft lip and palate, the hemifacial microsomia pa­
tient requires treatment that must be integrated between the dif­
ferent specialists comprising die craniofacial anomalies team.
Treatment extends from early childhood to the late teens, when
growth is completed. An integrated plan that considers all as­
pects of this complex deformity is essential.
The hemifacial microsomia patient has a skeletal defect
which is classified by the anatomy of the mandibular ramus
and the temporomandibularjoint along with the soft tissue com-
Fig. 8-43. Tracings of radiographs representing the skeletal
types of hemifacial microsomia. Note medial and
inferior displacement of the ramus and TMJ in type
IIB. (Source: Kaban LB. Pediatric Oral and Maxil­
lofacial Surgery. P hiladelphia, 1990; W.B.
Saunders.)
 Cleft Lip and Palate 369

ponent (Figure 8-43). A type I skeletal deformity consists of a
small mandible and TMJ. All structures are present, normal in
shape and location, but are small. A type II skeletal deformity
consists of a small and abnormally-shaped ramus and hypo­
plastic TMJ. This group is subdivided into DA and HB. In type
HA, the TMJ hypoplasia is mild and the TMJ does not need to
be replaced. In type IIB hemifacial microsomia, the TMJ is
hypoplastic and medially, anteriorly, and inferiorly displaced to
the extent that a new joint must be constructed. Type III pa­
tients have a complete absence of the ramus and TMJ. Since
condylar growth is an integral component of normal, symmetri­
cal mandibular growth, patients with an altered or missing condy­
lar growth will exhibit various degrees offacial asymmetry based
on the growth potential of the TMJ.
The soft tissue defects include reduced bulk of subcutane­
ous tissue, ranging in degree from mild to severe, with the de­
gree of soft tissue deficit usually correlated with the degree of
the skeletal defect. Hypoplasia of the muscles of mastication
and facial expression is quite common. The patient may have
macrostomia, plus there may be skin tags along a line from the
tragus to the commissure of the lip.
The auricular deformity was described by Meurman, as
follows: Grade 1, mild hypoplasia and mild cupping, but all
structures present; Grade 2, absence of the external auditory
canal and variable hypoplasia of the concha; and Grade 3, ab­
sent auricle, and anteriorly and inferiorly displaced lobule61.
There is usually a conductive hearing loss due to hypoplasia of
die ear ossicles. More than 25% of the patients have cranial
nerve abnormalities, usually consisting of facial nerve palsy and/
or deviation of the soft palate to the affected side with eleva­
tion. Palatal deviation is due to a combination of nerve weak­
ness and muscle hypoplasia. The severity of the seventh nerve
palsy correlates with the severity of the ear abnormalities and
not the skeletal defect. The most common facial nerve weak­
ness involves the marginal mandibular branch followed by the
branch to the frontalis muscle.
The treatment plan is based upon the severity of the skel­
etal defect and, therefore, an accurate classification is essential
for optimal treatment. The skeletal type predicts the rate and
progression of asymmetry. Table 8-6 provides a summary of
die general treatment principles by age and skeletal type. Treat­
ment of soft tissue deformities begins in infancy. Skin tags are
removed and macrostomia can be repaired during the first year.
The external ear deformity is not treated until the skeletal cor­
rection is completed to ensure correct positioning of the recon­
structed ear. Other soft tissue deficiencies are usually corrected
after the skeletal correction. Mild deformities can be corrected
with onlay bone grafts, but patients with severe defects require
soft tissue augmentation with vascularized tissue transfer.

Table 8-6. Hemifacial Microsomia Treatment Plan by Age and Skeletal Type.*

Skeletal Deciduous Dentition Mixed D entition . i

Type

^ancfibujar advancement . }MftxjlJa^and mandibular

%ppiiance1n'cooperative patient,
if asymmetry progresses to
produce occlusal.cant. .
IIA Jsame^asjortype L Activator
u S 11 ^effective than
^elongation' and rotation to
create open bite when occlusal
.cajgt/and mandibular asymmetry
'pro&fess;.
|Sff®e'asfor type I
osfeotomie&to correct
end-sfage asymmetry.
'^arrf^£a's for type I

IIB . Stx^ting^Ma^ndranius cannot ^ Sarfle as for ages 0-5. fTbtalfTMJ construction CO oj

plus maxillary and man- 7c ®
l l l l l 5.2 §m
fdl^arfdstebtomies to
correct end-stage %®
‘oa> m
maintained With appliance to .'asymmetry, P' CL >
>

^ r m it vertical mldfaee growth. CD o

cn)
O
III fTMd and jamqs-absent. •Same as for ages 0-5. ^Same^asfor type IIB,
,CpnstructioJ>of glenoid fossa,
^pndyfe, ^nd;ramus. Surgically
§ereated open bite maintained
^wjth,ap|3l|ance to permit
- vertieaL^idfaeegrowth.
370 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

The prosthodontic treatment is usually limited to the most Ectodermal Dysplasia

severe cases (Type IIB and III). Following surgery to recon­
struct the ramus and condyle, the prosthodontist may be called
upon to reestablish the mandibular occlusal plane when the per­
manent dentition is missing on the affected side. The presence
of mandibular teeth is essential to allow for the proper position
of the maxillary dentition. The maxillary teeth will be positioned
in the appropriate position by a combination of orthognathic
surgery and orthodontics. The patient shown in Figure 8-44
demonstrates the use of osseointegrated implants to support the
posterior mandibular dentition. This patient was missing the
permanent posterior teeth in the mandible on the left side. Fol­
lowing a costochondral graft to reconstruct the TMJ and the
ramus, as well as the body of the mandible, 4 osseointegrated
implants were inserted into the reconstructed mandible. Fol­
lowing second-stage surgery, a provisional implant prosthesis
restored the mandibular occlusal plane. As orthodontic treat­
ment is presently in progress, the definitive implant-supported
restoration will wait until after its completion. If the mandibu­
lar posterior dentition is not restored, there is a possibility that
the maxillary dentition will continue to erupt.
The ectodermal dysplasias (ED) are a group of hereditary
diseases that affect the hair, teeth, nails, sweat glands, and other
ectodermal derivatives of the body. Medical and dental treat­
ment can be complicated for the various groups of these pa­
tients. Dental treatment is particularly important since it is criti­
cal for the child’s normal diet, facial appearance, speech, and
emotional development (Figure 8-45).
Any part of the body that is formed from ectoderm may be
affected in ectodermal dysplasias. Hypohidrotic ectodermal
dysplasia (HED) was one of the first types of ED to be recog­
nized. It is the most common form of the disorder and is usually
transmitted as an X-linked trait, with males manifesting the dis­
order more frequently than females62. Individuals with this con­
dition have sparse, tightly pigmented hair, absent or sparse eye
brows and lashes, a reduced number of teeth, and an inability to
sweat. The skin is dry and other body secretions are diminished.
The physical appearance varies between individuals and fami­
lies. Other types of ED have varying degrees of dental malfor­
mations. Table 8-7 lists some of the commonly seen malforma-

Fig. 8-44. a: Patient (2-years-old) at initial presentation in 1979 with left hemifacial microsomia, b: Patient in 1992 prior to
mandibular reconstruction. Note short ramus with deviation to left, c: Panoramic radiograph following mandibular
reconstruction with a costochondral rib graft, d: Intraoral view following reconstruction, e: Panoramic radiograph
with 4 implants in reconstructed left mandible, f: Facial view in 1993 following surgery. Compare with (b). Note soft
tissue deficiency that persists on left side. Definitive implant-supported prosthesis will be fabricated on completion
of orthodontic treatment currently in progress. The implants are supporting a provisional acrylic resin prosthesis.
 Cleft Lip and Palate 371

F ig . 8-45. a: Study casts for 13-year-old boy with ectodermal dysplasia. The only permanent teeth present are the maxillary
central incisors, the mandibular incisors, and first molars. Remaining teeth were deciduous, b: Occlusion, c: Prepa­
ration o f maxillary deciduous cuspids and first molars for coping crowns, d: Coping crowns splinted together, e:
Thimble crowns in partial denture, f: Palatal view of prosthesis, g: Esthetics. (Treatment completed in 1968.)

tions and their inheritance pattern. While some rare forms of
ED are associated with mental retardation, the common forms
are not. The inheritance patterns of ectodermal dysplasias are
demonstrated in Figure 8-46.
Depending upon the type of ED, the dental problems can
vary from unpredictable patterns of tooth eruption and loss,
widely spaced teeth, poorly shaped crowns and roots, defective
enamel formation, and malformed teeth to partial or complete
anodontia. Once a diagnosis of ED has been made, a dentist
should be consulted. An early consultation provides parents with
an overview of treatment options, and introduces the child to
the dentist in a nonthreatening situation as well. Although early
restorative treatment is usually not necessary, regular checkups
are important When indicated, dental treatment can begin at as
early as 2 years of age.
In situations where the teeth are congenitally missing, there
is an associated failure of normal development of the corre­
sponding portion o f the alveolar process63,64. The rudimentary
alveolar process is deficient bucco-lingually. This lack of al­
veolar process development can lim it the placement of
endosseous implants. At the UCSF center for Craniofacial
Anomalies, we are conducting a 5-year prospective clinical trial
on the use of implants for patients with ectodermal dysplasia.
To date, 7 patients have been treated ranging in age from 7 to 16
years. These patients have either no teeth, or only a few mal­
formed maxillary incisors and molars. The patient shown in
Figure 8-47 is an example of the patients enrolled in the study.
In all the patients, narrow 3.3 mm diameter plasma sprayed
implants have been used. The completely edentulous maxilla
of HED patients almost always requires a bone graft to the an­
terior maxilla36. Prosthetic restoration for these patients is usu­
ally some type of implant-supported overdenture. In the man­
dible, 4 or 5 implants are customarily placed between the men­
tal foramina. The bar, which is fabricated, does not splint the
implants. The bar is sectioned in the midline, allowing normal
transverse mandibular growth. In the maxilla, at least 6 implants
372 M A X ILLO FA C IA L REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Table 8-7. Common types of ectodermal dysplasias that effect dental structures.

Type Most Obvious Features Inheritance*

. Book syndrome White h§ir, missing teeth, moist palms. , AD
Hypertrichosis Excessive hair, defective tooth AD
lanuginosa enamel.
Hypohidrotic ED Decreased sweating, sparse hair,; AD, AR, XLR
(anhidrotic ED) small teeth, missing teeth.

1Incontinentia Absent hair, missing teeth, malformed ..X L p ^ V -

pigmenti teeth, marbled pattern of pigmentation.

Marshall ED Missing teeth, decreased sweating AD

cataracts, hearing loss. .

Monilethrix - ".Twisted hajr^mfssing te e th /' . AD .

anodontia

Naegeli,ED Defective tooth enamel, thick palms- AD

and soles.

Otodentai dysplasia Abnormally shaped teeth, hearing loss AD

Robinson ED Missing teeth, defective naifsfhearing AD 1

loss. -

Tooth and nail, Thin hair, missing teeth, sfow nail AD Jj|
syndrome growth.

' Tricho-dento- Defective enamel, abnormal tooth AD

osseous synclrome roots, curly hair.

»T/icho-dental ^VThib hair, missing teeth. AD '

syndrome

Witkop ED Defective tooth enamel, defective AD

nails, decreased sweating.

* AD = autosomal dominant, AR = autosomal recessive,

XLD = X-linked dominant, and XLR = X-linked recessive.

Autosdnjal?Dominant; ^utosomal'Recessjye
' (one parent affected)
1 in 2 chance m 7 in 4 chance

X-linked Recessive
:;/4 (tyotke^^rrjerl ^ '
J in 4 chance

Fig. 8-46. Inheritance pattern of ectodermal dysplasias.

 Cleft Lip and Palate 373

should be placed. Again, the bar does not splint all the implants,
so normal transverse maxillary development may continue. At
this writing, it is premature to discuss any trends associated with
implant placement.
Some patients with ED have some permanent teeth,
often in the incisor and first molar areas. In general, these teeth
are small and abnormally shaped. These teeth should not be
removed; they can be restored with composite resin or crowns,
or used as overdenture abutments, possibly in combination with
implants. The decision to retain these teeth depends on root form,
crown morphology, and position in the arch. Many patients also
exhibit a closed vertical dimension of occlusion and deficient
lip support. These problems are accentuated when the patient
reaches adulthood (Figure 8-48 a,b,c). The vertical dimension
of occlusion and support for the lip are best restored with over­
lay prostheses. Osseointegrated implants and the residual den­
tition can be used effectively to retain and support these overlay
prostheses (Figure 8-48 d,e,f,g,h,i,j).

9 h
Fig. 8-47. Patient with hypohidrotic ectodermal dysplasia, a: Facial view at initial presentation, b: Intraoral view. Note mal­
formed maxillary anterior teeth, c: Pretreatment panoramic radiograph showing mandibular anodontia and partial
maxillary anodontia. d: Panoramic radiograph following placement of plasma-sprayed 3.3 mm diameter implants, e:
Panoramic radiograph following fabrication of Hader bar. Note mandibular bar is sectioned in midline to allow trans­
verse growth, f: The maxillary anterior teeth restored with composite resin restorations. Compare with (b). g: Com­
pleted prosthesis in place, h: Facial view 2 years following insertion of implant supported restorations.
374 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 8-48. a, b, and c: Adult with ectodermal dysplasia, d and e: Implants placed in anterior maxilla and mandible, f: Porcelain
fused to metal fixed partial denture made with UCLA abutments, g: Overlay bar in maxilla, and fixed partial denture
in mandible, inserted, h: Completed maxillary overlay prosthesis, i and j: Prostheses inserted. (Courtesy: Ray Lee.)

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Chapter 9
Restoration of Facial Defects
Etiology, Disability, and Rehabilitation
John Beumer III, Tsun Ma, Mark Marunick, Eleni Roumanas, and
Russell Nishimura
Facial defects can result from trauma, treatment of neo­
plasms, or congenital malformations. Facial defects referred to
the prosthodontist for restoration are usually the result of surgi­
cal resection of epithelial tumors (Figure 9-1). Occasionally,
however, remission of a tumor mass successfully treated with
radiation therapy or chemotherapy can result in significant fa­
cial deformity (Figure 9-2). Congenital malformations of the
head and neck region are usually habilitated with surgical re­
construction.
Restoration of facial defects is a difficult challenge for both
the surgeon and the prosthodontist. Both surgical reconstruc­
tion and prosthodontic restorations have distinct limitations. The
surgeon is limited by the availability of tissue, the compromise
Fig. 9-1. Large, nasal defect secondary to removal of basal
cell carcinoma.
of the local vascular bed by radiation in tumor patients, the need
for periodic visual inspection of an oncological defect, and the
physical condition of the patient. The prosthodontist is limited
by inadequate materials available for facial restorations, mov­
able tissue beds, difficulty in retaining large prostheses, and the
patient’s capability to accept the final result.
Patient acceptance and use of facial prostheses is not uni­
versal primarily due to unrealistic patient expectations. It is our
clinical impression that total nasal prostheses have the highest
level of acceptance, and orbital and midfacial prostheses have
the poorest acceptance. Acceptance of auricular prostheses
would be between these extremes.
Fig. 9-2. Nasal deformity secondary to radiation therapy.
378 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
However, only a single study (that we are aware of) has
investigated this problem. Jebreil sent a questionnaire to 27 pa­
tients treated at Roswell Park Memorial Institute over an 8 year
period with either a cosmetic orbital prosthesis, or a custom
acrylic resin eye patch1. Of the 18 patients who responded to
the questionnaire, 12 had been treated with an orbital prosthesis
and 6 with an eye patch. A total of 60 prostheses were fabri­
cated for the 18 patients over the 8 year period. However, only
12 of the 18 patients were using their orbital or eye patch pros­
thesis (i.e., 3 of die 12 orbital and 2 of 6 eye patch prosthesis
patients were not utilizing their prosthesis; 1 patient did not
answer the question).
It would be interesting to repeat a similar study using im­
plants for retention and support. Implants have improved the
prosthetic prognosis for all types of intra- and extraoral maxil­
lofacial prosthesis. However, the most significant impact cre­
ated by implants may be associated with extraoral facial pros­
theses. The retention provided by osseointegrated implants
makes possible the use of large prostheses on movable tissues,
as the margins can be made thinner and more flexible. Patient
acceptance is significantly enhanced because of the quality of
retention, improved esthetics due to repeatable positioning, and
ease of maintenance.
Whatever the mode of rehabilitation, the patient should be
fully informed of future problems and expected quality of the
final result In patients with extensive facial tumors requiring
resection, the method of facial restoration should be chosen prior
to surgery. The patient should be involved in this discussion
and participate in the decision making process. The objective to
be achieved is to have a well-informed patient with realistic
expectations prior to suigical resection. This is also true for both
posttraumatic and congenital defects, especially of the external
ear. Osseointegrated implants create effective bone anchors that
allow title prosthodontist to fabricate ear prostheses which the
patient will actually wear. Some of these patients may have re­
ceived treatment from early childhood to adulthood, so their
management must take into consideration the nature of the de­
fect, the attitude of the patient and their family, the manage­
ment of ear remnants, as well as the overall treatment of what
may be a complex congenital syndrome2.
Patients with craniofacial anomalies present with a variety
of complex facial deformities that require the expertise of many
individuals in the health science disciplines. Most of these de­
formities are best treated with surgical reconstruction. How­
ever, prosthodontic rehabilitation is a viable option for patients
with microtia because of the predictability of craniofacial im­
plants23,4. Reduced cost with fewer, less invasive suigical pro­
cedures and consistently excellent esthetic results make this
option one that is chosen with increased frequency by microtia
patients and their families.
The facial skin is the most common site for cutaneous can­
cer, and many of the tumors that arise on the face require exten­
Section on neoplasms of the facial area contributed by Roy Eversole and Henry Cherrick.
sive suigical intervention to achieve a cure. The surgical de­
fects that remain after tumor resection can be significant, re­
quiring reconstructive surgery, prosthetic rehabilitation, or a
combination of both in order to achieve adequate function and
esthetics. The malignant neoplasms that occur on the face may
invade underlying structures, necessitating the excision of
muscle, bone, or cartilage. When tumors invade the orbit, nose,
or ear, these anatomical structures may require resection, and
reconstructive surgery may not provide an acceptable esthetic
result. Therefore, maxillofacial prosthetics constitutes a viable
alternative for many of these patients.
The maxillofacial prosthodontist must be familiar with the
pathology and natural history of tumors in this location, since
interaction with the head and neck surgeon and radiotherapist is
an integral part of proper patient management. Indeed, the pros-
■thodonti st may offer valuable input on suigical treatment plan­
ning, advising the surgeon on which tissue contours that will be
most retentive and receptive for a prosthetic device. In addi­
tion, osseointegrated implants may serve as important retentive
and stabilization elements. Surgical contouring and reconstruc­
tion, as well as radiation fields and dosage, must be taken into
account prior to the planning and development of a prosthetic
treatment strategy that employs osseointegrated implants.
Neoplasms of the Facial Area*
Classification and Histogenesis
The neoplasms that occur on the face arise from the basilar
keratinocytes of the skin, melanocytes, and skin adnexal struc­
tures, including sebaceous glands, hair follicles, and sweat
glands. The most commonly encountered epithelial tumors of
the face are listed in Table 9-1.
The tumors derived from keratinocytes all take their origin
from the basal cell, since these are the germinative or dividing
cells of the epithelium. Many benign growths, including warts
and papillomas, are the consequence of human papillomavirus
infection. Other benign growths without a documented—al­
though probable—viral origin include seborrheic keratosis and
keratoacanthoma. Both are self-limited proliferations of
keratinocytes that are clinically characterized by well-demar-
cated borders and no ability to invade underlying structures.
Keratoacanthomas can be quite large and may require wide
excision. If located on or near the ear or nose, prosthetic recon­
struction may become necessary.
Basal cell carcinomas also arise from basal keratinocytes;
however, unlike the aforementioned benign lesions, they have
the potential for locally aggressive behavior characterized by
invasion of adjacent and underlying tissues. While some clini­
cians classify them as malignant tumors, basal cell carcinomas
do not typically metastasize (less than 1%), and they should be
considered locally aggressive benign neoplasms with the po­
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
tential for persistent growth and recurrence after removal. Con­
versely, squamous cell carcinomas of skin are true malignan­
cies with significant growth potential and a propensity to me­
tastasize to regional lymph nodes; hematogenous spread being
less frequent. Although both basal cell and squamous cell neo­
plasms arise from the same cell of origin, they can be differen­
tiated from one another on the basis of histopathologic features.
Melanocytes are derived from the neural crest and migrate
through the mesenchyme during embryonic life to the skin and
mucous membranes. These cells then populate the lower strata
of the epithelium, being interposed between basilar
keratinocytes. They synthesize melanin pigment, which shields
and protects the basal keratinocyte from the affects of solar ir­
radiation. In this regard, light-skinned individuals are more prone
to develop carcinomas than are dark-skinned people. Benign
proliferations of melanocytes, termed nevi, are self-limited in
their growth potential. Most nevi arise in childhood from basal
layer melanocytes at the junction of the epithelium and the con­
nective tissue. Malignant melanoma is a malignant neoplasm
that differs from nevi in that proliferation and invasion with
potential for hematogenous spread are the classic features. The
earliest change occurs in the basal layer and is termed mela­
noma in situ. The proliferating cells may then spread laterally
along the basal layer or invade into the connective tissue. Im­
portantly, melanomas are highly malignant tumors and require
extremely wide surgical margins.
The skin adnexa include hair follicles, sebaceous glands,
and sweat glands. Tumors derived from these differentiated cells
are collectively termed adnexal tumors. The benign lesions are
usually small, grow slowly, and are often self-limited, thereby
Table 9-1. Common Epithelial Facial Tumors.
K e ra tin o c y te O rig in
Seborrheic Keratosis
Keratoacanthoma
Basal Cell Carcinoma
Squamous Cell Carcinoma
M e la n o c y te O rig in
Nevi
Lentigo Maligna and Lentigo Maligna Melanoma
Superficial Spreading Melanoma
Nodular Melanoma
A d n e x a l O rig in
Benign Adenxal Epitheliomas
Microcystic Adenocarcinoma
Other Malignant Adnexal Carcinomas
Merkel Cell Carcinoma
379
requiring only minor surgical excision. Malignant adnexal tu­
mors are quite rare; yet they can behave in a fashion similar to
squamous cell carcinoma5,6,7. One aggressive adnexal tumor that
requires wide excision is microcystic adenocarcinoma6,8. Its cell
of origin is not known, but is probably the sweat gland duct.
This aggressive tumor rarely metastasizes. Other adnexal tu­
mors include sebaceous carcinoma, commonly found on the
eyelid, and ceruminous carcinoma of the ear canal (ear wax
glands). A rare, yet highly malignant tumor of the skin is the
Merkel cell carcinoma. This tumor arises from neuroepithelial
cells located at the epidermal connective tissuejunction, is highly
invasive, and has metastatic potential. Merkel cell carcinomas
histologically resemble other neuroendocrine round cell tumors
and may be mistaken for basal cell carcinomas9,10. Such tumors
have a poor prognosis.
• Only the more common skin cancers will be described in
detail, including basal cell carcinoma, squamous cell carcinoma,
and melanoma.
Basal Cell Carcinoma
Derived from basilar keratinocytes, basal cell carcinoma is
the most common form of skin cancer. As stated previously, the
terms cancer or carcinoma are applied to this tumor because of
its aggressive behavior and tendency for invasion of contigu­
ous tissues. In the context of true malignancy, basal cell carci­
noma does not fulfill the criteria as it does not metastasize. Some
exceptions do occur, and the literature indicates that an occa­
sional lymph node metastatic focus may be encountered in less
than 1% of cases11.
Actinic or solar irradiation plays an important role in the
etiology of basal cell carcinoma. The tumor is far more preva­
lent in “sun belt” regions, and it has a high predilection for indi­
viduals of light complexion. In the United States, Hawaii ap­
pears to have the highest incidence annually among Caucasoids
(whites), with 576 men and 298 women per 100,000 popula­
tion12. In Queensland, Australia, non-melanoma skin cancer in
white men and women aged 20-59 is very high, being 2,389/
100,000 and 1,908/100,00, respectively, with a4:l ratio of basal
cell to squamous cell carcinomas. In another study, the nevoid
basal cell carcinomas that accompany jaw keratocysts and bifid
rib tend to occur in cutaneous sites not exposed to sunlight;
however, individuals with this syndrome also show a greater
tendency to develop basal cell tumors on sun-exposed skin13.
The aforementioned studies concentrated on whites; basal cell
carcinoma is extremely rare among blacks.
Prior to the discovery of antibiotics, syphilis was treated
with arsenical compounds, and individuals so treated were prone
to develop both basal cell and squamous cell cancers. A role for
oncogenic viruses, such as herpes simplex, and human
papillomavirus in the genesis of basal cell carcinoma is not well
supported at this time.
380 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Clinical Features

Early basal cell carcinomas may appear as small, pearly

white nodules of the skin, and they will usually show erythema
or superimposed telangiectasia. A surface keratosis or scale may
also be evident. These nodules soon ulcerate and become a per­
sistent ulcer with rolled margins (Figure 9-3). The center of the
ulcer is often scabbed with a crusted core. If left untreated, they
will continue to invade and enlarge circumferentially. Negli­
gence in seeking care has resulted in loss of facial structures
including the lip, nose, eye, and ear. (Figure 9-4). Indeed, un­ Fig. 9-3. Early noduloulcerative-type basal cell carcinoma.
treated basal cells have been known to invade the facial and Note elevated margins and centrally depressed
skull bones, with extension into the sinuses and even into the area of ulceration.
brain (Figure 9-5). Although rare, some patients have died from
local disease despite the absence of any metastases.
The most common facial locations for basal cell carcino­
mas are the forehead, nose, malar region of the cheek, upper
lip, and helix of the ear. The fair-haired, light-skinned individual
may be prone to develop multiple lesions of the face, and such
tumors may be contiguous with cutaneous evidence of solar
damage and actinic keratoses, appearing as red maculae with a
fine surface scale. Certain variants of basal cell carcinoma are
known to occur and may show clinical appearances that differ
from the typical crateriform ulcer. A pigmented form is rare yet
may be mistaken for a nevus, since the tumor cells are accom­
panied by benign melanocytes that synthesize pigment. The
morphea variant is often invasive without surface ulceration or
rolled margins; rather, it appears yellowish, or shows pallor over
the surface of the skin, and is indurated. This form is highly
invasive and induces collagenization of the adjacent stromal
connective tissues. Tumor cells may extend for a considerable Fig. 9-4. A large facial defect secondary to numerous
distance in the dermis and subcutaneous tissues beyond areas surgical excisions for multiple and recurrent basal
of palpable induration, thereby necessitating wide excision to cell carcinomas.
prevent recurrence.

Histopathology

The early basal cell carcinoma usually shows continuity

and origin from the surface epithelium. More advanced inva­
sive lesions with ulceration may no longer show continuity with
the surface. The tumor is composed of solid sheets and nests of
cells that are monomorphic in nature. The outer stratum of cells
tend to be cuboidal, mimicking the normal basal layer of the
surface epidermis. These basal cells surround sheets of oval
monomoiphic cells that have poorly defined cell borders. Im­
portantly, cytologic atypia is not a feature and mitotic figures
are not prominent. The islands are seen to invade the underly­
ing dermal connective tissues, and they may be accompanied
by an inflammatory infiltrate composed of mononuclear leuko­
cytes. Inflammation is most prominent when ulceration occurs.
As the tumor cells proliferate into the connective tissue, the Fig. 9-5. Large noduloulcerative-type of basal cell carci-
overlying epithelium becomes ulcerated. Continued tumor noma. Note destructive nature of this lesion.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
growth often occurs about the margins of the lesion, and the
neoplastic cells have a tendency to undermine the borders,
thereby creating an elevation or rolled margin. This undermin­
ing growth can be quite extensive, with tumor cells being lo­
cated some distance from clinically obvious swelling and indu­
ration. Likewise, the inferior margins can be highly invasive,
extending into deep structures of the facial tissues. These histo­
logic findings are important considerations in determining the
extent of surgical excision.
Some basal cell carcinomas will actually exhibit squamous
differentiation with formation of keratin pearls. Such differen­
tiated tumors may share features in common with well-differ-
entiated squam ous cell carcinom as. The so-called
“basosquamous variant” is, however, a form of basal cell carci­
noma and, regardless of squamous differentiation, it lacks cel­
lular atypia, does not metastasize, and fails to show any differ­
ences in natural history or behavior when compared with ordi­
nary basal cell carcinoma. Pigmented basal cell carcinomas show
the typical histopathologic appearance; yet, neoplastic cells con­
tain melanin pigment granules14. This histologic variant does
not behave differently from the classic form of the tumor. Alter­
natively, the morphea variant is more aggressive and invasive.
Morphea type basal cell carcinomas are characterized by ex­
tensive collagenization with the appearance of scar tissue. The
neoplastic element is often obscured by this desmoplastic
fibrosing element. The tumor cells no longer form clean oval
islands. Instead, the cells are arranged in tubular, “Indian-file”
strands, are hyperchromatic, and appear to be compressed. These
thin strands may invade deeply and can sometimes be over­
looked when examining the margin of an excised tumor, owing
to their compressed, small size.
Treatment
Both surgery and radiation therapy have been employed
successfully in the management of basal cell carcinoma. It is
important to recall that basal cell carcinoma is invasive and may
extend for a considerable distance both laterally and deeply
beyond what clinically appears to be the tumor margin. Finger­
like projections of tumor islands are even more extensive in the
morphea-type tumor. Incomplete excision Will lead to recur­
rence, and each recurrence tends to become larger and more
extensive. Therefore, incomplete excision is to be avoided, and
this can be accomplished by taking adequate margins both lat­
erally and deeply. Although electrosurgical intervention has been
employed for early lesions, the adequacy of excision cannot be
verified histologically, since the electrocautery effects on tissue
obfuscate the histological appearance of residual tumor. Com­
plete excision is most readily confirmed by histologic exami­
nation of all margins. Frozen section examination during sur­
gery is most appropriate for basal cell carcinomas. Morphea-
type lesions may not always be adequately evaluated for com­
381
plete excision, requiring detailed examination of paraffin-em-
bedded material.
Mohs introduced a combined, surgical-chemical technique
for the definitive and complete excision and chemical cautery
of cutaneous neoplasms. The method involves the application
of zinc chloride paste, which causes necrosis and fixation of the
neoplastic tissues15,16. The chemically treated skin is excised and
examined by frozen section. Should tumor remain, the process
is repeated in an organized, mapped configuration until there is
no pathologic evidence of tumor cells. Although dermatologists
prefer this method, it is time-consuming and expensive. Its chief
advantage is maximized preservation of uninvolved tissue. Most
head and neck surgeons usually prefer to excise the tumors with
wide margins which are examined by frozen section at the time
of excision. In both approaches, the goal is to remove all tumor
cells with tumor-free margins. Large tumors will usually re­
quire reconstructive surgical approaches, using free grafts and
myocutaneous skin flaps, depending upon the size of the de­
fect. Loss of the orbital contents, external nose, or external ear
will usually require postsurgical fabrication of prosthetic de­
vices.
Radiation therapy has also proven effective in the treat­
ment of basal cell cancers, particularly for smaller lesions; how­
ever, tumors that have invaded bone and cartilage do not re­
spond well to irradiation. Those tumors amenable to radiation
are treated over a 3-5 week period, delivering an external beam
dosage from 4500-5000 cGy. Lesions that recur following ra­
diation therapy are often difficult to eradicate surgically17.
Topical chemotherapy is efficacious only in very early le­
sions. The most commonly employed agent is 5% 5-fluorou-
racil ointment, which is applied 2-3 times daily for 6-8 weeks.
Large lesions cannot be treated by this method. In early tumors,
the epithelium will become markedly inflamed within 2 weeks
and, after 1 month of application, this antimitotic drug will cause
ulceration. Recently, noduloulcerative basal cell tumors have
been treated by a combination of an intralesional injection of
interferon followed by Mohs surgery18. Interferon was found to
be only marginally effective.
In summary, basal cell carcinomas are amenable to both
surgical and radiation therapies for small lesions, whereas large
invasive tumors, particularly those invading bone and cartilage,
are most appropriately managed by wide surgical excision.
Despite attempts to document total excision microscopically,
recurrent disease is a common complication, particularly for
large lesions.
Squamous Cell Carcinoma
Squamous cell carcinoma of the skin has the same predis­
posing factors as basal cell tumors. Importantly, squamous can­
cers have metastatic potential and, therefore, constitute a much
more serious disease process19. Like basal cell tumors, there is a
382 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

propensity for involvement of sun-exposed skin, and light­
skinned subjects are more susceptible to the disease. In particu­
lar, blond or redheaded, fair-complected persons are much more
prone to the development of facial skin squamous cell carci­
noma than dark-skinned people. Although other etiologic fac­
tors, such as low-dose radiation, arsenic, and cold tars, have
been implicated in cutaneous squamous cancer, solar irradia­
tion remains the chief predisposing factor. It is noteworthy that
human papillomavirus has been implicated in a rare form of
cutaneous squamous cancer that occurs in individuals with a
genetic predisposition to this condition, which is termed
epidermodysplasia verruciformis. Most of these cancers arise
on non head and neck skin sites. Another genetic disease, one
which predisposes children to cutaneous squamous cancer, is
xeroderma pigmentosum; in which DNA repair mechanisms
are defective. Thus, the majority of facial skin squamous carci­
nomas appear to be related to excessive sun exposure on fair­
skinned persons.
Clinical Features
arising from the epidermis show early features of dysplasia and
carcinoma in situ. These precancerous changes are encountered
in actinic keratoses, and they consist of nuclear pleomorphism,
hyperchromatism, increased nuclear-to-cytoplasmic ratio, and
increased and/or atypical mitotic figures. When these atypical
cell changes occupy all strata of the epithelium, the term carci-
noma-in-situ is applied. Precancerous lesions at this stage of
development will then progress to superficially invasive carci­
noma whereby the atypical cells proliferate into the underlying
connective tissues. Unlike the tumor cells of basal cell carci­
noma, the cells of squamous cell carcinoma are capable of vas­
cular invasion, particularly lymphatic vessels. This capability
then eventuates in metastatic spread to regional lymph nodes.
Tumor cells lodge in the lymph nodes and continue to prolifer­
ate within the node, causing enlargement of the node. This en­
largement may be evident on magnetic resonance imaging (MRI)
or detectable by neck palpation. When the tumor cells prolifer­
ate outside the capsule of the node, adjacent tissues become
invaded, accounting for fixation and induration.

Akin to basal cell carcinomas, squamous cell carcinomas

are frequently associated with actinic keratoses. The early le­
sion is often an erythematous plaque with a keratotic scale.
Unlike basal cell tumors, squamous cancers usually have ir­
regular, jagged margins. Ulceration is commonly encountered
and rolled, indurated borders are the rule (Figure 9-6). As the
lesion enlarges, it is not uncommon to observe a keratotic pap­
illary or verrucous, warty appearance (Figure 9-7). Again, un­
like a viral wart, the lesion is not cleanly demarcated, and it Fig. 9-6.
usually lacks a smooth round or oval periphery. On palpation, Auricular squamous ceil car­
squamous cell carcinomas are indurated and not clearly defined, cinoma. Note granular crusty
particularly when they are laige. The skin of the forehead is a nature of lesion. Lesion
common location on the face, as is the lower lip. Indeed, squa­ invaded bone and required a
mous carcinomas of the lip may be preceded by actinic cheili­ temporal bone resection.
tis, a leukoplakia that can persist for many years before carci­
noma evolves20. Actinic cheilitis appears as a white keratosis of
the vermillion border of the lower lip among individuals who
work out of doors. When these keratotic lesions begin to ulcer­
ate and become nodular and indurated, carcinomatous transfor­
mation is probable21.
Neck metastases are seen in a minority of patients with
facial skin squamous cell carcinomas, usually the large exten­
sive lesions. Metastatic nodes from facial primaries are usually
detected along the cervical chain, whereas scalp tumors will
spread to posterior neck scalene nodes. The nodes are indurated
and may be fixed to adjacent tissues.

Histopathology Fig. 9-7.

Verrucoid-appearing squa­
Squamous cell carcinoma of the facial skin is derived from mous cell carcinoma of the
basilar keratinocytes of the epidermis. The transformed cells ear.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
Histologically, cutaneous squamous cancers are usually
well-differentiated; rarely are they poorly differentiated or un­
differentiated analogous to those arising in the nasopharynx.
The tumor cells are arranged as cohesive nests, islands, or cords
surrounded by a stratum of basal-type cells. These basilar cells
often show increased mitoses and are both hyperchromatic and
pleomorphic. In the center of the strands or islands are cells
with varying degrees of differentiation, and keratin pearls or
parakeratin eddies may be evident. Unlike basal cell tumors,
these center-most cells within the islands also show cytologic
atypia. The greater the evidence of keratin formation in con­
junction with minimal atypia, the lower the grade of malignancy
and the higher the degree of differentiation. Alternatively, when
keratin pearl formation is lacking, and the cells show marked
atypia with increased mitotic activity, the tumor is less differen­
tiated and of a high grade. The lesser differentiated the tumor,
the higher the cell turnover rate, implying a greater level of
susceptibility to radiation.
Variant forms of squamous cell carcinoma of the skin are
adenoid squamous cell carcinoma and spindle cell carcinoma.
The adenoid variant shows malignant squamous epithelial is­
lands with foci of acantholysis and duct-like configurations22.
Spindle cell carcinomas may be mistaken for sarcoma; how­
ever, origin from the basal layer of the surface epithelium can
usually be demonstrated, and epithelial markers, such as
cytokeratin and epithelial membrane antigen, can be employed
immunohistochemically to confirm the epidermal origin of the
spindle cells23. Both of these histologic variants behave as mod­
erately to poorly differentiated carcinomas.
Treatment
Squamous cell carcinoma of skin must be treated aggres­
sively, since it is infiltrative without well-delineated margins.
Surgical excision will include a wide margin of normal-appear­
ing skin, with microscopic assessment of the lateral and deep
margins to ensure complete removal of malignant tumor islands
and nests. Carcinomas that overlie bone will often invade the
periosteum, necessitating inclusion of bone in the surgical re­
section. Therefore, based on the size of the initial lesion, the
surgical defects can vary considerably in size and degree of
disfigurement. Loss of facial structures is unavoidable in large
tumors, thereby requiring plastic surgery, myocutaneous flaps,
and/or prosthetic reconstruction.
Due to the lymphatic and blood vessel wall invasion capa­
bilities of squamous cancers, assessment of both the regional
lymph node and distant metastases must be undertaken. When
lymph node involvement is clinically detectable, or when re­
gional nodes exceed 1 cm on MR imaging, lymph node dissec­
tion is included along with surgical excision of the primary tu­
mor. Achest x-ray is usually included in the workup to examine
for hematogenous spread to the lungs.
383
Radiation therapy is also effective in the treatment of skin
squamous cell carcinomas; either alone for smaller lesions, or
in combination with surgical excision24. External beam therapy
is generally used, thereby avoiding many complications that
attend radiation of mucosal carcinomas on the skin. In general,
4500 to 6000 cGy delivered in fractionated doses, is effective.
Radiation therapy may also be included for sterilization of neck
nodes and is sometimes prescribed for clinically negative find­
ings (elective node irradiation). In general, the prognosis for
cutaneous squamous carcinoma is much better than for squa­
mous cancers arising in the mucous membranes of the head and
neck. Carcinoma of the lower lip is slow to metastasize and has
a high (90%) 5-year survival. Carcinomas of the facial skin,
forehead, ear, and nose are more prone to metastasize; how­
ever, only large lesions have a bad prognosis. Recurrence is
more commonly encountered than metastasis. Metachronous
lesions are also common, particularly in patients with sun-dam­
aged skin (field cancerization). The spindle cell and adenoid
variants have a greater propensity for recurrence and metastasis
than do ordinary squamous cell carcinomas of the face.
M alignant Melanoma
Melanomas derive from melanocytes, the pigment-produc­
ing cells that embryologically migrate from the neural crest,
eventually becoming situated above and between basal
keratinocytes of the skin. Benign lesions of these cells are termed
nevi. Most nevi arise during childhood as focal, self-limited
proliferations of melanocytes. The proliferating cells are ini­
tially confined to the basal layer, at its junction with the dermis,
and are, therefore, termed junctional nevi. Within a few years,
these cells drop off into the connective tissue, compound nevi
and, by puberty, most nevus cells reside solely within the der­
mis, being intradermal nevi. Importantly, new nevi do not arise
in adulthood and the occurrence of a new pigmented lesion in
an adult is cause for concern. Some nevi are thought to be prone
to malignant transformation into melanomas, and this trend is
thought to often follow a familial pattern. Such dysplastic nevi
may be numerous. Fifty percent of melanomas probably arise
de novo, whereas the other half are thought to arise from preex­
isting nevi. Malignant melanoma accounts for about 2% of all
cancers.
On the facial and cervical skin, solar irradiation plays a
dominant role in the pathogenesis and etiology of malignant
melanoma25,26. The malar and lateral neck skin regions receive
maximal sun exposure and are favored sites. The disease is more
common among whites than dark-skinned peoples.
Clinical Features
There is generally no gender predilection for melanoma;
most patients are elderly, the average age being 60. Among
384 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
males, the skin of the ear auricle, neck, and scalp are most often
affected, whereas, in females, the facial skin is the most fre­
quently affected area. The clinical appearance of cutaneous
melanoma varies according to the histologic type. Since nevi
are so common in the general population, certain features must
be encountered to raise suspicion of melanoma. Most impor­
tant is duration or onset. As previously mentioned, most nevi
arise in childhood; hence, the occurrence of a new focus of pig­
mentation in an adult should be viewed with suspicion. Con­
figuration of the pigmented area is also important. Nevi are round
or oval shaped, are symmetrical, and have smooth margins.
Alternatively, melanomas often show ragged, irregular margins.
Some clinicians have likened these differences to the smooth
and straight coast of Florida (analogous to nevi) contrasted with
the jagged and rocky coast of Maine (analogous to melanoma).
A third feature is coloration. While nevi may be brown or black,
the color is always homogeneous for a given mole. Melanomas
tend to be heterogeneous with varying shades of black, grey,
and brown mixed together in a single lesion (Figure 9-8).
Those lesions that are macular without tumefaction usu­
ally represent melanomas that grow laterally or radially, super­
ficially spread, and have a better prognosis than raised lesions.
Lentigo maligna (LM) and lentigo maligna melanoma (LMM)
are also radial in their pattern of growth, yet such lesions differ
from the superficially spreading type both histologically and
clinically. Importantly, LM and LMM are progressive stages of
the same entity. Such lesions occur most often on the face of
elderly, light-complected individuals, and they may persist for
20 years before any invasion occurs. They are multicolored and
may show admixed foci of depigmentation, representing areas
of tumor regression. Those pigmented lesions with nodular ex­
crescences are prone to invasion of the dermis and are termed
nodular melanomas.; they are highly malignant with a great pro­
pensity for metastasis.
Fig. 9-8. Typical superficial spreading malignant melanoma.
Histopathology
Cutaneous melanomas evolve from junctional melanocytes
and, therefore, any junctional proliferation in an adult is suspi­
cious for melanoma. Three types ofjunctional changes are seen
in early melanomas. Those associated with dysplastic nevi are
unique, and the melanocytes show only mild cytologic atypia.
In lentigo maligna melanoma, thejunctional cells are more pleo­
morphic and can synthesize large quantities of melanin pigment
granules. When junctional activity with atypia is observed yet
is minimal, many pathologists will classify such lesions as
premelanoma or melanoma in situ. As the junctional activity
increases, atypical and pigment-producing melanocytes extend
upwards into the spinous layer and will also form nests and
clusters along the basal layer. Such lesions will often extend
radially for a considerable distance—even though no or mini­
mal invasion of the dermal connective tissue is evident. Such
lesions are usually macular and histologically represent super­
ficial spreading melanomas. Since invasion is superficial, the
prognosis after complete excision is usually good; less than 2%
metastasize to regional nodes and the 5-year survival is 95%.
Lentigo maligna and lentigo maligna melanoma are common
on the face, and are also junctional with only superficial foci of
invasion.
Nodular melanomas are characterized by more advanced
melanocytic proliferation and invasion into the dermis. Clark27
and Breslow28 have developed grading systems for nodular
melanomas that assess the level of invasion seen microscopi­
cally. These levels are based upon the premise that the biopsy
specimen has been properly oriented such that microtome cuts
into the tissue are 90° to the surface. The Clark level of invasion
is then graded 1-5, with level 1 lesions confined to the epithe­
lial-connective tissue junction, and level 5 tumors invade and
extend down to the subcutaneous fat. In the Breslow grading
system, the depth of invasion is measured in millimeters, with 5
mm corresponding to the Clark level of 5. The propensity for
metastasis dramatically escalates with increasing levels of in­
vasion. Lesions over 0.76 mm of invasion have a 58% preva­
lence of nodal metastasis, and 5-year survivals range from 20%
to 60%, depending on how deeply invasive the tumors may be.
The individual tumor cells in melanoma are varied from
one lesion to another and can be mistaken for other forms of
cancer, particularly when melanin pigment synthesis is mini­
mal or absent (amelanotic melanoma). The tumor cells may be
round, oval, or spindle in shape; anaplastic or pleomorphic; and
arranged in theques or islands, or lacking cohesiveness. Some
melanomas are neurotropic, tending to wrap around nerve fi­
bers. When pigment production is low, and other considerations
are included in the differential diagnosis, immunohistochemi-
cal markers become useful. In particular, melanomas usually
stain positively for the s-100 protein and the melanoma-spe­
cific protein, HMB-45.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
Treatment
Surgical excision is the treatment of choice and, as already
alluded to, the level of invasion dictates the prognosis29’30’31. Wide
excision is required, along with examination of the lateral and
deep margins, to ensure that all melanoma cells have been ex­
cised. Lentigo maligna melanoma of the face must be deeply
excised* since junctional changes extend down pilosebaceous
skin appendages. Superficial spreading and lentigo maligna
melanoma (thin tumors) enjoy a good prognosis after wide ex­
cision, whereas invasive nodular melanomas that arise de novo,
or evolve from SSM, metastasize widely and result in death in
50% of the patients—even with wide excision of the primary
tumor26. This is explained by the fact that invasive lesions have
probably already metastasized at the time of initial surgical ex­
cision of the primary tumor.
Rehabilitation
Surgical Reconstruction versus Prosthetic Restoration
The choice between surgical reconstruction and prosthetic
restoration of large facial defects is a difficult and complex de­
cision, one which depends on the size and etiology of the de­
fect, as well as on the wishes of the patient. Surgical reconstruc­
tion of small facial defects is, in most cases, preferable. Many
patients prefer masking a defect with their own tissue rather
than with a prosthetic restoration. However, it is sometimes dif­
ficult, if not impossible, for the surgeon to fabricate a facial part
that is as cosmetic as a well-made prosthesis. However, not ev­
eryone will accept an artificial part, and many would rather have
a permanent, reconstructed facial part rather than an artificial
one. The application of osseointegrated implants in facial de­
fects has, in part, changed patient perceptions about facial pros­
theses because of their effectiveness of retention and the im­
proved esthetic results.
The patient group who are often candidates for prostheses
are the elderly with neoplasms that have been extirpated. Ad­
vanced or recurrent tumors of the lips and skin of the face, al­
though often benign in behavior, may require aggressive surgi­
cal removal for control. These lesions may result in the exten­
sive loss of facial structures, including portions of the nose, upper
lip, cheek, orbital contents, and ear. Sometimes, facial defects
occur in combination with oral structures, such as portions of
the maxilla, mandible, teeth, and buccal mucosa. In large onco­
logic defects, reconstruction is technically difficult, and the fi­
nal cosmetic and functional results are often limited and unpre­
dictable.
A variety of circumstances may dictate prosthetic restora­
tion of facial defects: (1) When a large resection is necessary
and recurrence of tumor is likely, it is advantageous to be able
to monitor the surgical site closely. A prosthesis permits such
Section on surgical reconstruction of facial defects contributed by Mark E. Krugman.
385
observation, whereas primary surgical reconstruction makes
examination more difficult. (2) Surgical restoration of large
defects is technically difficult and requires multiple procedures
and hospitalizations. Patients confronted with this type of de­
fect are usually older and less able or willing to tolerate the
multiple procedures required for surgical reconstruction. (3)
Increasing numbers of the tumors in the region are being treated
with radiation therapy. Reduced vascularity, increased fibrosis,
and scarring of the tissues bordering the defect increase the risk
of complications associated with reconstruction. In many pa­
tients, therapeutic radiation therapy precludes successful surgi­
cal reconstruction, although the use of vascularized flaps has
reduced this problem significantly. (4) Even when surgical re­
construction is deemed possible, many surgeons prefer to wait
at least 1 year after a large resection before considering surgical
reconstruction of a facial defect resulting from a malignant tu­
mor. Therefore, a temporary prosthesis should be fabricated
during this interval. (5) Nasal reconstructive surgery is almost
an ancient art, but, in skilled hands, it can produce acceptable
results. Unfortunately, squamous cell carcinoma of the nasal
structures are prone to reoccur, so prostheses are often suggested.
(6) Although some surgeons have achieved excellentresults with
staged ear construction of congenital defects, consistently good
results have not been demonstrated by surgeons in general.
However, implant-retained ear prostheses have achieved good
acceptability.
Surgical Reconstruction of Facial Defects*
Auricular defects
Auricular defects may be either of congenital, or acquired
origin. The most common major congenital defect is known as
microtia. Microtia is usually associated with atresia of the ex­
ternal auditory canal. The classic remnant usually seen in mi­
crotia is “comma”-shaped, with the upper portion containing a
small nubbin of deformed cartilage. It is estimated that the inci­
dence of microtia in the general population occurs in 1 in 12,500
live births32. Complete absence of the auricle (anotia) is ex­
tremely rare. Microtia and anotia are part of a spectrum of first
and second branchial arch abnormalities known as hemifacial
m icrosom ia. Some congenital malformations, such as
Goldenhaar’s and Treacher-Collins syndromes, are associated
with ear anomalies and preauricular tags.
Before constructing the microtic ear, a CT scan is obtained
to assess the hearing reconstructive potential. If it appears as
though the hearing mechanism may be reconstructed, place­
ment of the auricular framework is jointly planned by the plas­
tic surgeon and the otologist. The principles of auricular recon­
struction, as practiced today, were laid down by Tanzer33 and
further defined by Brent34. The basis of major ear reconstruc­
tion is the fabrication of a framework from rib cartilage.
386 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
The framework is held together with stainless steel wire
and buried under the thin skin in the microtic area. The useless
cartilage in the remnant is discarded. It is necessary to wait un­
til after the child’s sixth birthday to perform this procedure to
assure presence of adequate rib cartilage. In the example shown
(Figure 9-9), the anomaly is a near-microtia. A framework of
rib cartilage is sculpted to match the plaster cast of the oppos­
ing ear. The final result is depicted after the framework has been
spliced to the remnant. In the usual microtia, a portion of the
remnant is rotated down in a second procedure to form a lobule.
In anotia, the lobule is simulated by carving this portion into the
cartilage framework. Several additional stages of reconstruc­
tion may be required. If projection is inadequate, the frame­
work may be elevated from behind and the raw area covered
with a skin graft to form a sulcus. Occasionally, a tragal recon­
struction and conchal deepening may be required. Use of
alloplastic frameworks, such as silastic, have been largely aban­
doned because of their high rate of extrusion.
Acquired major auricular defects, such as bums, trauma,
and cancer defects, are managed in a manner similar to micro­
tia. The major difference lies in the skin coverage. Deficient
skin cover must be corrected with a thin, full-thickness skin
graft. The temporoparietal fascial flap, a thin vascularized tis­
sue covering the temporalis muscle, is useful in covering the
framework and protecting it from exposure when skin resurfac­
ing needs to be done.
A variety of procedures have been devised to correct smaller
ear defects. The procedures of Antia and Buch35, as well as
Armagasso and Lewin36, depend on creation of chondro-cuta-
neous flaps. These procedures and variations are still useful in
repairing rim defects. Tubed flaps from the post-auricular area
are occasionally employed to reconstruct helical deficiencies.
Lastly, composite chondro-cutaneous grafts from the opposite
auricle are often valuable in smaller full-thickness repairs.
Fig. 9-9. a: Ear microtia known as “snail” or “shell” ear. b: Cartilage framework with plaster
cast of opposite ear. c: Completed auricular reconstruction.
Subtotal and Total Nasal Reconstruction
The prosthodontist is only occasionally called upon to cor­
rect small nasal defects. Most small defects are reconstructed
surgically. A variety of local flaps, skin, and composite auricu­
lar grafts are used to cover and repair smaller alar defects. Re­
construction of full thickness alar defects requires replacement
of mucosal lining, cartilaginous support, and external skin cover.
In reconstruction of defects caused by resection for cancer, the
disease must be controlled before reconstruction is begun. Cer­
tain situations may require use of a temporary prosthesis until
cancer control is assured.
The history of nasal reconstruction is multinational and
colorful. One of the better known names was GasparTagliacozzi,
a Sixteenth Century Italian surgeon who described total nasal
reconstruction with a forearm flap. The basic principles of na­
sal reconstruction were outlined by Converse37:
1. Adequateflap length A flap must be long enough so that
the columella is sufficiently long for adequate nasal pro­
jection.
2. Avoiding tension A well-planned and sufficiently long
flap avoids tension.
3. Providing a base fo r the new nose If tissue lining or
support is destroyed, it must be replaced first.
4. Establishing 1-piece reconstruction One should avoid
piecemeal reconstruction.
Burget and Mennick introduced the concept of the “sub­
units of the nose”38. These subunits are regions defined by gra­
dations of light and shadow determined by the underlying frame­
work of hard and soft tissue: They are the curves of the alar
cartilage, the palpable ridges of the bony and cartilaginous dor­
sum, the gentle slope of the nasal bone and upper lateral carti-
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
Fig. 9-10. a and b: Child with loss of nasal tip and nostril stenosis, c: Intermediate stage of reconstruction with uncfivided
forehead flap, d and e: Final result after division and revision of forehead flap.
lage, and the rounded bulge of the fibro-fatty ala. The regional
subunits are dorsal, tip, sidewalls, soft triangle, and alar-nostril
sills. Sometimes, it is necessary to sacrifice some normal tissue
in order to surface a subunit with the same material. The flap
used is the paramedian forehead flap based upon the supraor­
bital and supratrochlear vessels. Nasal lining is reconstructed
with local flaps. Cantilevered bone and auricular or rib carti­
lage supply support.
Figure 9-10 shows an 8-year-old who lost the tip of his
nose and acquired nasal stenosis from chicken pox. He had un­
dergone 5 previous unsuccessful operations. His nasal tip was
reconstructed, using the principles of Burget and Mennick38.
The lining was reconstructed with local flaps, and auricular car­
tilage was used for support. External coverage was supplied
with the paramedian forehead flap. Hollow nasal stents were
made to prevent re-stenosis. These stents were left in place for
over 6 months and cleaned daily. Figure 9-10c shows the fore­
head flap in place while Figures 9-10d and 9-10e reveal the
final result after release of the pedicle and defatting of the tip.
The reason normal tissues were not sacrificed to include the
entire tip subunit was the age of the patient and concerns about
future growth. If forehead tissue is not available, tissue must be
brought from distant sources. Cervical, deltopectoral, arm, back,
abdominal, and groin flaps have been utilized. Generally, smaller
defatting and touching up procedures are required to improve
the contour of the reconstructed nose. Many of the technical
details have been eliminated from this discussion, but it is hoped
that the preceding will familiarize the prosthodontist with the
surgical reconstruction of major facial parts
Prosthodontic Restoration of Facial Defects
As previously mentioned, prosthetic restoration of large
facial defects gives more pleasing esthetic results and is par­
ticularly preferable in older patients with oncologic defects. The
387
challenge to the prosthodontist is to fabricate an esthedcally
pleasing restoration. A conspicuous prosthesis may produce
more anxiety than no prosthesis at all, and it may curtail socol
readjustment.
Since successful patient utilization of the restoration may
depend on psychologic acceptance of the prosthesis, it is ve*y
beneficial to have the patient seen by a social worker during die
rehabilitation period. The most critical period occurs during the
first 2 or 3 days following delivery of the prosthesis. The c o b -
flicting emotional responses of the patient should be anticipated
and discussed prior to delivery. Some patients will not wear a
facial prosthesis because of unrealistic expectations. Since all
facial restorations are detectable under close scrutiny, a patient
must be made to understand the 2 situations of prosthesis utili­
zation. For family, close friends, or business associates, the pros­
thesis can only cosmetically replace the excised tissues. For the
public at large, however, the restoration generally provides
enough concealment to render the reconstructed defect incon­
spicuous.
Materials used for facial prostheses
A number of materials are available and have been used
for facial prostheses. These include wood, wax, metals, and. n
recent times, polymers. While the new materials have exhib­
ited some excellent properties, they also have exhibited some
frustrating deficiencies. As yet, a material has not emerged that
does not possess distinct and important undesirable character­
istics. Much effort has been expended recently in studying ex­
isting materials in the hope of ameliorating them. A discussion
follows of desirable physical, biologic, and clinical properties,
emphasizing those properties most important for achieving cliai-
cal success and patient acceptance (Table 9-2).
Esthetics The completed facial prosthesis should be no-
noticeable in public, faithfully reproducing lost structures in the
388 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
TABLE 9-2. Ideal Properties of Maxillofacial Prosthetic Materials
IDEAL PHYSICAL and MECHANICAL PROPERTIES
Dynamic properties comparable to tissues
High edge strength
High elongation
High resistance to abrasion
High tear strength
High tensile strength
Low coefficient of friction
4Low glass transition temperature
Low specific gravity
Low surface tension
Low thermal conductivity
Odorless
Non-inflammable
No water sorption
Softness compatible to tissue
Translucent
Variable flexibility without addition of teachable
plasticizer
IDEAL PROCESSING CHARACTERISTICS
Adjustability
Chemically inert after processing
Dimensionally stable during and after processing
Ease of intrinsic and extrinsic coloring with
commercially available colorants
Ease of mold fabrication
Ease of processing
Ease of repair or refabrication if needed
Fidelity of detail reproduction
High enough viscosity for maintaining even dispersion
of colorants
Long shelf life
finest detail. Its color, texture, form, and translucence must du­
plicate that of missing structures and adjacent skin. A conspicu­
ous prosthesis will increase, not decrease, patient anxiety, com­
promising social readjustments. The final esthetic result is the
most important factor relative to clinical success or failure.
Fabrication Materials that are easily processed with
readily available instrumentation offer distinct advantages. Po­
lymerization, or conversion from liquid to solid, occurring at
temperatures low enough to permit reusability of molds (ep­
oxy, dental stone, etc.) is desirable. Blending of individual com­
ponents should be easy, allowing some margin for error. Suit­
able working time is likewise beneficial. The material should
be adaptable to intrinsic as well as to extrinsic coloration.
IDEAL PROCESSING CHARACTERISTICS, CONT.
Long working time
Low enough viscosity for ease of processing
Low processing temperature
Low sensitivity to contamination during processing
Non-inflammable
No polymerization by-products
Non-toxic components
Non-porous after processing
No color change after processing
Odorless before and after processing
Reusable molds
Retain intrinsic and extrinsic coloration during use
Short processing time
IDEAL BIOLOGICAL PROPERTIES
Compatible with supporting tissues
Non allergenic
Non toxic
Cleansibility without loss of detail at surface or margins
Cleansible with disinfectants
Color stability
Dimensionally stable
Flexibility comparable to tissue
Flexibility stable at extreme of temperatures (-40 to 140
deg. F)
Inert to solvents and skin adhesives
Inexpensive
Permeable to moisture release from underlying tissue
Resistance to environmental discoloration
Resistance to growth of microorganisms
Softness maintained during use
Usable life of 2 or more years
Physicalproperties Ideally, the prosthesis should possess
sufficient flexibility for use on movable tissue beds. The mate­
rials should be dimensionally stable, be light in weight, and
possess suitable edge strength to permit thinning or feathering
of margins. Variations in temperature should not affect physical
properties, and thermal conductivity should be sufficiently low
to permit comfortable use in cold environments.
Biologic and chemical properties The material should
remain stable when exposed to environmental assaults, such as
ultraviolet rays, oxygen, secretions (sebaceous, perspiration,
nasal, and salivary), and adhesives and their solvents. The ma­
terial should not be toxic, allergenic, or carcinogenic, and it
must be biocompatible. Resistance to stains is a distinct advan­
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
tage for it allows use of cosmetics to camouflage margins. Last,
it is highly desirable that the prosthesis be durable and have the
capability of being used for at least 6 months without signifi­
cant compromise of esthetics and physical properties.
Historical Background
• Before 1600 A.D.
The origin of prosthetic reconstruction of facial defects has
not been well-documented by historians. Archaeologists have
found artificial eyes, noses, and ears constructed from waxes,
clay, and wood in ancient Chinese culture. Artificial eyes have
also been found in Egyptian mummies; however, it has now
been found that those eyes were placed postmortem39.
An interesting account of an artificial nose was quoted from
the life history of Tycho Brahe (1546-1601), who used an arti­
ficial nose made from gold to replace his own nose, which was
lost in a duel40. Ambroise Pare (1510-1590), a famous French
surgeon, appears to have been the first to describe fabrication
of a nasal prosthesis using gold, silver, paper, and linen cloth
glued together. He also described the fabrication of an auricular
prosthesis.
• 1600 to 1800
Pierre Fauchard (1678-1761) made a monumental contri­
bution to prosthetic facial reconstruction; he made a silver mask
to replace the lost portion of the mandible for a French soldier.
The silver prosthesis was painted with oil paints, and the mar­
gins of the prosthesis were made inconspicuous by covering
them with facial hair41.
• 1800 to 1900
William Morton (1819-1868) was credited with fabrica­
tion of a nasal prosthesis using enameled porcelain to match the
complexion of the patient. In 1880, Kingsley described a com­
bination nasal-palatal prosthesis in which the obturator portion
was an integral part of the nasal prosthesis. And before the end
of the decade, in 1889, Claude Martin described using a ce­
ramic material to fabricate a nasal prosthesis42.
• 1900 to 1940
Towards the end of the Nineteenth Century, vulcanite rub­
ber was widely used by the dental profession and was adapted
for use in facial prostheses. Upham described the fabrication of
nasal and auricular prostheses made from vulcanite rubber43. In
1905, Ottofy44, Baird45, and Baker46 all reported using black
vulcanized rubber as a foundation for a nasal prosthesis. They
processed pink vulcanized rubber onto the foundation, and
389
painted it with artist’s paint. The rigidity of the vulcanized rub­
ber presented a problem when adapted to facial skin. In 1913,
gelatin-glycerin compounds were introduced for use in facial
prostheses in order to mimic the softness and flexibility of hu­
man skin. Bercowitsch described the technique of fabrication
and coloring of gelatin-glycerin facial prostheses using water-
soluble dyes47. Unfortunately, the life span of the gelatin-glyc-
erin compound was too short for practical clinical application.
The use of vulcanized rubber for facial prostheses continued
despite its shortcomings. Various methods of coloring were used.
Kazanjian described the use of celluloid paints for coloring vul­
canized rubber facial prostheses48. With the introduction of la­
tex, which overcomes the rigidity of vulcanized rubber, tech­
niques were described by Bulbulian49 and Clarke50for the use
of prevulcanized latex with water-soluble dyes for facial pros­
theses.
• 1940 to 1960
Acrylic resin was introduced to the dental profession in
1937, and it replaced the older vulcanite rubber in both intra-
and extraoral prostheses. Its translucency, colorability, and ease
of processing was attractive to most clinicians in spite of its
rigidity. Transparent photographic paints were used by Henry
Bigelow for coloring of an acrylic resin facial prosthesis51. To
overcome the rigidity problem of acrylic resin, Tylman intro­
duced the use of a resilient vinyl copolymer acrylic resin for
facial prostheses52. He used acrylic resin polymer stains for in­
trinsic coloring and water color for external tinting. The super­
ficial tinting was further protected by a thin layer of clear acrylic
resin. A wide variety of coloring materials were also described.
Adolph Brown used colorants certified by the Food and Drug
Administration for coloring facial prostheses53. Brasier used
acrylic resin polymer stains (pink, clear, dentin, and enamel
colored) for intrinsic coloring, and oil colors mixed with acrylic
resin monomer for external tinting of facial prostheses54. A case
report written by Fonder described using autopolymerizing
acrylic resin painted with oil paints for fabrication of a nasal
prosthesis55.
• 1960 to 1970
The introduction of various kinds of elastomers resulted in
major changes in the fabrication of facial prostheses. Silicone
elastomers have gained popularity among clinicians. Many tech­
niques and materials using silicone elastomers for fabrication
of facial prostheses were documented in the literature.
Barnhart was the first to use silicone rubber for construct­
ing and coloring facial prostheses by combining a silicone rub­
ber base material with acrylic resin polymer stains56. Tashma
used dry earth pigments dispersed in colorless acrylic resin poly­
mer powder for intrinsic coloring of silicone facial prostheses57.
390 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Ouelette mixed dry mineral earth pigments in a silicone base
material thinned with xylene for external spray coloring of sili­
cone facial prostheses58. The final tinting was further protected
by spraying a thin layer of catalyst on the prosthesis, and then
allowing it to polymerize.
Firtell and Bartlett used dry mineral earth pigments and
silicone base material to produce stock colors from which base
shades and surface colors could be formulated59. The custom
formulation for base shade, and surface tinting for each patient,
was recorded for future reference. Schaaf reported the use of
standard artist’s oil paint tattooed into the surface of silicone
facial prostheses to simulate freckles, blood vessels, and gen­
eral shading60. Fine described the use of colored nylon flockings
as a major colorant for both internal and external coloring of
facial prostheses61,62. It was claimed that nylon flockings were
more color-stable and imparted a more natural appearance to a
prosthesis than did dry earth mineral pigments. A multi-layer­
ing technique for shade matching was also introduced for both
chairside and laboratory procedures.
• 1970 to 1990
Different types of elastomers were also used for fabrica­
tion of facial prostheses. Lontz used modified polysiloxane elas­
tomers63. Gonzalez described the use of polyurethane elas­
tomers64. Lewis and Castleberry described the potential use of
siphenylenes for facial prostheses65. Turner documented the use
of isophorone polyurethane66-67.
Udagama and Drane introduced the use of Silastic Medi­
cal Adhesive Silicone Type A for fabrication of facial prosthe­
ses68. The thin edges of the prostheses tear easily and, to over­
come this problem, Udagama reported using prefabricated poly­
urethane film as a lining for facial prostheses fabricated using
Medical Adhesive Type A69.
• 1990 to present
Advances in polymer chemistry have renewed interest in
developing new materials for facial prostheses. New genera­
tions of acrylic resins are being investigated by Antonucci and
Stansbuiy70. Gettleman described using polyphosphazenes for
facial prostheses71. Silicone block copolymers are also being
evaluated72.
Materials available
Acrylic resin On occasion, acrylic resins can be success­
fully employed for specific types of facial defects, particularly
those in which little movement occurs in the tissue bed during
function (e.g., fabrication of orbital prostheses). The material is
readily available, and most dentists are familiar with its physi­
cal and chemical properties, as well as processing techniques.
Both intrinsic and extrinsic coloration can be utilized. Extrinsic
coloration is easily accomplished with acrylic base paints, us­
ing chloroform or monomer as a solvent. The strength of this
material enables the clinician to feather exposed maigins. When
needed, alterations are easily affected. It is compatible with most
adhesive systems and is easily cleansed of adhesive or debris.
Heat-polymerizing methyl methacrylate is preferred over the
autopolymerizing form because of the presence of free toxic
tertiary amines in the latter. Also, the color stability, when ex­
posed to ultraviolet light, is better in heat-polymerizing methyl
methacrylate. Facial prostheses made of this material remain
serviceable for up to 2 years, but they require occasional sur­
face repainting. With age, however, the prosthesis becomes shiny
and crazing is occasionally noted. If the processed prosthesis
has a well-stippled surface, its useful life can be prolonged.
Surface color applications are more easily applied to such a
surface and last for longer periods.
Rigidity is the primary disadvantage of acrylic resin. Its
usefulness is compromised in highly movable tissue beds, lead­
ing to local discomfort and exposure of margins. Its relatively
high thermal conductivity may precipitate discomfort in cold
climates. Duplicate prostheses are not possible because of the
destruction of the mold during removal from the flasking appa­
ratus.
Molds must be prepared in dental flasks to permit process­
ing under pressure. Acrylic resin is particularly well suited to
temporary facial restorations. Some clinicians still favor it as a
permanent material because it is durable, color stable, and cos­
metic. Also, it is easily repaired or relined with either a tissue
conditioner, or temporary denture reliner, and it can be quickly
and easily processed. Yet, a recent survey has indicated that a
small percentage of clinicians (6%) are still using the mate­
rial73. Excellent cosmetic results can be achieved with acrylic
resin (Figure 9-11).
Acrylic copolymers Acrylic copolymers are soft and elas­
tic but have not received wide acceptance because of a number
of objectionable properties. They possess poor edge strength,
a b
Fig. 9-11. a: Acrylic resin nasal prosthesis, b: Acrylic resin
ear prosthesis.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
poor durability, and are subject to degradation when exposed to
sunlight. Processing and coloration are difficult. The completed
restorations often become tacky, predisposing to dust collec­
tion and staining. A well-documented discussion of the proper­
ties and fabrication of prostheses with Palamed (a plasticized
methyl methacrylate) is provided by Cantor and Hildestad74.
Data on mechanical and reflective spectrophotometric proper­
ties of Palamed was reported by Cantor75.
Development of a new generation of acrylic monomers,
oligomers, and macromeres was reported by Antonucci and
Stansbury70. They reported that these materials can be polymer­
ized easily by using different polymerization methods: thermal,
chemical, photo-initiated, or even dual-cure initiators. Their
approach is to incorporate high-molecular-weight acrylic poly­
mers with molecular blocks of other types of polymers (e.g.,
poly-etherurethane, -hydrocarbon, -fluorocarbon, or -siloxane)
that can eliminate the shortcomings of traditional acrylic co­
polymers and meet the requirements of a maxillofacial elas­
tomer. A wide spectrum of physical and mechanical properties
which may satisfy the requirements in maxillofacial applica­
tion can be obtained by varying modes of polymerization. How­
ever, the results of laboratory and clinical tests of potential poly­
mers have not yet been published.
Polyvinyl chloride and copolymers—realistic, mediplast,
prototype III At one time, vinyl polymers and copolymers
were popular and widely used for facial restorations. The earli­
est form consisted of a combination of polyvinylchloride (a hard,
clear resin that is tasteless and odorless) and plasticizers, which
allows for processing at reasonably low temperatures. These
additives, however, extended processing time and predisposed
to undesirable shrinkage. These materials are cured at high tem­
peratures in metal molds. Recently, a copolymer of 5% to 20%
vinyl acetate, with the remaining percentage being vinylchloride,
has been introduced. This copolymer is more flexible but ap­
parently less chemically resistant than polyvinylchloride itself.
This family of polymers exhibits a number of desirable
properties. They are somewhat flexible, adaptable to both in­
trinsic and extrinsic coloration, and present an acceptable ini­
tial appearance when properly manipulated. The primary defi­
ciency arises from plasticizer migration and loss, resulting in
discoloration and hardening of the prosthesis, particularly at
the margins. Edges tear easily if thin and may require reinforce­
ment with nylon fabric. These compounds are easily stained
and degrade when exposed to ultraviolet light, peroxides, and
ozone. They lack lifelike translucence and tend to absorb seba­
ceous secretions, cosmetics, and solvents that further compro­
mise their physical properties. They soil easily because of sur­
face tackiness. The polymer is a thermoplastic material which
is supplied as a solid suspension in a solvent Metal molds are
required, as curing is accomplished at high temperatures. Their
clinical usefulness may extend anywhere from 1 to 6 months.
391
Excellent discussions relative to processing these materials and
the fabrication of metal molds have been outlined by Bulbulian76.
Efforts have been made to improve polyvinylchlorides by
limiting the amount of plasticizer, hoping to minimize migra­
tion and loss at the margin of the prostheses. With these alter­
ations, the life span of polyvinylchloride prostheses, as reported
by Castleberry77, has been extended to 9 to 11 months. How­
ever, serious problems remain relative to polymer degradation
and darkening of the material secondary to ultraviolet expo­
sure. The poor dimensional stability of polyvinylchlorides is
another disadvantage78.
Chlorinatedpolyethylene Lewis and Castleberry reported
testing of chlorinated polyethylene, a material which is similar
to polyvinylchloride in both chemical composition and physi­
cal properties65. The processing procedure involves high heat
curing of pigmented sheets of the thermoplastic polymer in metal
molds. Coloration, using oil-soluble dyes and repeated mold­
ing, is possible. However, the use of metal molds is a disadvan­
tage of the system.
Gettleman also reported the evaluation of thermoplastic
chlorinated polyethylene, CPE 726/19-15, as a potential maxil­
lofacial material71. Processing technique, using steam autoclaves
with gypsum molds, was developed, and a laminated technique
of coloring was also described. Clinical trials of this material
have just been initiated.
Polyurethane elastomers Polyurethane elastomers serve
a variety of commercial and medical uses, but only 1 (Epithane-
3) is available for use in facial restorations. They can be synthe­
sized with a wide range of physical properties by varying the
reactants and their amounts. These elastomers are denoted as
polyurethanes because they contain urethane linkages. They arise
from 2 major reactants. In the presence of a catalyst, a polymer
terminating with an isocyanate is combined with one terminat­
ing with a hydroxyl group. Varying the amount of isocyanates
will change the physical properties of the final product.
The polyurethanes possess a number of excellent proper­
ties. They can be made quite elastic without compromising edge
strength, thus permitting thinning and feathering of exposed tis­
sue margins. Their flexibility is especially well-suited to de­
fects with movable tissue beds. They can be colored both in­
trinsically and extrinsically77. Superior cosmetic results can be
obtained, surpassing the other materials currently available (Fig­
ure 9-12).
However, serious deficiencies remain. These materials are
difficult to process consistently. Little margin for error is pos­
sible when measuring the constituents. In addition, the isocyan­
ates are moisture-sensitive and, when water contamination oc­
curs, gas bubbles cause defects and poor curing of the material
results. Water contamination is particularly difficult to control
in humid environments. If stone molds are employed, they must
392MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 9-12. a ar>d b: Polyurethane nasal and ear prostheses.
Superior cosmodc results can be achieved be­
cause margins ol prosthesis can bo made very
thin, so the transluconce and coloration can du
plicate that of human skin.
be thoroughly dehydrated before processing. Unfortunately, ilic
I polyurethane currently available for facial restoration is not
color-siable, presumably bccause of the effects of ultraviolet
light and surface oxidation. In addition, coloration applied ex-
trinsically tends to wear off rapidly. In our experience, the clini­
cal usefulness of this material is generally less titan 6 months
and more often approaches 3 months. The details of casting this
material are discussed by Gonzalez*.
Anotherdiscouraging property is tl»e poorcompatibility of
this material with existing adhesive systems. Cleansing the ad­
hesive from the prosthesis is difficult and frustrating for many
patients. Often, extrinsic coloration is removed during this pro­
cedure. Care must be taken when handling tl>e isocyanates, as
these compounds are toxic. Free isocyanates have been found
in cured restorations*0, indicating a potential for local irritation.
No irritation, however, has been reported by any of the major
users. Stone, epoxy, urethane, or metal molds can be employed
for processing. If stone molds arc used, sculpting the contours
of the prosthesis should be completed in wax. as clay residues
will contaminate the molds and result in staining of ll>eprosthe­
sis and poof adhesion of (lie extrinsic coloration.
Several centers have investigated llic family of polyure­
thanes in attempts to find an elastomer that exhibits more dura­
bility and color stability, and better processing characteristics.
Additives improving light stability are employed in commer­
cial polyurethanes, but some of these are toxic or mutagenic.
Hence, extensive testing will be required to evaluate individual
agents. The structural integrity of the urethane chains is not suf­
ficient to avoid breakage of chemical bonds when exposed to
ultraviolet light. Therefore, degradation is not preventable with­
out these light stabilizers. Lewis and Castleberry reported the
development of an aliphatic polyurethane prepolymer.
isofthoronc, and preliminary data on its physical and mechani­
cal properties'''. Turner, having evaluated mcchanical proper
ties of |)olyurethanc elastomers before ami after 900 hours of
accelerated aging, reported that the material did not disintegrate,
and that it demonstrated many desirable characteristics for use
as a maxillofacial elastomer". However, funher evaluation on
biocompatiblityand clinical trials of the material arc still needed.
Silicone elastomers The silicones are probably the most
widely used materials for facial restoration, but they exhibit
objectionable properties that prevent them from being accepted
by all clinicians. Most of these materials have poor tensile and
tear strengths and receive colors poorly or with difficulty. Some
fomis are opaque, resulting in prostheses that are "cold" and
"lifeless”.
Silicones arc a combination of organic and inorganic com­
pounds. The first step in their production is t!*c reduction of
silica to elemental silicon. Then, by various reactions, the sili­
con is combined with methyl chloride to form dimethyl
dichlorosiloxanc which, when it reacts with water, forms a poly­
mer. These polymers are translucent, watery, white fluids whose
viscosity is deiemiiitcd by the length of the polymer chain.
Polydimethyl siloxane.commonly referred toas silicone, is made
front these silicon fluid polymers. Most rubbery fomts of sili­
cone arc compounded with fillers that provide additional
strength. Additives are used to provide color. Antioxidants and
vulcanizing agents arc used to transform the raw mass from a
plastic to a rubbery resin during processing. The long-chained
polymers, when tied together at various points (cross-linked),
create a network that can be separated only with difficulty. This
network makes the silicones especially resistant to degradation
from ultraviolet light exposure.
The process of cross-linking the polymers is referred to as
vulcanization. Vulcanization occur* both with and without heat
and depends on the cataly tic or cross-linking agents utilized.
Using a chain of silica and oxygen atoms, ai>d attaching suit­
able side chains or organic radicals to them, a material evolves
with the inertness of quartz and the flexibility of the organic
plastics. The silicone elastomers are available in 2 forms: those
requiring heat toeffect vulcanization (HTV)and those that vul­
canize at loom temperature (RTV).
Silicones are classified into 4 groups, according to their
applications. The first classification is Implant Grade, which
requires the material to undergo extensive testingand must meet
or exceed FDA requirements. Recent health problems caused
by silicone breast implants have created controversies regard­
ing the safety of the material to be implanted intcrsiitially. The
second classification is Medical Grade, which is approved for
external use only. This is the material most commonly used in
fabrication of maxillofacial prostheses. Adverse reactions caused
by direct contact between Medical Grade silicone and human
skin have not been reported. Very often, the term, medicalgrade.
creates confusion among clinicians. TIk third classification is
Clean Grade and the fourth is Industrial Grade, which is mostly
used for industrial applications.
 Restoration of Facial Defects: Etiology. Disability, ami Rehabilitation
/{TV silicones
Silastic 370,372,373.4-4514,4-451$ HTV silicone is
usually a white, opaque material with a highly viscous,
putty-like consistency. The material may be supplied as a
I-component or 2-component putty. The catalytic, or vul­
canizing, agent of the HTV silicones is dichlorobenzoyl
peroxide or platinum salt, depending on the type of poly­
merization used (condensation reaction or addition reac­
tion. respectively). These silicones can be preformed into
various shapes for alloplastic implantation or facial pros-
theses. Varying amounts of filler arc added to these poly­
mers. depending on the degree of hardness, strength, and
elongation desired. Generally, the more filler, the harder
and less resilient the compounded rubber will be. The filler
is usually a very pure, finely divided silica with a particle
size ofabout 30y. In addition, the copolymerization of sili*
cone with small amounts of methyl vinyl, or methyl phe­
nyl siloxy radical, varies the relative softness and tear
strength.
Processing of heat-cured silicones requires sophisti­
cated instrumentation and high temperature. An excellent
description is provided by Chalian". These silicones ex­
hibit excellent tlicmial stability, arc color-stable wlien ex­
posed to ultraviolet light, and arc biologically inert. How­
ever. they do not possess sufficient elasticity to function in
movable tissue beds. Polydimcthylsiloxanc oJigomer(£/rt--
tronic Fluid 200. Dow Coming) may be added to reduce
the stiffness and hardness of the prostheses. Also, the ma­
terial itself has low edge strength and may require nylon
reinforcement at the margins. Important objections arc their
opacity and lifeless appearance. They do not readily ac­
cept extrinsic coloration, so the internal colorants must be
incoiporated into the gum stock with a milling device.
Because high temperatures arc required for vulcanization,
metal molds are nccessary,
PDM siloxant A HTV silicone was developed by the
Veterans Administration and reported by Lontz and
Schweiger*3and Lontz'\ Independent evaluation of physi­
cal and mechanical properties were reported by
Abdclnnabi*’. Results show that both materials exceeded
values considered clinically acceptable.
Q7-463S, Q7-46S0, Q7-4735, SE-4524U A new genera­
tion of HTV silicones evaluated by BellMwere shown to
have improved physical and mechanical properties com­
pared to MDX4 4210 (a RTV silicone) and MDX 14.
The processing characteristics' of Q7-4635 and SE-4524U
were particularly favorable because of their single compo­
nent system with unlimited shelf life.
393
In general, HTV silicones have better physical and me­
chanical properties than do RTV silicones. The drawback of the
material is its opacity, difficulty in intrinsic coloration, high su­
perficial surface liardness. and difficulty in processing.
RTV siliconcs
Silastic 382.399 This viscous silicone polynter includes
a filler, a stannous octoatc catalyst, ;ind a orthoalkyl sili­
cate cross-linking agent. The polymerization is by conden­
sation reaction. Fillers, usually diatomaccous earths, are
used to improve strength. Tlie properties of the original
RTV silicones (Silastic 382. 399) arc similar to the HTV
types. They are color-stable, biologically inert, and retain
their physical and chemical properties at wide temperature
ranges. They are available as clear solutions that enable
the fabrication of translucent proslhcses. The RTVs arc
much easier to process than the heat-cured forms. Molds
of dental stone can be used. The RTVs share some of the
undesirable properties of the HTV silicones in that they
have poor edge strength and are difficult to color. In our
experience, at delivery. tl»e cosnKtic appearances of these
materials is inferior to that of the polyurethanes, acrylic
resins, and polyvinylchloridcs.
MDX 4-4210 This medical-gradc silicone elastomer has
shown to be the most popularamong clinicians'"'1*'. From
the results of the survey by Andres*5, 41% of clinicians
used this material for fabrication of maxillofacial prosthe-
ses. Moore reported that it exhibits improved qualities rela­
tive to coloration and edge strength**. This material is not
heavily filled, making it translucent. It has a chloroplatinic
acid catalyst and hydro-mcthylsiloxanc as a cross-linking
agent. The polymerization reaction is an addition reaction
with no reaction by-products. The cured material has been
shown to exhibit adequate tensile strength. More impor­
tant. increased elongation and resistance to tear have re­
duced tlw need for reinforcement of the thin edges of the
prosthesis. In addition, the surface texture and Shore A
hardness measurements arc well within the range of hu­
man skin. Modifications of the physical properties can be
accomplished by the addition of silicone fluid*. In the study
by Moore, the material was found to be nontoxic, color-
stable. and biologically compatible. Early clinical testing
reveals Silastic MDX 4-4210 to be quite desirable, and it
appears to be compatible with most skin adhesive systems.
Shade guides for intrinsic coloration have been developed.
Accelerated aging testing have shown that the elastomer is
very color stable” .
Extensive testing on the physical and mechanical prop­
erties of MDX 4-4210 has been documcnted1,/A>'*‘A'-M
Results indicate that, even though it is not
394 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
the ideal material, MDX4-4210has shown many improve­
ments when compared to earlier materials, and it possesses
many desirable characteristics.
Processing is simple, as molds of dental stone arc ac­
ceptable. A 5% solution of mild soap can be employed as a
releasing agent. Care should be taken to avoid contamina­
tion ol' the mold with petrolatum or clay residues. The pre­
pared molds are pineed in a dry heat oven at 50°C for ap­
proximately 30 minutes prior to their use. Warming all the
mold segments will assist in retaining the position of the
custom colors used for intrinsic shade matching. After ap­
propriate surface detail has been reproduced, a syringe is
loaded and used to fill Ihe mold parts with the material that
l»as recovered its viscosity after mixing. Tlie mold is closed
with finger pressure and a web clamp is secured in posi­
tion to hold the sections together tightly. Tl»e mold is re­
turned to the dry heat oven and the temperature is elevated
to 80°C. The mold is left in the oven for I hour. Surface
cliaracterization can be achieved with pigments immersed
in a siliconc adhesive?*.
Using unflasked gypsum mold in dry heat for mul­
tiple processing will dehydrate the gypsum and cause loss
of surface detail or disintegration of the mold. Flasking of
the mold and using moist heat will increase the longevity
of tlx; mold. Research on porosity and density of both RTV
and HTV silicones, using various processing techniques
by Kent", indicates that de-airing the fluid siliconc prior to
packing, using a controlled injection pocking technique,
and soaking of a llasked mold in slurry water prior to moist
heat application will result in a dense and porosity-free pros
thesis. Superior cosmetic results arc achieved with this
material (Figure 9-13).
Fig. 9-13. a and b: Ear prosthesis and nasal prosthesis from
MDX4-4210. Nolo excellent color matching, sur­
face texture reproduction, and marginal acapta-
Silastic 891 Udagama and Drane first reported the use of
this material. also known as Silastic MedicalAdhesive Sili­
cone Type A, for fabrication of facial prostheses6*. ll has
gained popularity among clinicians. Twenty-five percent
of clinicians surveyed use this material1''. It is a translu­
cent, non-flowing paste which polymerizes at room tem­
perature on contact with moisture in tlie air. It can also be
processed in a gypsum mold. Metal molds are not recom­
mended because its surface may react with acetic acid,
which is liberated as a by-product of polymerization. The
advantages of the material arc no catalyst is required and it
is compatible with a wide range of colorants. However, the
material docs share some of the disadvantages of RTV sili­
cones. In 1987. Udagama reported improving the edge
strength of siliconc prosthesis fabricated by Medical Ad­
hesive Type A by bonding the prostl*esis to a prefabricated
polyurethane film using primer, S2260 (Dow Coming
Corp.). Farah studied the mechanical properties of mix­
tures ofAdhesiw Type A and uncatalyzed MDX 4-4210
base elastomer'1. It was reported that different mechanical
properties can be obtained by varying the amount of MDX
4-4210 base elastomer to Medical Adhesive Type -4 to al­
low for better simulation of facial tissues.
Cosmesil Cosmesil is a RTV siliconc which can be pro­
cessed to varying degrees of hardness as described by
Woofaardf*’. The material was sitown to have higher tear
strength at failure than MDX 4-4210. Studies on surface
texture, wettability, and hardness were also rejxwted by
Veres*00*• w.
A-2I86 A-2186, a recently developed material (Factor II
Ii>c., Lakeside. Ariz.). initially showed improved physical
and mechanical properties when compared to MDX 4-
4210^. However. Haug reported that, after subjected to
environmental variables, the A-2186 elastomer did not re­
tain its improved physical and mechanical properties when
compared to MDX4-4210”.
Foaming silicones
Silastic 3S6 A form of RTV silicone that has limited
use in m;txillofacial prosthetics is the foam-forming vari­
ety10*. The basic siliconc has an additive so that a gas is
released when tlie catalyst, stannous octate. is introduced.
TJ>cgas forms bubbles within the vulcanizingsilicone. After
the siliconc is processed, the gas is eventually released,
leaving a spongy material. The formation of the bubbles
within the mass can cause tl)c volume to increase by as
 Restoration o f Facial Defects: Etiology, Disability, andRehabilitation 395

The purpose of the foam-forming siliconc is co reduce the
weight of the prosthesis. However, the foamed material has re­
duced strength and is susceptible to tearing. This weakness can
be partially overcome by coating the foam with another sili­
cone. Thiscoaling adds strength but increases stiffness. Becausc
of these problems, the foaming silicones have been used by few
clinicians for facial prostheses.
Siphenylenes Siplxrnylcnes are siloxane copolymers that
contain methyl and phenyl groups. The catalyst is similar to
that of Silastic 382 and 399. These polymers possesses many
desirable propertiesof RTVsilicones. including biocompatibility
and resistance to degradation on exposure to ultraviolet light
and heat. In addition, they exhibit improved edge strength, low
modulus of elasticity, and colonibility over the more conven­
tional polydimethyl siloxanes^-'. Ginkal testing will determine
whether this compound represents a significant improvement.
weaknesses of silicone elastomers, such as low tear strength,
low-percent elongation, and the potential to support bacterial
or fungal growth. It has been found that siliconc block copoly­
mers are more tear-resistant than are conventional cross-linked
siliconc polymers. The type of block copolymer being investi­
gated is one that incorporates Poly Methyl Methacrylate
(PMMA) into siloxane blocks’2. Various methods of synthesis
are under investigation. Data on physical and mechanical prop­
erties of silicone block elastomers have not been reported.
Polyphosphazenes Polyphosphazenes fluoroclastomer has
been developed for use as a resilient denture liner (Afowtf™.
Hygcnic Corp.) and has the potential to be used as a maxillofa­
cial prosthetic material”. Modifications of physical and me­
chanical properties of this commerciallyavailable elastomer may
be needed to satisfy the requirements for fabrication of maxil­
lofacial prostheses.

Net*' materials Physicaland mechanicalproperties o f silicon* elastomers The

physical and mcdianical properties of the most commonly used
silicone elastomers are shown in Table 9-3. This data has been
provided by the respective manufacturers.

Table 9-3. Physical and Mechanical Properties of Silicone Elastometers (source: manufacturers' data).

Silastic 382 MDX 4-4210 MDX 4-4515 MDX 4-4516

Factor II Products Dow Corning Dow Corning Dow Coming Dow Corning

Medical Grade Medical Grade Mcdtcal Grade Medical Grade

Translucent Translucent Translucent

Shore A Hardness

Tensile Strength, psl

396 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Primers (1200.1205, S-2260,4040, Z6032, Z6076) Since the
introduction of urethane-lined silicone prostheses” there has
been an increased interest in primers used for promotion of bond­
ing between silicone and other maxillofacial prosthetic materi­
als. Udagama investigated 1250and S-2260 primer (Dow Com­
ing Co.) for bonding Medical Adhesive Type A to polyurethane
sheets. The S-2260 primer was found to be most effective clini­
cally.
Singer, el al.. (1988) evaluated the bond strength of Medi­
cal Adhesive Type A and MDX 4-4210 to polyurethane sheets,
using 3 commercially available primers. A-4-4. S2260. and 1205
(Dow Coming Co.). It was found that the S-2260 and A 4040
primers formed the strongest bond between the polyurethane
sheet and the mixture of 50% MDX plus 50% Medical Adhe­
sive Type A.
McMordie and King evaluated the bonding of Silastic 891
to Lucitione 199 denture base resin, using 3 primers. 4040. S-
2260, and 1200 (Dow Coming Co.)10*. Results indicated that
the 4040 printer showed the greatest bond strength.
Polyzois evaluated the bond strength of silicone elastomer
(Silskin II, Cosmcsil SM4) to a light-activated resin (Triad).
using 3 dift'crent primers <Triad VLC bonding agent. Z-6032.
and Z6076)1'*'. The results showed that the primer. Z-6032. pro­
duced the highest bond strength between the resin and the 2
silicone elastomers used in the study.
Adhesives A variety of adhesive systems have been employed
to retain facial prostheses in position. They arc commonly clas­
sified by the method in which they arc dispensed: pastes, liquid
emulsions, spray-ons. and double-sided tapes. Double-sided tape
is the most commonly used (41%) among patients with facial
prostheses'" because of its case of application, removal, and
maintenance. Double-sided adhesive tape is useful in materials
with poor flexibility and for patients whose defects demonstrate
little or no movement. The poor flexibility of double-sided tape
limits its usefulness. Most facial prostheses arc retained with a
medical-gradc adhesive. A number arc available, and selection
depends on patient tolerance, case of application and removal,
and compatibility with the material used for the facial prosthe­
sis. Survey data regarding which is the mast commonly used
skin adhesive is not available. Unfortunately, the formulations
for most of commercially available medical adhesives are un-
Most cured silicones, bccausc of their low solubility and
low surface energy, will not adhere to conventional tissue adhe­
sives. The single-component RTV silicones were developed to
serve as adhesives for silicone prostheses (Medical Adhesive
Tyi>e -4). They are relatively low molecular weight polymers
with hydroxy blocked ends. When the material is extruded from
the storage tube, the cross-linking agent, methyl
triacetoxyxiloxane. is easily hydrolyzed by the water vapor
present in air. When water contacts methyl triacetoxysiloxane.
acetic acid is formed, replacing an acctoxy with a hydroxyl
group. Methyl siloxanes with multiple hydroxyl groups are very
unstable, and they will condense with the hydroxy end blocked
silicone polymer, creating longer polymers while simultaneously
forming cross linkages. The filler used in these compounds is
similar to that used in heat vulcanizing silicones. A variation of
this formulation is contained in an aerosol, using Freon as 3
propellant.
The type of adhesives and the cleaning solution to be used
with a maxillofacial elastomer should be carefully chosen. It
has been shown that adhesives and solvents can have adverse
effects on physical and optical properties of maxillofacial elas­
tomers'". Additional research is needed todetcrminc (3)the com­
patibility of commercially available medical adhesives with dif­
ferent types of maxillofacial elastomers, and (b) the compat­
ibility of cleansing solvents with maxillofacial prosthetic elas-
Rcpons on evaluation of clinical performance and
biocompatibility of medical adhesives arc limited. Evaluation
is problematic, since no performance standards or standardized
methods of testing have been established. Testing apparatus have
been designed for evaluation of skin adhesives'0” *. Clinical
application of results from standardized mechanical testing may
not be reliable due to biological variability of human skin. Ad­
ditional research and standardization of testing is needed.
An alternative to reduce tl>e dependency on medical skin
adhesives is the use of osseointegrated implants to retain the
facial prosthesis. Since some patients arc not candidates for
implant intervention (for various reasons, including tumor prog­
nosis. compromised tissue beds, and financial limitations) many
of them will have to rely on skin adhesives to retain their facial
prosthesis.
The incorporation of osseointegrated implants in retaining
facial prostheses creates additional demands on maxillofacial
prosthetic materials. Incorporating retentive elements (bar-clips
or magnets) within the prosthesis requires fabrication of a rigid
housing within the prosthesis. The overall bulk of the maxillo­
facial prosthetic material around the housing will be decreased,
which decreases the overall strength of the prosthesis. A good
adhesive joint between the housing and the maxillofacial pros­
thetic material Ls needed to avoid adhesive failure between the
2 surfaces during routine removal of the prosthesis.
Literature review on physical and mechanical properties o f
materials for extraoral maxillofacial prosthetics Numcrous
investigations of the physical and mechanical properties of fa­
cial prosthetic materials have been conducted. A thorough re­
view is beyond the scope of this chapter However, a compre­
hensive list is prov idcd in Table 9-4 for the interested student or
investigator.
 Restoration of Facial Defects: Etiology. Disability, ami Rehalfilitation 397

Table 9-4. Maxillofacial Materials Evaluated*. human skin is a result of combinations of light reflected, re­
POLY (Methyl Methacrylate fracted, and scattered directly or diffusely by tlie multilayered
structure. Many different types of colorants used in maxillofa­
Palamed ,l
Vinyl Polymers and Copolymers cial prostheses have been described in the literature (Table 9-5).
Dioor71 The choicc of colorants depends on the preferences of the indi­
Geon 121 (Prototype I. II, III) vidual clinician and also the type of materials used for fabrica­
Prototype III Soft tion of the facial prostheses. Certain types of colorants may not
be compatible with the base elastomer, and they may produce
Chloronated Polyethylene M
Polyurethane Elastomers adverse effects on the physical and mechanical properties4'. For
Epithane 3 1» “* example, a substantial decrease in tear and tensile strength was
Dermathane 100 ,M found when kaolin and dry earth pigments were used with
isophorone polyurethane"1. Artist’s oils were found to interfere
Isophorone Polyurethane •MMT
Silicone Elastomers with the setting reaction of MDX4-4210.
Various methods of coloration have been described in the
HTV Silicones
ES-4524U «* liter,uure. Coloration techniques can basically be divided into 3
groups: extrinsic, intrinsic, or combination of both. The combi­
07-4635 "
nation technique is widely used bccausc it produces prostheses
07-465081 *
with a more natural appearance. The color match of the pros­
07-4735 **
thesis depends largely on the skill of the clinician. It also de­
Silastic 4-4514
Silastic 4 4515 w“ *c*’*SST,c*'i4 pends on the color acuity of the individual ;utd the light source
(color temperature) under which the color-matching procedure
RTV Silicones
is performed. Al present, the procedure is done using an empiri­
A-0102**7
cal trial-and-error method, having no standardization for future
A 2186 •»**
reference. Attempts have been made to record the amount of
Cosmesil
colorants used for custom formulation of base shade and ex­
MDX 4-4210
MDX 4-4210 (Modified) «*«” *•* trinsic characterization for future needs’*.At present, there is no
scientific method developed for color matching of maxillofa­
Silastic 362 (Opaque White) ■*XIM
cial prostheses. In the past, concerns with color deterioration of
Silastic 386 (Foam),M
maxillofacial prostheses have directed most of the investiga­
Silastic 399 (Translucent)
tions on color stability of base elastomer and
Silastic 891 (Medical Adhesive Type A)
Silphenylene *» colorants*ruw-,;a" , "1" ‘. Since then, with the introduction of a
color-stable maxillofacial elastomers and colorants, there has
Saskin“ ’»
been more emphasis on research towards developing methods
• See back of chapter for corresponding references.
Table 9-5. Colorants Documented in Ihe Literature’.
Coloration Coloration of the prosthesis varies with the mate­
rials used and the preference of the clinician. Basic skin tones Enamel Porcelain **
should be developed into a shade guide for the materials that Ceramics **
arc used. The base shade selected for a patient should he slightly Artist's Paint
lighter than the lightest skin tones of the patient bccausc the Water Soluble Oyes4,30
prosthesis will darken as color is added. Surface details and Celluloid Paints **
character can be added by either intrinsic or extrinsic colora­ Photographic StainsM
tion. Intrinsic coloration is longer lasting and is therefore pre­ Acrylic Rosin Stains
ferred. but it is more difficult to accomplish than is extrinsic Food Coloring u
Oa Colors M
Color matching of maxillofacial prostheses to human skin Oil Paints »
has long been a challenge for maxillofacial prosthodontists. Dry Earth Pigments
Human skin is a multilayered structure, composed of epider­ Nylon Flockings
mis. dennis. hypodcmiis, and subcutaneous tissue. Each layer Commercial Cosmetics w
differs in thickness, histological components, and pigments Ceramic Pigments "*
(melanin, hemoglobin, and beta carotene). The color effect of
*See back of chaptor lor corresponding references.
398 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
for the color matching of maxillofacial prostheses to human
skin"1 , Spectral measurements of human skin have been
documented” " \ Scientific color matching involves quantita­
tively describing the optical properties of colorants and apply­
ing them to a mathematical model which simulates the multi­
layered optical characteristics of human skin. Until a scientific
method is developed with simplified clinical applications, color
matching remains a fine art in the profession.
Color research—extraoral maxillofacial materials Color
stability of maxillofacial prostheses in a service environment
lias been a major concern for both clinicians and patients. Al­
though many materials and techniques arc available, scientific
studies on color of maxillofacial materials were very limited.
Cantor was first in the dental literature to report using a reflec­
tance spectrophotometer to evaluate the color of human skin
and selected maxillofacial siliconc elastomers*. It was suggested
that, by studying the reflectance characteristics of human skin,
an isomctrk pignwnt may be developed to be used for coloring
of maxillofacial prostheses.
The discoloration of a maxillofacial prosthesis may be due
to color change within the base elastomer. Goklberg evaluated
the color stability of several polyurethane elastomers using a
sunlamp and a reflectance spectrophotometer111. It was found
that a light-stabil i/cd elastomer showed no change in color while
there was yellowing in elastomers not containing L’V-stabiliz-
ing agents.
The color stability of 6 maxillofacial elastomers (Polyvi­
nyl Chloride. Polyurethane. Silastic 382. 399.4-4210. and 4-
4515) were evaluated by Craig, using reflectance spectropho­
tometry under 900 Itours of accelerated aging in a Weather-O-
Mcter*'. The polyvinyl chloride material became lighter in color
after 100 hours of aging, and the polyurethane material disinte­
grated after 600 hours. However, all of the silicone elastomers
evaluated in the study demonstrated good color stability, espe­
cially Silastic 4-4210. It was suggested that other factors might
be responsible for the discoloration of a siliconc maxillofacial
prosthesis.
Since the color stability of siliconc elastomers were proven
under accelerated aging conditions, the discoloration of a facial
prosthesis n»ay be due to the colorants used. Koran studied the
color stability of 11 dry mineral earth pigments under acceler­
ated aging, using Silastic 4-4210 as the base elastomer” . Quan•
titative color analysis showed that 4 of the 11 pigments showed
small but statistically significant color changes. However, the
extent of observed color changes did not correspond with what
is observed clinically. It was also suggested that, since the re­
sults do not adequately explain the degree of discoloration seen
clinically, additional factors may be responsible and should also
be investigated.
Continuing the investigation. Koran evaluated the resis­
tance of I polyvinyl chloride and 3 silicone elastomers (Silastic
382. 4-4210. and 4-4515) to staining by tea lipstick, and dis­
closing solution”*. Color parameters were measured by reflec­
tance spectrophotometry. It was found that the changes in color
caused by staining were much greater than the color instability
of base elastomers or pigments, as found in previous studies.
The results indicate that discoloration of maxillofacial prosthc-
scs may be due largely to environmental factors.
The removal of environmental staining, using cleansers,
may cause discoloration of the prostheses. Yu evaluated the ef­
fects of superficial stain removal from intrinsically pigmented
Silastic 4-4210. using 4 organic solvents (toluene, bcn/ene. n-
hcxanc and I. I. I-trichloroethanc)w". It was found that the sol­
vents were effective in stain removal ami did not affect either
the color of the pigments or the base elastomer. However, the
experiment was performed on intrinsically-colored red silicone
specimens: the effects of solvents on extrinsic coloration were
not tested.
Yu also Studied the effects of cigarette staining on Silastic
4-4210 and stain removal, using 1,1.1-trichlorocthane' '.It was
found that the solvent was effective in renwving cigarette stains
witltout affecting the color erf the base elastomer. Again, the
effects of solvents on external coloration was not investigated.
Turner evaluated the color stability of isophorone polyure­
thane with 4 intrinsic color systems (artist s oil paints. Art Skin
dry mineral earth pigments. Kaolin with 7 to 10% pigments,
and Daro skin pigments)*’. It was found that 2 of the 4 coloring
systems (artist's oil paints and Art Skin dry mineral earth pig­
ments) and the base elastomer were color-stable after900 hours
of accelerated aging. The Kaolin coloring system had the most
change in color. Whik the Daro coloring system is color stabk.
it caused the greatest decrease in tear strength after aging.
Seluk evaluated the color stability of unsintered pign»cnis
and pigments sintered in a porcelain matrix"*. It was found that
sintered pigments were more color-stabk after accekratcd ag­
ingand have the potential to be used to color maxillofacial pros-
thcscs. However, reports of this specific type of colorant, and
its potential effects on the physical propcrtks of the base elas­
tomer. have not been published.
According to the results of the survey by Andres, a major­
ity of clinicians (51%) use dry mineral earth pigments to color
facial prostheses” . The amount of pigments incorporated into
the base elastomer may affect the physical properties of the fin-
isl*ed prosthesis. Yu investigated the physical and mechankal
properties of intrinskally colored Silastic 44210 under acceler­
ated aging, finding that incorporation of 0.2% (by weight) of
pigments can alter the physkal and mcchankal properties of
the base elastomer’'1.
Commonproblems of maxillofacialprostheses The ideal prop­
erties of elastomers for maxillofacial prostheses were discussed
previously. To date, none of the commercially availabk materi­
als satisfy all the requirements of the ideal material. Each of the
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
materials available has its strengths and weaknesses. Even
though each type of maxillofacial elastomer has its own unique
physical and mechanical properties, they all share a few com­
mon clinical problems which can be grouped into 2 categories:
(1) discoloration of the prosthesis over time (Table 9-6) and (2)
degradation of static and dynamic physical properties of the
polymeric materials (Table 9-7).
Table 9-6. Discoloration Over Time.
Discoloration of intrinsic and extrinsic coloration
due to external environmental factors:
• Intrinsic color change of elastomers
• Intrinsic color change of colorants (pigments,
flockings)
Discoloration of prosthesis due to loss o f external
coloration:
• Loss of adhesion of extrinsic coloration to
prosthesis.
• Primers and Adhesives
• Patient handling
• Staining (handling and other environmental
factors)
• Solvents
• Medical adhesives and cleansers
Table 9-7. Degradation of Physical and Mechanical
Properties.
• Tear at margins (tear strength, fatigue)
• Change in surface texture
• Elongation at margins (permanent deformation)
• Compatibility with medical adhesives
• Weakening of margins by colorants, adhesives,
solvents, cleansers (colorants are not chemically
adhered to elastomer)
• Deterioration of static and dynamic mechanical
properties
The discoloration of a facial prosthesis has both intrinsic
and extrinsic components. Investigations so far have been con­
centrated on the intrinsic color stability of elastomers and
colorants. The extrinsic discoloration of facial prostheses has
another added factor, a loss of adhesion between extrinsic col­
oration and the base elastomer. Investigations of materials and
techniques for bonding extrinsic coloration to the base elastomer
have been very limited. Effects of cleansers, or methods of
399
cleansing on adhesion and color stability of extrinsic colorants
to base elastomers, have not been reported.
Regardless of the type of maxillofacial prosthetic materi­
als used in fabrication of the prosthesis, the service life time of
a facial prosthesis is usually from 6 months to 2 years. A survey
by Chen indicated that the average wearing time of a facial pros­
theses was 10 months106.
Summary The physical and mechanical properties of various
facial prosthetic materials have been studied by researchers. A
variety of methods for testing physical and mechanical proper­
ties were reported. While laboratory evaluation of the physical
and mechanical properties of facial prosthetic materials identi­
fied each material’s characteristics, using standardized testing
procedures, not all the data obtained reflected the clinical per­
formance of the materials. The ultimate challenge to a facial
prosthetic material is its clinical performance testing. To be more
useful, the results of laboratory testing should be correlated to
clinical performance. Standardized laboratory testing methods
should be modified to simulate a clinical environment.
Future research should concentrate on 2 major goals: First,
improving the physical and mechanical properties of the mate­
rial so that it will behave more like human tissue and increase
the service life of the prosthesis. Second, finding color-stable
coloring agents for coloring facial prostheses, and developing a
scientific method of color matching to human skin.
Presently, there are no ADA specifications for maxillofa­
cial elastomers. However, there have been 2 publications in the
literature, one by Sweeney in 1972120 and one by Lewis and
Castleberry in 198065, defining the desirable physical and me­
chanical properties of a maxillofacial elastomer. The article by
Lewis and Castleberry also listed new materials under investi­
gation. The proposed specifications, which have some common
characteristics, are summarized in Table 9-8.
Many articles have been published on the laboratory evalu­
ation of physical and mechanical properties of maxillofacial
elastomers. There is no doubt that laboratory testing is an im­
portant step in developing a better maxillofacial elastomer.
However, publications on long-term clinical evaluation of per­
formance of facial prostheses is limited. With all the laboratory
testing data available on currently available maxillofacial ma­
terials, it would be very helpful if a correlation could be drawn
between clinical performance and laboratory data. In addition,
new methods of laboratory testing should be developed which
would provide more accurate predictions of clinical perfor­
mance.
Restoration of Auricular Defects
Auricular defects occur secondary to congenital malfor­
mations, trauma, or surgical removal of neoplasms. Defects sec­
ondary to total resection of the auricle are easily restored pros-
400 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Table 9-8. Maxillofacial Elastomer Specifications. (helically. Defects secondary io partial resection of the auricle
or secondary to microtia arc more difficult to restore. Preopera-
Swccncy Lewis
live consultations are extremely valuable for patients with au­
Performance
ricular tumors requiring resection. In addition to facilitating tlie
Characteristics
task of informing tlie patient of the nature of the defect and the
Tear (pants test) 30-35 ppi
future prosthesis, prcoperativc impressions and photographs
Tear resistance 33 ppi
make construction of the postsurgical auricular prosthesis simple.
Tear strength 30-100 ps<
After surgery, the wax duplicate of Ihc patient's car is easily
Tensile strength 1800 psi 1000-2000 psi
positioned and adapted to tl»cdefect. All that remains to be com­
Modulus of elasticity 600
pleted is the placement and feathering of margins and the incor­
Modulus @100%
poration of appropriate surface detail.
elongation 50-250 psi
If suigical reconstruction of the auricle Is not contemplated,
Elongation @ break 400-800 %
the entire ear should be removed, leaving a flat tissue bed. The
Glass transition temp. < 0 deg C
tissue bed should be lined with either split-thickncss skin, full-
Heat distortion tomp.150-175 deg. C >120 deg. C
thickness skin, or a pedicle flap. Hair bearing Hap* should be
Critical surface tension 30-45 dynoKtm
avoided. The presence of hair precludes Ihc placement of im­
Coefficient of friction 0.4-0.6
plants. and skin adhesives for the prostliesis are difficult to use
Shore A hardness 48-52 25-35
<Figure 9-14). The tragus, however, should be retained because
Water sorption none
this structure creates a less obvious anterior line of juncture
Weathering hours
between the prosthesis and ihc skin (Figure 9-15). Residual tis­
(no color Change) 2000
sue tags have no retentive value and may complicate sculpture
and positioning of a prosthetic ear that is symmetrical with the
remaining auricle (Figure 9-16). In selected tumor patients, par­
ticularly those with benign tumors of Ihc auricle, implants can
aColor
mb«enttemp. be placed during the same surgical session as tumor resection.
Ear remnants secondary to congenital malformations should also
Solubility parameter be removed if reconstructive surgery is not contemplated. How­
Working time ever. compromises are sometimes necessary, especially in young
Curing time children. Surgical reconstruction of the tragus is sometimes
Curing temp. 75-80 deg. C < 100 deg. C

Fig. 9-14.
a and b: In this auricu­
lar defect, movement
of mandible created
movement of tissue
bed covered by the
prosthesis. Conse­
quently. selected rolief
of the p'osthesis was
required. Presence of
hair complicated the
application and re­
moval of skin adhe­
sive. Prosthosis bear­
ing surfaces should be Fig. 9-15. a: Only tragus remains in surgical defect. Remain­
replaced with a hair­ ing area is flat and lined with a hairless scalp flap,
less split-thickness making it an ideal ease for an ear prosthesis, b:
skin gralt. Prosthesis in position. Note how tragus hides
anterior margin.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
Temporary auricular prostheses In most patients, the tissue
bed is sufficiently organized 3 to 4 weeks after surgery to allow
placement of a temporary ear prosthesis. Fabricating this tem­
porary prosthesis in heat polymerizing acrylic resin will allow
for periodic adjustment and relining with a temporary denture
reliner. Early restoration of the defect is appreciated by the pa­
tient, and few complications have resulted from this practice.
Retention is accomplished with medical grade skin adhesives.
In most patients, 4 to 5 months is a suitable period to allow for
organization and contracture of the wound. Fabrication of the
permanent prosthesis may then begin.
a b
Fig. 9-16. a: Ear lobe in patient prevents creation and place­
ment of a prosthetic auricle which is symmetrical
with opposite auricle, b: Line of junction between
prosthesis and ear lobe is difficult to hide.
Definitive auricular prostheses
Impressions Unlike orbital or nasal defects, the tissue
bed in the auricular area is not displaceable and, therefore, dis­
tortions do not result from postural changes. Consequently, the
impression can be obtained with the patient lying on his or her
side in a supine position. However, condylar movements should
be closely examined, for they may result in tissue bed mobility,
which can affect margin placement, tissue coverage, and, ulti­
mately, the retention of the prosthesis (Figure 9-14). The defect
area is isolated with drapes, cotton placed in the ear canal, and
a suitable impression material is applied. Adjacent hair should
be taped or covered with petrolatum. Disposable syringes are
useful for depositing impression material into areas with diffi­
cult access. Light body polysulfide, silicone, or irreversible
hydrocolloid are appropriate impression materials. If irrevers­
ible hydrocolloid is used, the addition of 50% more water will
improve its flow properties and facilitate the impression proce­
dure. A backing of quick setting plaster will provide suitable
support for the impression. Gauze painted with the appropriate
adhesive is used to unite the impression material with its plaster
backing.
401
Sculpting If a presurgical cast of the resected ear is avail­
able, it is reproduced in wax and compared to the remaining
ear. Appropriate changes are made in the basic contours and, at
the next appointment, the wax ear is positioned and adapted to
the defect to achieve natural symmetry in all planes with the
opposite side (Figure 9-17). A water bath and flame are neces­
sary to complete this procedure successfully. A modified face-
bow may be useful to verify the position of the wax prosthesis.
If preoperative casts are not available, the prosthesis can
either be sculpted from the beginning or the “donor technique”
may be employed. Sculpting an ear from the beginning is a
difficult and time-consuming task, but it may be necessary in
selected patients. This task is facilitated by dividing the cast of
the normal ear into equal sections (Figure 9-18) so that con­
tours are more easily verified. The donor technique is an easier
method. A person with ear contours that closely mimic those of
the patient is selected. An impression is obtained of the appro­
priate ear of the donor and a wax cast is retrieved. The wax ear
is adapted and recontoured as necessary. If the clinician makes
wax duplicates of all auriculectomy patients’ ears, the clinician
soon will have a suitable donor supply and will no longer need
to seek a donor.
When the position and basic contours of the wax pattern
are acceptable, the patient is dismissed and the surface details
are applied. The entire surface must be stippled to match the
skin textures of the patient. The stipple should be made a little
more prominent, for some detail is lost during processing. Proper
stippling is important for a number of reasons. First, without
texture the adjacent skin can never be suitably matched. The
prosthesis must match the color and form of the normal ear,
but, just as important, it must also match the texture of the op-
a b
Fig. 9-17. a and b: Since the tumor did not alter auricular
contours, wax reproduction of the auricle was cre­
ated and applied to the cast of postsurgical de­
fect. Note surface texture.
402 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
posite ear and adjacent skin. Second, without stippling, extrin­
sic tinting becomes extremely difficult inasmuch as appropri­
ate application control and distribution of paint on a smooth
surface is almost impossible. Third, stippling provides mechani­
cal retention for extrinsic colorants and lengthens the period of
service of the prosthesis (Figures 9-17 and 9-18).
The margins are then feathered and the wax pattern is luted
to the cast. Usually, the only exposed lines of juncture are lo­
cated anteriorly. These margins should be thinned with con­
tours blended into those of adjacent skin. A residual tragus will
serve to camouflage approximately 25% of the anterior margin.
Sideburns can be valuable in camouflaging the remainder Of
the anterior line of juncture, particularly in large defects.
Fig. 9-18. Dividing normal ear into equal compartments will
aid sculpting. Note how the anterior margin is
wrapped around the tragus.
Processing The wax ear is invested in a manner to con­
struct a 3-part mold (Figure 9-19). Three-part molds are neces­
sary, when using flexible materials, in order to remove the cast­
ing from the mold without tearing (Figure 9-19f). The appro­
priate material is selected, base shades determined, and the pro­
cessing is completed. Surface characterization can be effected
eiiher intrinsically or extrinsically (Figure 9-19g), although the
former results in a prosthesis with longer lasting color. All ex­
trinsic colorations, regardless of the material employed, tend to
nib off eventually.
Delivery and retention Additional benefits, besides the
obvious cosmetic improvement (Figure 9-19h), are derived from
the prosthesis. The prosthesis helps to support eyeglass frames
and protects the ear canal from wind, dust, and other particulate
matter. Hearing will also be improved, as will the perception of
specific pitches and tones.
Retention is accomplished by means of tissue adhesives or
osseointegrated implants, or by engaging bony or soft tissue
undercuts. If an adhesive is used, selection is dependent upon
the material from which the prosthesis is fabricated. Patients
should be instructed to apply adhesivejudiciously. After removal
of the prosthesis, all residual adhesive must be removed from
the skin and prosthesis. Most patients will be able to wear their
restoration 1 or 2 days before the prosthesis requires removal
for cleaning. Quarterly follow-up is suggested.
Restoration of nasal defects
The vast majority of nasal defects are secondary to treat­
ment of neoplasms, although, occasionally, defects secondary
to trauma are seen. In general, most partial nasal defects are
best restored surgically, whereas total nasal defects are best re­
stored prosthetically. The wishes of the patient, however, are of
paramount importance, and they must be carefully considered
when determining the method of rehabilitation.
If the defect is going to be permanently or temporarily re­
stored with a prosthesis, presurgical consultation with both the
patient and the surgeon is necessary. In partial rhinectomy de­
fects, the surgeon may wish to restore the defect temporarily
with a prosthesis (Figure 9-20) and consider surgical reconstruc­
tion only after a suitable observation period has elapsed. Cov­
ering the defect with a local flap may significantly delay dis­
covery of recurrent tumor. Observation is especially important
in advanced and/or recurrent basal cell carcinomas of the
midfacial region, since these tumors are locally invasive and
may ultimately cause significant destruction of local tissue.
When a total rhinectomy is contemplated, the nasal bones
should be removed—even though these structures may not be
infiltrated with tumor (Figure 9-21a). If the nasal bones remain,
the prosthesis must either terminate just above the superior sur­
gical margin, disrupting concealment of the prosthetic margin,
or extend superiorly over the nasal bridge. Extension of the pros­
thesis over the nasal bones results in proper margin placement
but creates a thin, over-contoured prosthesis in this area. In ad­
dition, these areas of the prosthesis are subject to tearing. Of
greater significance is that retained nasal bones will dictate the
prosthetic contours of the nasal tip. The resultant nasal prosthe­
sis may then appear larger than normal, leading to an unpleas-
ing esthetic result. It is usually not possible to insert implants in
the nasal bones. The frontal bone above them appears to be a
good site because of the dense nature of the bone, but results
have been inconsistent2.
Care should be taken to avoid surgical displacement and/
or distortion of the upper lip during resection and closure (Fig­
ure 9-21b). If the lip is retracted posteriorly or displaced superi­
orly to aid in closure, it is impossible to fabricate a nasal pros­
thesis which will faithfully reproduce presurgical facial con­
tours, particularly from the lateral perspective. A retracted up­
per lip immediately draws attention to the patient’s midfacial
defect and compromises the concealment of the prosthetic mar-
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
Fig. 9-20. a: Patient with history of multiple recurrences of
9 h
Fig. 9-19. a, b, c, and d: Three-part mold is made to facili­
tate removal of auricular casting without tearing,
e: Facial material is syringed into mold. Polymer­
ized prosthesis is removed (f), painted to match
opposite ear and adjacent skin (g), allowed to cure
in a dry heat oven, deglossed, and delivered (h).
gins. During surgical resection of the tumor, care should also be
taken to avoid undue distortion of the cheeks and nasolabial
folds (Figure 9-22). Obliteration or displacement of the nasola­
bial folds adversely affects the contour and position of the nos­
tril and columella portions of the prosthesis. During surgical
resection, the nasal bones, alae, columella, and the anterior por­
tion of the nasal septum should be removed without distortion
of adjacent facial contours. The osseous and soft tissue margins
403
a b c
basal cell carcinoma arising on tip of nose, b:
Following resection, surgeon chose not to imme­
diately reconstruct the area with flap to be able to
closely monitor the surgical site for recurrence, c:
Prosthesis fabricated. Two years of follow-up
failed to reveal persistent disease, and defect was
subsequently reconstructed with forehead flap.
a b
Fig. 9-21. a: Unfavorable detect. It was difficult to attain ac­
ceptable contours of nasal bridge. Problem is
accentuated by retraction of upper lip superiorly,
b: In this patient, primary closure of the wound
resulted in distortions of adjacent facial structures.
of the surgical defect should be smooth and covered with skin
grafts. Primary closure of these defects should be avoided be­
cause of the possibility of distorting midfacial contours. In se­
lected patients, osseointegrated implants can be placed imme­
diately following tumor resection. The preferred site is the floor
of the nose. In dentate patients, care must be taken to avoid the
roots of the maxillary teeth during implant placement (Figure
9-23).
404 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

The patient should be informed of the benefits and limita­

tions of the prosthesis. Photographs of patients with similar na­
sal defects are valuable educational aids. Some patients will
benefit from a conversation with a rhinectomy patient who is
wearing a nasal prosthesis. It is important that the expectations
of the patient be realistic. Family members are encouraged to
be present during these consultations. Psychosocial evaluations
and consultations should be provided prior to the resection.
Prior to surgery, facial impressions and photographs should
be obtained. Facial impressions are preferred because they pro­
vide useful information for the clinician to fabricate the post-
surgical nasal prosthesis. Prior to obtaining the impression, un­
desirable tissue undercuts should be blocked out with petrola­
tum gauze.

Temporary nasalprostheses Approximately 3 to 4 weeks fol­

lowing surgery, the wound has usually healed sufficiently to
allow placement of a temporary nasal prosthesis. Early restora­
tion of the nasal defect is appreciated by patients, as it enables
them to resume social interactions and to return to work. Heat-
polymerizing methyl methacrylate is the material preferred by
some clinicians because it can be relined with a temporary den­
ture reliner, and because it compensates for tissue changes sec­
ondary to scar contracture and wound organization. Retention
of the prosthesis is accomplished with a medical grade skin
adhesive. As in auricular defects, 4 to 5 months is sufficient
time to account for contraction and organization of the tissue c d
bed before fabrication of the definitive prosthesis is begun.
Fig. 9-23. a and b: Following total rhinectomy. c:
Osseointegrated implants placed into floor of the
nose, d: Six months later they were ready for use.

Definitive nasalprostheses The effectiveness of the nasal pros­

thesis is dependent on the nature and extent of the defect Flat
defects in which the nasolabial folds remain undisturbed are
the easiest to restore prosthetically (Figure 9-24). Defects with
surgical margins that extend beyond the nasal area are more
difficult to restore because of exposure of the lines of juncture.
In males, margins that extend onto the upper lip may be camou­
flaged by facial hair (Figure 9-25), but those extending laterally
beyond the eyeglasses will always be apparent.
In most patients, the tissues bordering the lower portion of
the defect are highly mobile. It is difficult to account for this
mobility with impression procedures. Therefore, the prosthesis
should be designed to be highly flexible in this region.

Fig. 9-22. a and b: Although resection was similar to that
seen in Figure 9-21 b, the lip portion of the wound
was covered with split-thickness skin graft. This
minimized distortion and retraction of upper lip,
allowing fabrication of a prosthesis in more favor­
able position and with more ideal contours.
Permlastic, Kerr USA, Romulus, MI.
Impressions As in orbital defects, postural changes may
result in distortions of the tissue bed. Therefore, it is advisable
to obtain the master impression with the patient in an upright
position (Figure 9-26). Elastic impression materials that pos­
sess good flow properties are suitable for this task. We prefer to
use a light body polysulfide*. The nasal passage should be
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
Fig. 9-25. Defect extended inferiorly onto upper lip. Line of
juncture in this area was camouflaged with a
mustache incorporated within nasal prosthesis.
Upper lip extension thinned to enhance its flex­
ibility.
Fugirock, G.C. Dental Industrial Corp., Chicago, IL.
405
Fig. 9-24.
a, b, c, d, e, and f: These total
rhinectomy defects were ideally
suited for a prosthesis. Note lat­
eral and superior lines of junc­
ture are positioned beneath
eyeglass frames.
blocked with gauze to prevent entry of impression material. A
syringe is used to inject impression material into skin creases,
areas of difficult access, and usable undercut areas; a very thin
layer of impression material is allowed to flow over the desired
skin surfaces (Figure 9-26c). Small gauze segments are imbed­
ded within the impression material as it begins to polymerize. A
thin layer of adhesive is then applied to the gauze and impres­
sion material followed by succeeding layers of fast setting im­
pression plaster (Figure 9-26e). The first 2 layers should be kept
as thin as possible in order to avoid distortion of the underlying
polysulfide layer. The impression is removed and poured with
an improved dental stone*.
Sculpting To be effective, the nasal prosthesis must re­
produce the contour and texture of the resected nose. Another
important factor is the placement and camouflage of the lines
of juncture. In an ideal total rhinectomy defect, only small por­
tions of the lines ofjuncture are apparent with aproperly sculpted
nasal prosthesis. If a presurgical facial cast has been fabricated,
a wax duplicate of the nasal portion is adapted to the cast of the
postsurgical defect. If presurgical casts are not available, a mass
of clay or wax is adapted to the cast of the defect, and basic
406 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 9-26. a and b: Impression made with polysulfide impression material. Upper denture is inserted prior to making impres­
sion to support upper lip. c: Thin layer of polysulfide impression material is applied followed by a layer o f gauze (d).
e: A thin layer of quick-setting plaster is applied, followed by succeeding layers, f: Completed impression, g: Master
cast.

contours are completed. The patient will usually have numer­
ous facial photographs available for reference. It is always help­
ful to have a family member present during sculpting for such a
person may have a better perception of appropriate contours
than does the patient.
The alae should be located in their appropriate position in
relationship to the nasolabial folds. By tucking a portion of the
ala into the nasolabial fold, these margins can be made incon­
spicuous. Care should be taken not to make the nose too wide
in the ala region. Usually, this distance is no greater than the
medial inner canthus distance. The nares should be symmetri­
cal and consistent with presurgical contours. They can only be
made appropriate by accurately contouring the columella. The
juncture between columella and skin should be at a right angle
or an acute angle. By doing so, this line of juncture is usually
difficult to detect because of the shadow cast by the tip of the
nose. The nostril portion should not be connected to the col­
umella portion; otherwise, the flexibility of this portion of the
prosthesis will be impaired. The tip, dorsum, and bridge of the
nose must reproduce presurgical contours. Care must be taken
not to make the bridge too wide. Presuigical photos, casts, or a
pair of eyeglass frames previously worn by the patient can be
used to verify this dimension (Figure 9-27).
Eyeglass frames should be worn by the patient, for they
improve the appearance of the prosthesis immeasurably. If pos­
sible, the lateral and superior margins of the prosthesis should
be placed directly beneath the eyeglass frames (Figure 9-28). In
prostheses in which lines of juncture are properly positioned,
only the margins from the bottom of the eyeglass frame to the
point where the alae insert into the nasolabial groove will be
exposed. Care should be taken to feather this margin and de­
velop the lateral contours of the prosthesis, so that there is a
smooth transition between prosthesis and adjacent cheek. These
lateral contours are especially significant if the margin of the
defect extends far beyond the eyeglass frame.
As in auricular prostheses, development of proper surface
texture is also important. The texture developed in the sculp­
ture should be slightly more prominent than that of the adjacent
skin because some of this detail is lost during processing and
painting. Stippling is usually most prominent on the tip and
nostrils.
 Restoration of Facial Defects: Etiology, Disability, and Rehabilitation 407

a b

a b
Fig. 9-28. a and b: Lines of juncture are hidden by eyeglass
frames or tucked into skin creases and folds.

Processing The wax pattern is invested with appropriate

c
Fig. 9-27. a: Alar groove should be continuous with nasal-
labial fold, b: Ala should be tucked underneath so
prosthesis will cast a shadow on line of juncture,
c: Note symmetrical nasal aperture and contour
of columella.
mold material. Two-piece molds are adequate. The wax pattern
should be thinned internally to reduce weight as well as to al­
low for normal nasal air flow. Ahole is placed through the mas­
ter cast in the middle of the defect area, and the wax pattern is
luted in position (Figure 9-29a). Stone is then poured through
the hole in back of the cast in order to fill the air space behind
the wax pattern (Figure 9-29b). When the prosthesis is processed,
it will be thin, flexible, and light in weight (Figure 9-29c). The
basic shade of the prosthesis should closely match the lightest
area of coloration in the local area. If the basic shade is too
dark, it will not be possible to achieve an esthetic match be­
cause, as more extrinsic coloration is added, the prosthesis be-

a b c d e

Fig. 9-29. a: Hole is placed through master cast as shown, b and c: Wax sculpture is luted to cast externally and also from
back, d: Stone is vibrated through opening in back of cast, e: Polymerized casting is thin and light weight.
408 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

comes progressively darker. Extrinsic colorations should he
applied with the patient present and under adequate lighting.
Evaluation of coloration undervarious light sources is suggested
(Figure 9-30).
Delivery andfollow-up Retention is achieved with adhe­
sives, engagement of undercuts (Figure 9-31), or with
osseointegrated implants. If adhesives are used, the patient
should be warned to avoid adhesive buildup on either the skin
or the prosthesis. After the initial adjustment period, the patient
is placed on a follow-up schedule consistent with the life of the
prosthesis.
a b
Fig. 9-30. a: Extrinsic coloration completed, b: Completed
prosthesis.
Partial nasalprostheses These partial prostheses are fab­
ricated in the same fashion as are total nasal prostheses. If the
remaining nose is not displaced or distorted, acceptable esthetic
results can be attained (Figure 9-32). However, more of the lines
of juncture between prosthesis and adjacent tissues will be ex­
posed, as most partial nasal resections are below the level of the
eyeglass frames. These margins should be carefully contoured,
feathered, and colored in order to achieve an acceptable result.
Restoration of large midfacial defects
Advanced tumors of the midfacial region occasionally re­
quire extensive surgical removal to eradicate the disease. The
resulting surgical defect may involve loss of both extraoral and
intraoral structures, including portions of the nose, upper lip,
cheek, and orbital contents. Also, segments of the maxilla, man­
dible, associated soft tissues, and teeth may be involved. The
functional impairment produced by such extirpative procedures
is severe. Loss of the integrity of the oral cavity results in diffi­
culty in mastication, swallowing, control of saliva, and speech
production. These functional disabilities, in combination with
the accompanying cosmetic disfigurement, usually have a se­
vere psychological impact on the patient and his or her family.
However, many patients with such surgical defects have been
rehabilitated successfully with prosthetic restorations. Speech
and swallowing may be restored to nearly normal levels, and
control of saliva and mastication may be improved. The cos­
metic appearance of the patient, although far from ideal, make
participation in social activities conceivable.

a b c
Fig. 9-31. Retention achieved by engagement of undercuts in nasal cavity, a and b:
Nasal prosthesis. Note posterior portion is hollow to reduce weight and
improve flexibility, c: Prosthesis in position. Adhesive was not necessary.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
Fig. 9-32. a: Patient underwent
partial rhinectomy. b
and c: P artial nasal
prosthesis fabricated.
Lines of juncture are
easily seen. Note con­
tour of ala, columella,
and nares.
Best results are obtained when all members of the therapy
rehabilitation team have the opportunity to see and discuss the
patient prior to treatment It gives the clinician the opportunity
to obtain records, such as photographs and facial impressions,
that will be useful during fabrication of the facial restoration.
This consultation also provides the dentist with the opportunity
to explain to the patient the potential for prosthetic restoration.
Successful adjustment to the postsurgical defect often is depen­
dent on a realistic understanding by the patient of the degree of
rehabilitation afforded by the future restoration.
Surgical reconstruction of small facial defects is usually
preferable to a prosthesis. However, in large midfacial defects,
surgical reconstruction is almost impossible because of their
size and extent. In addition, since most patients had extensive
disease prior to surgery, radiation therapy may have been used
as an adjunct. In most patients, this precludes the possibility of
surgical reconstruction.
a b
409
Prosthetic prognosis The prosthetic prognosis is primarily
dependent upon the presence and condition of the teeth, the
amount and contour of the remaining hard palate, functional
status of the lower lip, and the motivation and adaptability of
the patient. The presence of a small amount of upper lip is usu­
ally of little value and, in most defects, it is not advisable to
reconstruct the upper lip surgically (Figure 9-33). The recon­
structed upper lip is often improperly positioned and immobile,
and access to the oral cavity is compromised as a result The
reconstructed lip can prevent normal lip valving during speech.
In addition, the poor esthetics of the reconstructed upper lip
will tend to focus attention on the defect and the midfacial pros­
thesis. Usually, the reconstructed upper lip must be overlaid or
covered with the prosthesis to restore speech and esthetics. The
small oral opening, and the impaired flexibility of the recon­
structed oral stoma, make it difficult for the prosthodontist to
fabricate accompanying oral prostheses, and make insertion and
Fig. 9-33.
a: Lateral portion of face and up­
per lip has been reconstructed, b:
However, the lip portion retracted
superiorly, c: Lip overlaid with pros­
thesis to restore speech articula­
tion and appearance.
c
410 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

removal difficult for the patient. In addition, oral hygiene pro­
cedures will be compromised by the impaired oral access.
Equally important to the successful tolerance of these res­
torations is the adaptability of the patient. His or her emotional
responses should be anticipated. The importance of social ser­
vice counseling and consultations cannot be overemphasized
in the care of these patients. In some instances, patients will not
accept the restoration because of unrealistic expectations. The
clinician must prepare the patient for the prostheses and realis­
tically explain the level of rehabilitation he or she should hope
to achieve. Experienced denture wearers seem to do best with
these prostheses; they have learned to tolerate and manipulate
foreign objects within their mouths and, generally, have mas­
tered the delicate balance between function and stability when
wearing their prostheses121,122.
These prostheses may be of great value in the care of ter­
minal cancer patients123. Limited life expectancy should not pre­
clude such prosthetic therapy. These restorations give the pa­
tient the opportunity to live the remainder of his or her life in a
more comfortable and productive manner.
Surgical modifications at tumor resection that may be in­
dicated include: (1) retention of teeth that can be used to sup­
port and retain the combined facial and intraoral prosthesis, (2)
preparation of the soft tissue bed so that undercut areas are cre­
ated for retention, (3) placement of skin grafts to minimize tis­
sue distortion or contraction of the tissue bed, and (4) place­
ment of osseointegrated implants for retention and support of
future prosthesis (Figures 9-34 and 9-35). If soft tissue under­
cuts are created surgically, they should be lined with split-thick-
ness skin. Failure to do so results in excessive contracture and,
in some cases, loss of the created undercut. In addition, these
tissues will usually become epithelialized with non-keratinized
squamous or respiratory epithelium, thereby limiting their use­
fulness as prosthesis-bearing areas. Keratinized tissue at the
anterior palatal margin will also increase the bearing surface
available for the prosthesis. If the nasal floor of the residual
hard palate is skin grafted, it may be used to retain the midfacial
prosthesis.

Fig. 9-34. a: Portions of this midfacial defect have

been lined with skin grafts, b: Osseo­
integrated implants placed in all avail­
able implant sites.

Fig. 9-35. a: inferior, lateral, and posterior walls of maxillary sinus have been lined with skin, permitting design and fabrication
of a 2-piece oral prosthesis (b, c, and d). e: Facial prosthesis secured to oral prosthesis from which it derives
retention and support.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 411

Placement of osseointegrated implants has had a dramatic
impact on the function on these large and heretofore difficult to
retain midfacial prostheses. Possible sites for implants include
the lateral orbital rim, the floor of the nose, the residual malar or
zygoma, and the glabella region. These large facial prosthesis
can be effectively retained with implants. When possible, the
implants should be placed at the time of the tumor resection.
Temporary midfacialprostheses A temporary restoration may
aid recovery during the immediate postoperative period by elimi­
nating the need for large bandages and permitting social inter­
course. A temporary facial prosthesis, constructed of
autopolymerizing acrylic resin or silicone, and combined with
an oral prosthesis, will permit swallowing, facilitate salivary
control, and enhance speech articulation.
In patients with residual dentition, a 2-piece prosthesis is
preferred. One piece restores the integrity of the oral cavity and
other masks the facial defect. Some edentulous patients will
prefer a 1-piece prosthesis at this interim stage because it is
easier to manipulate. Treatment partial dentures are fabricated
for patients with residual dentition. The purpose of these pros­
theses is to restore the integrity of the oral cavity, thereby en­
abling the patient to masticate and swallow more effectively
and also improving speech. The facial portion is then fabricated
after completion of the oral prosthesis. If possible, it should be
designed to gain at least some of its retention and stability from
the oral prosthesis. Magnets or attachments can be used to con­
nect the two together (Figure 9-36). The facial portion is usu­
ally made of silicone and designed to be as light as possible. A
completed temporary prosthesis is shown in Figure 9-36. Eye­

Fig. 9-36. Interim midfacial prosthesis a: Mounted casts of patient with large midfacial
defect, b: Treatment partial denture with magnetic attachments, c: Wax sculp­
ture of facial prosthesis, d: Clear acrylic resin substructure designed to house
magnetic attachments. Note that it is contoured to fit within contours of the
upper lip portion of the facial prosthesis, e and f: Interim prosthesis in posi­
tion. Note maxillary anterior teeth exposed to allow for articulation with lower
lip.
412 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
glass frames and straps can also be used to facilitate retention,
as adhesives are not effective for these large facial prostheses.
Definitive midfacial prostheses
Orbital-nasal-cheek defects A 1-piece prosthesis is usu­
ally preferred for large facial defects involving the orbit-nasal-
cheek region but not the lip or the oral cavity. In these large
defects, craniofacial implants are a necessity if the prosthesis is
to be retained effectively. It is almost impossible to retain such
large prosthetic restorations with adhesives or by engaging un­
dercuts.
Accurate impressions are difficult to obtain because the
tissues bordering the defect may not have an underlying bony
foundation. Therefore, these tissues are easily compressed with
the impression material or distorted by changes in posture. Se­
lected areas in the defect are blocked out with gauze. When
Permlastic, Kerr USA, Romulus, MI.
possible, we prefer to place the patient in a semi-upright posi­
tion and apply a thin layer of light body polysulfide rubber im­
pression material to the tissues associated with the defect. The
light body polysulfide material* seems to possess the correct
combination of viscosity and flow. It is important to make this
layer thin in order to avoid compression and distortion of the
tissues. As the material polymerizes, gauze strips followed by a
thin layer of adhesive is applied to the polysulfide impression
material. Diluting the adhesive with acetone is usually advis­
able in order to apply a thin layer of adhesive. Next, a very thin
layer of fast setting impression plaster is applied. This layer is
followed by succeeding layers (generally, 4 or 5) until suffi­
cient support has been developed for the polysulfide material.
The impression is removed and poured with an improved den­
tal stone (Figure 9-37). Distortion of the impression is avoided
if the impression is poured in layers.
f
Fig. 9-37.
impression making, a: Patient positioned
and draped. Note implant retention bars
(previously fabricated) have been se­
cured. b and c: Thin layer of polysulfide
impression material applied, d: Gauze with
layer of adhesive for retention of plaster
backing, e: First layer of plaster is thin, f:
Succeeding layers will support impression
material, g: Completed impression, h:
Master cast. Plaster is poured in layers to
minimize distortion of master cast.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 413

A wax sculpture is developed on the master cast. Restora­
tion of presurgical contours and symmetry may not be possible
or desirable. In these defects, significant distortion of contour,
symmetry, and skin coloration, secondary to multiple surgeries
and/or courses of radiation therapy, may be present. For best
results, the contours, texture, and color of the prosthesis must
blend and meld with the contours and coloration of the patient.
Matching the surface texture of the prosthesis with the existing
skin is particularly important. A template is made if implants
have been previously positioned. The retentive apparatus is at­
tached to the implants, and the retentive resin housing that is to
be imbedded within the prosthesis is designed and fabricated
(see Implant section for details). The pattern is then flasked and
the prosthesis processed in the customary way. Intrinsic and
extrinsic coloration are applied as previously described (Figure
9-38).
Midfacial defects involving the upper lip and oral cavity
These defects usually result from resection of advanced nasal
or nasal cavity tumors and may lead to resection of the nose,
upper lip, and orbital contents with extension into the oral cav­
ity. The prosthetic prognosis is primarily dependent on the pres­
ence and condition of the teeth, the amount and contour of the
remaining hard palate, the functional status of the lower lip,
and the motivation and adaptability of the patient (Figure 9-
39). Oral function can be restored to impressive levels accom­
panied by an acceptable esthetic result, but there must be a solid
foundation on which to build the oral prosthesis. In most pa­
tients, particularly the edentulous ones, osseointegrated implants
should be positioned in all available sites (Figure 9-40).
The presence of small amounts of upper lip is usually of
little value and, in most defects, it is not advisable to recon­
struct the upper lip surgically. The reconstructed upper lip is
often improperly positioned posteriorly and inferiorly, and is
immobile. The poor esthetics of the reconstructed lip often fo­
cus more attention on the defect and the midfacial prosthesis.
Usually, the reconstructed upper lip must be covered with the
midfacial prosthesis to restore speech and esthetics. The reduced
size of the oral opening and impaired flexibility of the recon­
structed oral stoma make it a challenge for the prosthodontist to

d f

Fig. 9-38. a: Wax sculpture on master cast, b: Sculpture on patient, c: Acrylic resin substructure housing retentive elements
designed to fit within contours of facial prosthesis, d: Silicone being injected into mold, e: Extrinsic coloration being
added, f: Completed prosthesis.
414 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 9-39. a: Significant portions of palate remain in this edentulous patient with a large midfacial defect. There are
many suitable implant sites, b: Little palate remains and prosthetic prognosis is poor fo r this patient. There
are few implant sites available, c: Presence of teeth dramatically improves the prosthetic prognosis for this
midfacial defect.

Fig. 9-41.
Fabrication of retention bar. a:
UCLA abutm ent technique
used to fabricate bar in gla­
bella region because of lack
Fig. 9-40. a: Following resection of large midfacial neoplasm, b and c: of space. Conventional abut­
Implants positioned in frontal bone and palatal bone, d: Note ments used a t other sites, b:
lateral portion of defect reconstructed with scapula free flap. Bar in position.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
fabricate these oral prostheses, and insertion and removal is dif­
ficult for the patient. In addition, oral hygiene procedures will
invariably be compromised by the impaired oral opening pre­
disposing to caries and periodontal disease.
The oral prosthesis is completed first. In dentate patients,
removable partial denture designs are dictated by the nature and
direction of the occlusal forces. Most will exhibit anterior ex­
tension bases (Kennedy class IV), requiring distal or cingulum
rests on the anterior abutments and properly contoured guide
planes. The partial denture must be designed to direct occlusal
forces along the long axis of the teeth. Indirect retainers should
be placed bilaterally and as far posteriorly as is feasible to coun­
teract gravitational forces from the anterior partial denture ex­
tension and the attached facial prosthesis.
In patients with implants, the retention bar designs may be
very complex. If the bar and the implants are to be subjected to
forces secondary to mastication they should be designed to ab­
sorb and distribute these forces in a favorable manner (Figure
9-41). The bar mechanism should be rigid and fit in a passive
manner124 (see Implant section for details). The bar must be
designed so it and the acrylic resin housing containing the at­
tachments fit within the ideal contours of the facial prosthesis.
Upon completion of the removable partial denture frame­
work or retentive bar, the oral prosthesis may be completed.
The vertical dimension of occlusion and centric relation records
are obtained. In these patients, this task is complicated by lack
of an upper lip, unstable record bases, compromised motor con­
trol, and altered proprioceptive patterns. Swallowing and speech
articulation are usually the most useful guides in determining
the vertical dimension of occlusion. It is advisable to reverify
the vertical dimension when the lip contours of the facial pros­
thesis have been completed. Teeth are arranged according to
the requirements of speech articulation, esthetics, and occlusal
function, and the prosthesis is completed and delivered (Figure
9-42).
Fig. 9-42. Maxillary removable partial denture inserted. An­
terior teeth are positioned to permit normal ar­
ticulation with lower lip. Patient now ready for fa­
cial impression. Note presence of male portion of
“0 ”-ring-type attachments. Facial prosthesis will
be secured with these attachments.
* Iso Compound, G. C. Dent. Indust. Corp., Scottsdale, AZ.
Permlastic, Kerr USA, Romulus, MI.
415
Impressions for the facial portion of the prosthesis can now
be made. Variable degrees of tissue bed mobility will be en­
countered in these facial defects. The movement of structures,
such as the anterior border of the ramus, the comer of the mouth,
and the lower lip, should be accounted for in the impression
procedure. Modeling plastic and thermoplastic waxes can be
used to record the movement of these tissues. The oral prosthe­
sis is positioned, a preliminary impression is obtained, and a
master impression tray fabricated from the resulting cast. The
patient should be in a semi-upright position during the making
of the master impression in order to avoid distortions second­
ary to postural changes. The movable portions of the defect are
recorded with a thermoplastic modeling material*. After the tray
is border molded, the impression is completed with a polysul­
fide impression material**. A syringe is useful in injecting im­
pression material into desirable undercuts or into areas of diffi­
cult access.
The facial prosthesis is then completed in the usual fash­
ion. The defect should be utilized as much as possible to facili­
tate stability and retention of the prosthesis. It is important to
engage areas in the defect that will provide resistance to the
forces of gravity so as not to expose abutment teeth or implants
to undesirable stresses. The prosthetic upper lip must function­
ally engage the lower lip and, at the same time, allow the lower
lip to articulate with the maxillary anterior teeth (Figures 9-36
and 9-43).
Since the introduction of implants, these prosthesis have
been fabricated in 2 sections, as opposed to 1-piece restora­
tions. Two-piece restorations are advantageous because the oral
prosthesis can be designed so that the movement created during
Fig. 9-43. Completed midfacial prosthesis. Note excellent
lip seal.
416 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
swallowing and mastication need not be transferred to the fa­
cial portion: Also, the forces generated by retention and stabil­
ity in the facial portion can be directed to areas in the defect that
have been designed and prepared sp e c ific ^ ior that purpose,
such as the extensions into undercuts and/or the use of implants.
Retention of the facial portion may be enhanced by straps,
adhesives, double sided tape, eyeglass frames, and engaging
usable undercuts. The prosthesis is delivered in the customary
fashion, taking care to identify areas of overextension and ex­
cessive pressure. The finished restoration usually provides the
patient with an acceptable appearance and excellent function.
In males, a mustache can be attached to the upper lip to enhance
esthetics (Figure 9-44).
Fig. 9-44. a: Midfacial defect restored with intraoral and fa­
cial prosthesis, b: Addition of mustache enhances
esthetics.
Fig. 9-45. Extensive tumor (a) resulted in large lateral facial defect (b). c: Scapula flap effectively restores lateral defect.
Lateral Facial Defects
Most large lateral facial defects are best restored surgically
fetes, cgtokb^ and,
as a result, prosthetic restorations are ineffective or poorly tol­
erated by the patient. Facial prosthesis are most effective when
they restore structures that are relatively immobile, like the ear,
nose, upper lip, and so forth. Some of these issues are addressed
in the patient shown in Figure 9-33. The lateral portion of this
large defect was covered with a flap. The orbital structures,
midcheek area, nose, and upper lip were restored with a pros­
thesis. Speech was essentially normal and the patient exhibited
reasonable oral competence. Mastication was effectively restored
with a complete denture and maxillary obturator. The esthetic
result was excellent.
Maxillectomy-orbital exenteration defects that involve a
significant portion of the cheek require a combined prosthetic-
surgical approach. The orbital and maxillectomy defects are best
restored with a prosthesis, but the cheek defect should be re­
constructed with a flap. The radial forearm free flap is ideal for
this purpose. However, care should be taken to avoid oblitera­
tion of either the orbital or maxillary defect.
The patient in Figure 9-46 illustrates the limitations asso­
ciated with restoring large orbital-cheek defects with a prosthe­
sis. The prosthesis is large, heavy, and extends onto mobile tis­
sues. When the mandible moves during speech, mastication, or
swallowing, the prosthesis is displaced. Retention is difficult to
maintain—even with osseointegrated implants. More impor­
tantly, oral competence cannot be restored by a prosthesis when
the cheek defect approximates the oral commissure. Saliva will
leak from the inferior portion of the defect regardless of the
design or fit of the prosthesis.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
The best results are obtained when the maxillary defect is
maintained and the cheek is reconstructed with a flap (Figure 9-
47 a,b,c). The maxillectomy defect should not be obliterated.
The presence of the reconstructed cheek flap actually enhances
the retention and stability of the maxillary obturator prosthesis,
while the obturator extension provides support for the recon­
structed cheek, resulting in more symmetrical midfacial con­
tours (Figure 9-47 d,e,f) (see Chapter 5). The defect allows res­
toration of normal palatal contours and proper positioning of
anterior and posterior teeth. The orbital defect is restored with a
facial prosthesis. Upon completion of rehabilitation, the patient
has an acceptable esthetic result, and speech and swallowing
are restored to near normal (Figure 9-47g).
Ffg. 9-46.
a: Large orbital-facial defect, b: Intraoral defect was restored
effectively with obturator prosthesis, c: Large, ineffective
extraoral prosthesis. The lateral and inferior margins were
mobile. Mobility of border tissues and weight of prosthesis
compromised retention. Seal of cheek defect could not be
maintained, so saliva leaked constantly from inferior portion
of facial defect.
Section on restoration of ocular defects contributed by Gregory A. Waskewicz.
417
Restoration o f ocular defects*
The rem oval o f an eye and m anagem ent o f the
anophthalmic socket requires the combined efforts of the oph­
thalmologist and the maxillofacial prosthetist. The goal of any
ocular prosthetic procedure is to return the patient to society
with a normal appearance and reasonable motility of the pros­
thetic eye. The disfigurement resulting from loss of an eye can
cause significant psychological, as well as social, consequences.
However, with the advancement in ophthalmic surgery and ocu­
lar prosthetics, the anophthalmic patient can be rehabilitated
very effectively.
The fabrication of artificial eyes are not limited to this
modem age. They have been used for centuries, with the earli­
est known examples found in mummies dating back to the Fourth
Dynasty in Egypt (1613-2494 B.C.)41. Ambroise Pare, a French
surgeon-dentist, is considered to be the pioneer of modem arti­
ficial eyes. In 1575, Pare fabricated artificial eyes made of glass
as well as porcelain. The glass eye was considered the state of
the art until the advent of World War II, which made it impos­
sible to obtain glass or glass eyes from Germany. Acrylic resins
had replaced vulcanite as a denture base material by the early
1940’s and the Naval Dental School tested the use of acrylic
resin in fabricating a custom-fitted ocular prosthesis125. Unlike
a glass eye, an acrylic resin eye was easy to fit and adjust, un­
breakable, inert to ocular fluids, esthetically good, longer last­
ing, and easier to fabricate. The dental influence in the develop­
ment of acrylic resin eyes accounts for the ocular prosthesis
being fitted from an impression of an eye socket rather than the
traditional empirical method126. Treatment of the anophthalmic
patient, along with recent advances in ocular prosthetics, will
be described in this section.
Surgical considerations in ocular implants Indications for
removal of an eye include: irreparable trauma; tumor; a blind,
painful eye; the need for histologic confirmation of a suspected
diagnosis; the possible prevention of sympathetic ophthalmia;
and cosmetic reasons127. The surgical procedures in the removal
of an eye are classified into 3 general categories: evisceration,
enucleation, and exenteration.
Evisceration involves removing the contents of the globe,
but leaving the sclera and sometimes the cornea in place. A loss
of volume results from its removal, and the volume is usually
replaced by placing a 16 to 18 mm spherical implant within the
remaining scleral space128. Motility of the implanted eviscer­
ated globe is excellent, since the extraocular muscles are intact.
Careful selection of the size of the spherical implant is impor­
tant to prevent extrusion of the implant and creation of an ex­
ophthalmic appearance. The eye should approximate its origi­
nal size and, therefore, a thin, scleral cover or shell-type pros­
thesis is made. The fitting of the prosthesis may be difficult
because there is often more sensitivity to the socket. With lini-
418 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 9-47. a: Large recurrent carcinoma invading skin of cheek, orbital area, and maxillary sinus, b: Orbital exenteration,
maxillectomy, and cheek resection defect, c and d: Conventional maxillectomy-orbital exenteration defect created.
Cheek restored with radial forearm free flap, e and f: Oral defect restored first with obturator prosthesis. Obturator
supports and contours reconstructed cheek, g: Completed orbital prosthesis.

Fig. 9-48. E n u c le a tio n o f g lo b e . E x tra o c u la r

muscles are identified and tagged with
sutures. Fig. 9-49. Three types of ocular implants: buried, noninte­
grated (a); buried, se m i-integrated (b); and
nonburied, integrated hydroxyapatiite sphere im­
plant (c).
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
ited space within the fomices, the prosthesis is more difficult to
fabricate. Since the iris may need painting on the outer comeal
curve, the cosmetic results are compromised, as compared with
a prosthesis with a comeal depth of at least 1 mm over the iris.
The advantage of an eviscerated defect is that the light scleral
shell will not depress the lower eyelid with its weight, and a
bulk of material is not required to fill a sunken superior sulcus.
Most patients remove scleral shells at night since the remaining
globe is usually very sensitive.
Enucleation is the surgical removal of the eyeball after the
eye muscles and optic nerve have been severed (Figure 9-48).
The advantages of enucleation, as compared with evisceration,
include: the entire globe is available for histopathological ex­
amination, the risk of spreading an ocular tumor is negated,
prevention of sympathetic ophthalmia, and adequate space is
created for fabricating the ocular prosthesis129.
The placement of an orbital implant into an enucleated
socket was first described by Frost in 1886. Since then, there
have been numerous modifications. Soil described an improved
surgical method of placing the orbital implant deep within the
muscle cone, and buried beneath the posterior layer of Tenon’s
capsule, following the enucleation of the eye130. The optic nerve
and its associated vessels are severed and tied close to the pos­
terior wall of the capsule. The implant is placed, and the poste­
rior portion of Tenon’s capsule is closed over the implant, pro­
viding the first layer of closure. Next, the anterior portion of
Tenon’s capsule and conjunctiva are then closed to form the
second and third layers over the implant. The horizontal rectus
muscles are then attached to the medial and lateral fornix.
It is the movement of the fomix in the enucleated socket
that provides the motility to the artificial eye. For example, as a
person looks up, the inferior fomix shortens, the superior fomix
deepens, and the prosthesis revolves upward. By utilizing the
posterior layer of Tenon’s capsule, a larger implant can be placed
deep within the muscle cone decreasing the incidence of im­
plant migration, and reducing the tension on the anteriorTenon’s
capsule sutures. The larger implant reduces the volume deficit
in the superior and inferior sulcus, preventing enophthalmos
which can be produced by smaller implants130.
Postoperative complications may develop during the first
few weeks following surgeiy. Early extrusion of the implant
may occur secondary to orbital hematoma formation and infec­
tion, traumatic manipulation of the tissues, or placement of too
large an implant, thus creating excess tension on Tenon’s cap­
sule. Hie technique of wrapping the orbital implant with fresh
or preserved scleral tissue is thought to be a deterrent for extru­
sion and migration of the implant, and it is a technique used
quite frequently with enucleation127.
After enucleation, a plastic conformer and corticosteroid
antibiotic ointment is placed in the socket. The conformer should
fit the contour of the socket and fill the depths of the fomices.
The conformer should not be removed by the patient, and should
419
be unnecessary, as it is designed with drainage holes to allow
mucoid discharge to escape and for insertion of postoperative
medication. The plastic conformer is left in place for 4 to 6
weeks to reduce edema and maintain the socket contours for
the prosthetic eye. Following healing of the anophthalmic socket,
a stock or custom eye should be placed temporarily for cos­
metic and psychological reasons.
Materials and types o f ocular implants The first material used
for orbital implants was glass. Mules introduced the hollow
spherical glass implant in 1884, which is still used today and
preferred by many ophthalmologists. Since that time, many
materials have been tried, including cartilage, fat, bone, silk,
wool, aluminum, cork, ivory, Vaseline, and paraffin.
Ocular implants are classified as integrated, semi-integrated,
nonintegrated, and either buried or non buried. The 3 basic types
of ocular implants are shown in Figure 9-49. Integrated im­
plants are designed to improve prosthesis motility by coupling
to the overlying prosthesis (Figure 9-50). In the past, many in­
tegrated implants have been non-buried; that is, exposed through
the conjunctiva to be directly coupled to the prosthesis with a
peg, pin, screw, or other method131.
Rudermann introduced the first partially exposed, non-bur­
ied, integrated implant132. Extraocular muscles were attached
with a tantalum mesh screen for improved motility. These non­
buried, integrated implants had limited success due to extru­
sion, migration, and excessive infection rates. They were aban­
doned by the 1950’s.
The buried, semi-integrated ocular implants (e.g., Allen
implant, Iowa implant, Universal implant) consist of an acrylic
resin implant with 4 protruding mounds on the anterior surface
(Figure 9-51). These acrylic resin mounds on the implant pro­
trude against the encapsulating tissue. When an ocular prosthe­
sis is made, a counter contour to the implant is formed on the
posterior surface of the prosthesis. Vertical and horizontal val­
leys traversing the implant’s anterior surface accommodate the
rectus muscles and allow their imbrication at the points of cross­
ing, resulting in excellent movement of the implant. Since this
implant is buried, there is always tissue between the implant
and the ocular prosthesis. The “keying” affect of the protmding
tissue mounds against the ocular prosthesis provide excellent
support and motility133.
One of the more common complications of the Iowa im­
plant was the exposure of the resin mounds with time, resulting
in implant extrusion. The extrusion rate for the Iowa implant,
however, is reported to be similar to other implants134. This type
of implant is contraindicated for patients with marked congeni­
tal nystagmus, or in conditions with severe scaring, such as pem­
phigus, trachoma, and severe posttraumatic or postoperative
scarring. Additionally, this type of implant requires an excel­
lent fit of the custom prosthesis127.
420 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 9-50. Hydroxyapatite-integrated implant with round
methylmethacrylate motility peg.
Fig. 9-52. Buried, nonintegrated Mules acrylic sphere im­
plant.
Fig. 9-53. Solid acrylic resin 18 mm sphere implant com­
pared to porous coral-derived hydroxyapaptite 18
mm sphere implant.
The buried, nonintegrated implant is the most common
method of replacing volume loss in the socket following enucle­
ation or evisceration. The implant consists of a hollow or solid
acrylic resin sphere (e.g., Mules’ sphere), ranging from 10 to 22
mm in diameter (Figure 9-52). An implant 19 mm or greater in
diameter should be used with discretion, since they have a greater
tendency to crowd the fomices of the lids and to impede pros­
thetic movement135. Pressure necrosis and superior lid ptosis
are also problems associated with an oversized implant. How­
ever, it is important to replace the volume in the socket. Reten­
tion of a comfortable and esthetic prosthesis should be the pri­
mary consideration.
Success has been reported using a simple acrylic resin
sphere as a nonintegrated, buried implant in enucleated eye sock­
ets. The spherical surface is easy to fit with the prosthesis, and it
tends to minimize pressure and friction. Shields did not observe
any extrusion or infection of this implant in 1,000 consecutive
cases during a 15-year period136. However, prosthesis motility
was limited due to lack of coupling of the implant to the pros­
thesis.
Hydroxyapatite integrated ocular implant During the
past decade, coralline hydroxyapatite has been used as a substi­
tute for autogenous bone in a variety of surgical procedures.
Since 1985, porous hydroxyapatite has been used as an ocular
implant for reconstruction after enucleation and evisceration.
This form of implant was approved by the Food and Drug Ad­
ministration for orbital implantation in 1989. The technique was
developed by Perry137. This integrated, non-buried implant pro­
vides a more natural appearance because of the increased mo­
tility of the artificial eye. The ocular prosthesis is connected to
the vascularized hydroxyapatite implant through a surgically-
placed acrylic resin peg, which transfers the increased motility
of the implant to the prosthesis136. Patients exhibit darting eye
movements, which are normally not seen with conventional
ocular prostheses (Figure 9-53).
Coralline hydroxyapatite as an ocular implant appears to
offer significant advantages, as compared with previously used
materials. Unlike early integrated implants, hydroxyapatite is
completely buried beneath Tenon’s capsule and conjunctiva. The
central hole for the motility peg is lined with conjunctiva mu­
cosa, so the implant is not exposed. The implant is a simple
sphere without the projecting mounds that might erode the con­
junctiva. The hydroxyapatite consists of interconnecting pores
500(1 in diameter138. After 4 to 6 months, the implant becomes
fibrovascularized in the orbit, making it unlikely to extrude be­
cause it is biologically fixed to the investing soft tissues. The
implant is less likely to become infected, since it is incorpo­
rated with host blood vessels and immune defenses are im­
proved139.
Prior to insertion, the hydroxyapatite implant is wrapped
in a scleral shell obtained from an eye bank. Windows are made
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 421

in the sclera, exposing the hydroxyapatite, to allow attachment

of the extraocular muscles and promote fibrovascular growth
within the implant (Figure 9-54). Attachment of the extraocular
muscles in their approximate anatomical positions allows nearly
full motility of the implant. The integration of the implant and
prosthesis through the motility peg transfers this exceptional
implant movement to the artificial eye.
In order to allow time for complete vascularization, the
drilling of the central hole for the motility peg is performed 5 to
6 months after implant placement. A bone scan or MRI should Fig. 9-54. Scleral-coated hydroxyapatite implant with win­
be performed first to determine if an ample blood supply is avail­ dows cut at proposed sites of rectus muscle at­
able to support tissue growth into the drilled implant hole. The tachment. Windows provide ingrowth of fibrovas­
hole is drilled as a secondary procedure and is performed under cular tissue.
local anesthetic. A surgical guide stent is strongly suggested to
aid in drilling the guide hole in the proper position (Figure 9-
55). The guide hole is drilled in the area of the corneal promi­
nence, which is the thickest portion of the ocular prosthesis.
This will allow ample acrylic resin for placement of the 5 mm
wide by 3 mm deep peg recess hole.
A point is marked through the stent onto the conjunctiva,
and a 12 mm deep by 3 mm wide hole is drilled into the hy­
droxyapatite implant (Figure 9-56). A flat plastic healing peg is
then inserted to maintain the integrity of the hole while epithe­
lial growth develops into and around the drilled hole. The ocu­ Fig. 9-55. Surgical guide stent with 3 mm guide hole posi­
lar prosthesis or conformer is replaced into the socket and over tioned at the corneal prominence. Stent made
the healing peg, and is worn for 6 weeks to ensure adequate from clear ocular acrylic resin, with anterior sur­
healing. The healing peg should not be replaced with the motil­ face cut back so the hole will not bind the drill.
ity peg too soon or necrosis may result around the hole. When
epithelial tissue can be seen in the peg hole, the healing peg
may be removed by wiggling it slowly with a small hemostat to
break the suction. The healing peg is then exchanged with the
sterile motility peg (Figure 9-57).
There are 2 methods of fabricating integrated ocular pros­
thesis. The first method is to make a custom acrylic resin eye
from an impression of the intaglio surface of the implant and
motility peg. Lid contour, symmetry, and exact coupling of the
recess well to the motility peg can be evaluated at the wax try-
in stage, before processing in acrylic resin. Fig. 9-56. Drilling of motility peg hole.
The second method utilizes the patient’s existing ocular
prosthesis or a stock eye. The ocular prosthesis is placed into
the socket prior to removal of the flat healing peg and com­
pared with the companion eye for proper size, gaze, and sym­
metry of the lid. Once these aspects are satisfied, the patient is
instructed to gaze straight ahead at a fixed point, and a small
amount of alginate impression material is placed on the tissue
surface of the ocular prosthesis then inserted into the socket
under slight pressure. After the gaze of the prosthesis is evalu­
ated, it is removed and the impression examined to ensure that
the surface of the flat healing peg has been properly recorded. Fig. 9-57. Round motility peg is placed in implant, which will
The prosthesis is flasked, processed in acrylic resin, and care­ support and provide the quick, darting movements
fully polished. The flat, round spot indicating the position of of ocular prosthesis. Note extensive vascular tis­
the peg on the back of the ocular prosthesis is used as a tem­ sue growth after 6 months.
422 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 9-58. Posterior surface of ocular prosthesis showing the
5 mm wide and 3 mm deep recess for round mo­
tility peg.
Fig. 9-59. Completed prosthesis with outstanding retention
and movement.
Fig. 9-60. Ptosis due to volume loss between implant and
lids.
Fig. 9-61. Ocular prosthesis corrects ptosis and restores
symmetry and contour of eyelids.
plate to drill a 5 mm wide and 3 mm deep recess for the motility
peg (Figure 9-58). The ocular prosthesis is evaluated for fit and
delivered to the patient (Figure 9-59).
Complications in fitting the anophthalmic socket Following
enucleation or evisceration, the condition of the socket, fomices,
and lids may create problems with the fitting of the ocular pros­
thesis. It is not uncommon for an implant to migrate into a su­
perior, inferior, medial, or lateral position within Tenon’s cap­
sule. Implant migration may cause superior lid drooping, loss
of motility, pressure necrosis, and an inadequate space to retain
the prosthesis. With excessive implant migration, a prosthesis
may not achieve acceptable cosmetics and function within the
socket. A consultation with an ophthalmologist for surgical cor­
rection is required.
Ptosis Superior eyelid ptosis is a frequent problem in the
restoration of the anophthalmic patient True or persistent pto­
sis of the upper lid may result from accidental trauma, surgical
trauma, or separation of the third cranial nerve from the levator
muscle140. Making a large prosthesis to wedge the eyelids apart
is a poor method to correct this problem, as a downward gaze
with poor retention usually results. An understanding of orbital
anatomy and appropriate recontouring will improve the pros­
thesis in most instances.
Pseudoptosis is due to the loss of volume between the im­
plant and the lids after removal of the eye (Figure 9-60). If the
physiological function of the eyelids is intact, correction of
pseudoptosis is achieved by increasing the volume of the pros­
thesis in the socket (Figure 9-61). This condition usually occurs
whenever a small, poorly-fitted prosthesis is used. Pseudopto­
sis is also due to microphthalmos, enophthalmos, or phthisical
globes which can be corrected with a scleral shell prosthesis141.
A simple technique of correcting pseudoptosis is to make a
“larger prosthesis” that will thrust forward and separate the eye­
lids. This is achieved by adding wax above the iris and extend­
ing posteriorly beyond the superior margin to reduce the ptosis
while keeping the iris, cornea, and pupillary segments properly
aligned142. After correction is achieved, the wax is converted
into acrylic resin and delivered to the patient.
Persistent ptosis requires modification of the ocular pros­
thesis to correct for a deficient levator muscle which causes the
upper eyelid to droop. Attempts aimed at increasing the size of
the ocular prosthesis, as seen in pseudoptosis, will not correct
the problem in persistent ptosis. The tension on the superior lid
forces the larger prosthesis downward, thus depressing the lower
eyelid, deflecting the gaze downward and creating patient dis­
comfort126.
Correction of persistent ptosis requires a specially config­
ured prosthesis (Figure 9-62). The patient’s existing prosthesis
can be reshaped and modified to correct this problem; however,
this method is not recommended, since it is more time-consnm-
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
ing and the iris gaze is usually not appropriate. The best method
is to use a wax pattern which can be adjusted freely in size,
form, and alignment. The existing prosthesis can be either du­
plicated in wax, or an impression of the socket can be made to
custom form the wax pattern to the contours of the implant,
fomices, and available space.
The first step to correct a ptosis, as described by Allen and
Webster126, is to extend the anterior surface of the prosthesis or
wax model forward, matching the prominence of the cornea of
the companion eye while wedging the eyelid margins apart. If
this corrects the problem, the patient is then considered to have
pseudoptosis. If ptosis is still evident, the following additional
steps are indicated.
Resin is removed from the top surface, near the tissue sur­
face of the prosthesis, to allow the tarsal plate to rotate back­
ward. A 11.5 mm flat plane must be created to accommodate
the normal vertical width of the superior tarsus. This allows the
upper eyelid to rotate upward and backward around its hinges,
which are formed by the insertions of the palpebral ligaments
into the bony orbit. Allen compared the leather-like tarsus, palpe­
bral ligaments, and insertions to an inverted hammock142. As
pressure is applied to one edge of a hammock, it rotates away
from the pressure and around the axis between the points of
suspension. The space on the superior and tissue surface of the
prosthesis is the space into which the edge of the hammock
must swing.
After this step, the upper eyelid should be compared with
the companion eye for correct symmetry and dimension. Often,
the lower lid will sag following reduction for ptosis, but this
can be corrected by relieving the anterior-inferior aspect of the
prosthesis just below the limbus. This extension in the prosthe­
sis will generate pressure against the inferior tarsus and elevate
the lower lid.
423
One final step may be required if the superior margin of
the eyelid still droops. The superior tissue surface of the pros­
thesis is extended upward until all the space in the superior fomix
is occupied. This projection must be at least 11.5 mm from the
intended margin of the eyelid to accommodate the tarsal plates.
This extension of the prosthesis is to use up any excess con­
junctiva and create a bend in Mueller’s muscle and the levator,
thus shortening the span of the tarsus-Miller’s muscle levator
complex and raising the margin of the upper eyelid.
The size and extension of the superior ridge will depend
upon the potential space in the superior fomix. In some sockets,
there is little space and a ridge extension will force the prosthe­
sis downward. In other sockets, ridges 4 mm in height and 3
mm in width may be placed. Displacement of the prosthesis
will dictate the size of the ridge.
Extended shelf When these methods fail to correct ptosis,
a thin transparent shelf can be made across the front surface of
the eye to hold the upper eyelid at the desired open position.
The shelf is 3 to 4 mm wide and is placed along the upper lim­
bus. This modification of the prosthesis works well for ptosis
caused by a superiorly migrated, large, spherical implant with
limited socket space between the implant and the upper eyelid.
The major drawback to the shelf is that the eye cannot blink
or close. The weight of the upper eyelid and the action of the
orbicularis muscle may press the eye downward. This may be
corrected by adding material to the inferior tissue surface of the
prosthesis to contour it backward and upward. The surface above
the shelf can be reduced to decrease the weight of the prosthesis
and to create space for a tight upper eyelid.
Ectropion Inferior displacement of the implant can lead
to the loss of the inferior fomix and cause ectropion of the lower
Fig. 9-62.
Correction of persistent ptosis. Left: Cross sec­
tion drawing of an eye socket with ptosis of the
upper eyelid. Iris-cornea gaze is directed down­
ward. Center: Cross section of modified pros­
thesis: (a) superior aspect of prosthesis reduced
for tarsal plates, (b) material added to anterior
corneal area to steeper curve, (c) anterior-infe-
rior surface of prosthesis reduced, and (d) ma­
terial added to posterior-superior edge of pros­
thesis to buckle levator and lift margin of eye.
Right: Cross section of socket after modifications.
Superior extension of ocular prosthesis correct­
ing ptosis.
424 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

lid. Patients have difficulty with retention of the prosthesis, since

it has a tendency to slip down and out over the everted lower
lid. As in the correction of ptosis, an impression should be made
of the socket and a wax pattern fabricated.
The wax pattern is modified by extending a thin lower edge
that will press downward upon the tarsus, and rotate it into a
more vertical plane, thus creating a lower fornix. The lower
edge should be rounded and at least 1 mm in thickness so it will
not cut into the socket. The lower fornix will deepen within
minutes of modification, and insertion of the prosthesis and re­
tention will improve (Figure 9-63).

Contracted socket Contraction of the anophthalmic socket

is extremely difficult to manage prosthetically. Ectropion of the
upper and lower eyelids is a common result of reduction in the
volume of the socket. Prosthetic modification consists of re­
moving resin from the superior-anterior and inferior-anterior
portions of the prosthesis to direct the acrylic resin lids into a
more acceptable physiologic and cosmetic position. Material is
added to the comeal aspect to maintain lid contour. Surgical
correction is often the only predictable method of successful Fig. 9-63. Correction of ectropic lower lid. a: Cross section
treatment140. of socket with ectropic lower lid and shallow fornix,
b: Cross section of socket after modifications. In­
Sagging lower eyelid The weight of the prosthesis, per se, ferior extension of prosthesis creating lower fornix.
and the contraction force of the upper eyelid on the prosthesis
can cause a downward displacement of the lower lid. Degen­
erative disease may also weaken the lower eyelid, causing it to
droop. By removing resin from the mid inferior margin of the
prosthesis, downward pressure against the middle of the lower
fomix is relieved. Wax is added to extend the nasal and tempo­
ral aspects of the inferior margin to create pressure in the me­
dial and lateral areas of the lid. This directs the weight of the
prosthesis where the lower eyelid is strongest, near the palpe­
bral ligaments. These modifications tilt the tarsus of the lower
eyelid favorably so that the eyelid margin is elevated (Figure 9-
64). Fig. 9-64. Correction of sagging lower lid with modified pros­
thesis (solid line).
Fabrication o f ocular prostheses* When the surgical site is
well-healed and dimensionally stable, fabrication of an ocular ful information and guidance. Pictures of patients treated previ­
prosthesis can begin. A thorough examination of the enucleated ously can also be useful.
socket must be made to ensure proper healing and the absence There are various techniques used in fitting and fabricat­
of infection. The location of the implant, the movement of the ing artificial eyes. In the past, empirically fitting a stock eye
tissue bed, and the size and extent of the socket should be noted. was a popular method, and it is still in use today. This method
The psychological status of the patient should also be assessed involves modifying a stock shape by grinding and repolishing
relative to the ability of the patient to accept a prosthetic eye. the surface of the eye, and trial-and-error fitting the borders of
Most patients will have a very limited knowledge regarding the the prosthesis into the socket This method relies heavily on
fabrication, use, care, expectations, and acceptance of the pros­ intuition and the ability to visualize the anatomy and contours
thetic eye. While some patients will have realistic expectations of the socket.
and be somewhat philosophical about their loss, others will not A more precise method of fitting artificial eyes is the modi­
be so predisposed and will require considerable education. Of­ fied impression technique. This method employs the use of an
ten, the primary care physician or the surgeon can provide help- impression to establish the initial contours of a trial wax shape,

Section on fabrication o f ocular prostheses contributed by John A. Kennedy; figures provided by Gregory A. Waskewicz.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 425

and modifying this shape to establish the proper fit and support rial to set quickly. Once mixed, the impression material is placed
of the socket and eye lids. Variations of the modified impres­ into a 10 cc disposable plastic syringe. Enlarging the opening
sion technique have been developed over the years to suit the of the syringe tip will facilitate expression of the impression
individual ocularist. These variations all have some common material. The syringe is inserted into the end of the hollow handle
traits, such as the use of impression trays, impression material, while simultaneously grasping the tray handle with the other
and a trial shape usually made of wax. An impression can be hand. The impression material is injected into the socket through
used at various stages in the fitting procedure. An impression the tray until the material begins to flow out of the socket and
can also be made by using an artificial eye as the tray. retention holes in the tray (Figure 9-65). Throughout the injec­
Today, ocular prostheses are fabricated in acrylic resin. tion procedure, the operator must check to see that the tray does
Although the material is standard, some variations in technique not become dislodged. An alternative is to place alginate im­
exist, such as the use of a microwave oven for processing, length pression material into a disposable syringe and, while gently
of processing times, and the methods of assembly of the com­ separating the lids, the impression material is deposited along
ponent parts of the prosthesis. The following is a detailed de­ the inner side or the palpebral opening, allowing it to flow across
scription of a common method of fitting and fabricating a cus­ the base of the socket and drive out air and lacrimal fluid. Ex­
tom ocular prosthesis. cess material is ejected over and around the lids, and a pre­
formed-perforated tray is held over the orbital area.
Impressions An impression of the socket is made with an After the material sets, the cheek, nose, and eyebrow re­
ophthalmic irreversible hydrocolloid* in conjunction with a suit­ gions are massaged to break the seal. While the patient gazes
able impression tray. Stock acrylic resin impression trays** are upward, the cheek is pulled down and the inferior portion of the
available in different sizes for ophthalmic impressions. These impression is rotated out of the socket. The impression is checked
trays have a hollow handle which accommodates an impres­ for accuracy and voids (Figure 9-66). Excess impression mate­
sion syringe. The alginate material may then be injected directly rial is trimmed with scissors. The operator should remove all
into the socket through the seated tray during impression mak­ but a slight indication of the palpebral fissure section of the
ing. In addition, custom impression trays can easily be made impression. This landmark will be used to locate the nasal and
from dental tray material.*** temporal canthus.
The procedure begins by selecting a tray that will fit in the
enucleated socket passively. Slight discomfort may be caused
by the-handle of the tray or from a tray that is too large. An
oversized tray can distort the fatty tissues and eye lids, resulting
in an inaccurate impression. Comparing the palpebral fissure
with the patients natural eye can aid in determining the correct
tray size to use for the impression. To insert the tray, lift the
upper eye lid, grasp the tray by the handle and slip it in behind
the upper lid. Release the upper lid, pull the lower lid down,
insert the inferior border of the tray into the lower lid fomix,
and then release the lower lid.
The patient is seated in an erect position, with the head
tilted backward at approximately 45 degrees, while the socket Fig. 9-65. Irre ve rsib le h ydrocolloid being injected into
is being filled with the impression material. Once filled, the socket.
head is moved back to the vertical position and the patient is
directed to move their eyes both up and down. This will facili­
tate the flow of the impression material into all aspects of the
socket. Next, the patient is asked to look at a distant spot at eye
level with his or her gaze maintained in a forward direction.
This will ensure that the posterior aspect of the enucleated socket
and tissue bed will be in the correct position for the fitting pro­
cedure.
The ophthalmic irreversible hydrocolloid is mixed in a 30
ml medicine cup, using approximately 5 ml of powder to 5 cc
of room temperature water ratio. The alginate should be a warm,
runny mix so it will flow easily and not distort the fatty tissues
in the socket. The warm water will allow the impression mate- Fig. 9-66. Completed impression.

Prosthetic Grade Cream, Teledyne Getz, Elk Grove, IL.

American Optical Corp., Southbridge, MA.
Coe-Sep, Coe Laboratories, Chicago, IL.
426 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Formulation o f the cast The impression is poured in 2

sections, using a 30 ml medicine cup filled halfway with dental
stone. Dental stone is added to title posterior surface of the im­
Impression material pression and then placed into the medicine cup, up to the ante­
rior of the posterior edge of the impression, and allowed to set.
Two keyways are made, 1 each adjacent to the region of the
nasal and temporal canthus (Figure 9-67). The stone is coated
layer of stone with a separating medium, such as a tin foil substitute*, and
allowed to dry. The second half of the mold is poured with den­
tal stone, leaving a funnel-shaped hole around the stem of the
1st layer of stone
tray. This hole will be used as a funnel to fill the mold with
rim of cup molten wax. After the dental stone has set, the 2 halves of the
mold are separated and the impression material is removed (Fig­
ure 9-68).
Fig. 9-67. Diagrammatic representation of one-half of the
cast prepared. Wax pattern A dental ladle is used to melt sticks of ivory
inlay wax** over a Bunsen burner in preparation for making the
wax pattern. After the wax has melted, it is poured through the
funnel-shaped hole and into the assembled mold. Additional
wax should be poured into the mold, as the wax shrinks signifi-
cantiy as it cools. Soaking the mold in water for a few minutes
prior to filling it with molten wax will prevent the wax from
adhering to the stone.
After the wax has cooled, the mold is opened and the wax
pattern is recovered (Figure 9-69). With a knife, the ridge of
wax that represents the palpebral fissure is trimmed and
Fig. 9-68. Separated master cast. recontoured into a smooth hemispheroid. The nasal and tempo­
ral canthus on the wax pattern are located by using the keyways
that were made on the posterior section of the mold. A thin line
is scored about 1 mm deep across the anterior curve of the wax
pattern, from the nasal to the temporal canthus. This line is filled
with red wax. The wax pattern is tried in the socket repeatedly
while being sculpted to the correct shape. The red line will aid
in determining what changes have occurred when it is placed in
the socket for evaluation. The posterior surface of the pattern
will reflect the topography of the tissue bed of the socket, in­
cluding indentations from fatty tissue, scar bands, or the pres­
ence of an ocular implant. Bubbles and other irregularities are
removed from the posterior surface of the pattern. Once the
wax pattern has been smoothed and polished, it is ready to be
tried in the eye socket (Figure 9-70). To insert the wax pattern,
the upper lid is lifted and the superior edge of the pattern is
placed behind the lid and gently pushed upward. While draw­
ing the lower lid down, the inferior border of the pattern is seated
in the inferior fornix, and then the lower lid is released.
The wax pattern will feel comfortable to most patients, but,
in some instances, it may cause mild irritation. A few moments
may be needed for the eye muscles to relax so that contours can
be evaluated. The wax will not move as freely as the finished
acrylic resin prosthesis, but the application of an ophthalmic
lubricant*** will aid movement. Pressure points or areas of dis­
Fig. 9-70. Wax sclera in position. comfort should be noted and relieved as necessary. When the

Coe-Sep, Coe Laboratories, Chicago, BL.

** Ivory Inlay Wax, Kerr, Emeryville, CA.
*** Lacri-lube, Alergan, Irvine, CA.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 427

patient is comfortable, the eye contours and lid configurations
are checked from several angles (Figure 9-70). In ideal situa­
tions, the contours and palpebral fissure should resemble the
patient’s natural eye. The eyelids should close completely over
the wax pattern. Without complete lid closure, mucous and dried
tears accumulate on the anterior curved surface of the prosthe­
sis, leading to irritation of the adjacent tissues.
Iris position Once the appropriate contours of the wax
pattern have been developed, the gaze and position of the iris is
determined. The wax pattern is inserted in the socket and the
patient instructed to look straight ahead at a distant point.
Anophthalmic, or 1-eyed, patients sometimes favor their sighted
side, and they will turn their head slightly when looking at an
object. Using the companion live eye for comparison, the iris
position is located on the wax pattern with an indelible marking
pen. Once the position is verified, the wax pattern is removed.
To help visualize the iris position, a circle is scribed with an
architects compass on the wax pattern that is the correct diam­
eter of the iris. The pupil is used as the center of this circle. A
straight piece of #10 gauge, round sprue wax, about 1 cm long,
is attached to the center of the pupil. The wax pattern is in­
serted. While the patient is looking straight ahead, the #10 wax
stem is pointed so it is pointing to the same spot as is the natural
eye (Figure 9-7,1).
The size and location of the iris must match that of the
companion live eye. This is verified by sight and by measuring
with a millimeter rule, using the inner canthus and inner edge
of the limbus as points of reference. The location of the iris, in
relationship to the opening of the lids, must also be considered.
Usually, the upper lid covers a portion of the upper half of the
iris, whereas the lower border of the iris rests at or slightly above
the lower lid.
Porosity is reduced if the resin is processed at 150°F for 9 hours
followed by 212°F for 2 hours.
Selection o f iris components Ocular discs**, which are
used in the iris painting, are available in half-millimeter-sized
increments, ranging from 11.0 mm to 13.0 mm. They come in
black or clear, and either with or without pupil apertures. Clear
comeal buttons are available in the same sizes as the discs. The
buttons can also be purchased with pupils of various sizes al­
ready in place. To determine the correct size of the iris, the di­
ameter of the patient’s natural iris is measured with a millime­
ter ruler. The average diameter of the pupil is determined in
both full and subdued light.
Painting materials One method of painting is to use oil
paints or dry earth pigments mixed into a painting medium called
mono-poly. Mono-poly is a syrup of polymethylmethacrylate.
It is available commercially or by combining 10 parts of type I,
class I (heat cure) acrylic resin monomer to 1 part of type I,
class I clear acrylic resin polymer by weight. The monomer is
poured into a Pyrex beaker and placed in a pan of boiling water.
When the monomer is warm, the polymer is sifted slowly into
the monomer while stirring continuously with a glass rod. After
10 minutes, the solution obtains the viscosity of a light oil. Af­
ter the mono-poly has cooled to room temperature, it is poured
into a dark glass bottle and refrigerated.

Fabrication o f the sclera The wax sclera is now ready to

be invested. Either a denture flask or a round ocularist flask
may be used. After filling the lower portion of the flask with
dental stone, stone is carefully vibrated onto the posterior sur­
face of the wax pattern. The wax pattern is laid on top of the
stone in the flask, taking care not to entrap air. The stone should
not overlap the anterior-posterior border of the wax pattern. After
the stone has set, it is coated with a separating medium, such as
a tinfoil substitute. The flask is reassembled, the upper half of
the flask is filled with dental stone, and the flask lid is placed on
top to close the mold.
After the stone has set, the flask is separated by gently pry­
ing it apart. No boil-out is necessary. The wax pattern is lifted
out and the mold is checked for voids. The wax stem is also
removed from the mold. After the mold is cleaned, a coat of
tinfoil substitute is applied to both sides. White scleral acrylic b
resin* is packed into the mold, using the compression method. Fig. 9-71. a and b: Wax sprue must point to same spot as
does the companion, natural eye.

* American Optical Corp., Southbridge, MA.

** Factor n , Lakeside, AZ.
428 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

The colors commonly used in painting are cobalt blue, al­
izarin crimson, yellow ochre, burnt sienna, burnt umber, lamp
black, and titanium white; however, other colors may be used
occasionally. Small quantities of each oil paint color are placed
on a glass or plastic palette. When a color is selected, it is mixed
with 1 or 2 drops of heat-cured monomer, and to this mixture a
smaller amount of mono-poly is added. The oil paint and mono­
poly mixture will dry very quickly. Adding more monomer to
the mix will increase the painting time.
Pupilfabrication Pupils can be made in various ways. If
an ocular disc with a pupil aperture is being used, placing an­
other black disc behind it will create the pupil. If a solid ocular
disc has been selected, then either painting a pupil directly on
the disc, or punching out a pupil made from a dried sheet of
black mono-poly syrup can be used. Finally, a comeal button,
with the appropriate pupil size already in place, can be used
when gluing the painted disc and comeal button together.
of mono-poly is applied to the painted surface. Immediately,
the comeal button is positioned on top of the painted disc and
pressed down lightly until excess mono-poly is forced out and
the corneal button is seated firmly on the disc (Figure 9-73).
Light pressure is continued for 30 to 60 seconds. The assembly
is allowed to dry for about 30 minutes. The button is now ready
to be inserted into the mold (Figure 9-74). Using the stem on
the comeal button as a guide, the button is positioned in the
mold where the wax stem had previously been located. A suffi­
cient amount of the stem is removed from the comeal button to
permit the curved surface of the cornea to seat in the mold.

Painting the iris and sclera There are 5 basic compo­

nents to painting an iris; namely, the pupil, the base color, the
detail, the collarette, and the limbus (Figure 9-72). Iris painting
is usually completed in 2 stages. This technique gives the iris
greater depth and a more lifelike appearance. To begin, the ba­
sic color of the body of the iris is selected. The background
color between the collarette and the limbus is used as a guide­
line. This base color is usually blue, gray, green, brown, or a 9-72. Iris anatomy.
combination of these colors, and it will vary in both chroma
and value. The addition of a small amount of white and black to
this base color will help opaque the color and block out the
black disc. The black disc is painted to match the body color.
Each brush stroke is layered over the previous one. This helps
to suggest striations in the iris and also create depth in the paint­
ing. The correct colors of the iris can be developed by adjusting
the 3 principles of color (hue, chroma, and value) to match the
patient’s natural iris. To evaluate the color match, use either a
drop of water or a custom made painting lens. Water is placed Fig. 9-73. Painted disc adhered to corneal button.
on the iris painting and compared with the natural eye. The use
of the painting lens or water droplet magnifies and intensifies
the light on the painted surface, making the painting appear
slightly lighter in color. This technique allows the artist to visu­
alize what the true hue, chroma, and value of the painting will
be in the finished eye prosthesis. The first stage of the iris paint­
ing is now complete. The iris disc should have the basic back­
ground colors of the patient’s natural eye. One or 2 coats of the
mono-poly syrup is applied to the painted surface of the iris
disc and allowed to dry.

Adhering the painted disc to the comeal button and pro­

cessing To adhere the painted disc to the comeal button, the Fig. 9-74. Mold ready to receive disc-corneal button assem-
disc is placed on a flat surface painted side up. One or 2 drops bly.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
In a clean jar, 6 cc of scleral polymer is mixed with 2 cc of
type I, class I monomer. Once the acrylic resin is in the dough
stage, it is added to the top of the button, and the 2 halves of the
flask are united and pressed together under pressure. The resin
is processed in a curing tank, starting with cold water. Gradu­
ally, temperature is increased to a boil. Processing should take
about 1 hour. Once boiling is achieved, the flask is removed
and allowed to cool in water. The flask is separated and the eye
prosthesis removed.
Scleral and second iris painting The following steps de­
scribe the procedures used to reduce the anterior curvature of
the prosthesis to allow room for the scleral painting and sec­
ond-stage iris painting. Reducing the anterior curve also pro­
vides space for the application of a 1 mm layer of clear acrylic
resin. The clear layer gives the eye a very realistic appearance,
once processed and polished.
The anterior curvature of the eye is reduced approximately
1 mm with a pear-shaped bur. Excess flash from processing is
removed, and the clear cornea is then reduced, stopping just
short of the iris painting. The surface of the reduced cornea
should be at the same angle as is Ihe iris painting. A small, 2
mm shoulder or land area should extend beyond the outer edge
of the iris. Next, depth grooves are cut about 1 mm deep, radiat­
ing outward from the land area to and including the borders of
the eye. The remaining ridges are blended to the level of the
depth grooves. A fine, white stone is used to smooth the ante­
rior surface. For cosmetic concerns, the edge of the nasal cor­
ner is the only area along the borders of the eye that is not re­
duced. Once the anterior curve has been reduced and smoothed,
a layer of mono-poly is applied and allowed to dry. The eye is
now ready for the second-stage iris painting.
The patient is seated and the iris painting is evaluated, us­
ing the painting lens. The painting is done in similar fashion as
was the first-stage painting. During the painting procedure, the
operator must pay attention to the small flecks of color as well
as the type and amount of radiating spokes of the companion
eye. The spokes of the iris are painted by using either a small,
triple-O brush, or by flaring the hairs of a larger brush. When
adding details, change in value and chroma should be noted
and corrections made. Between each layer of paint, a thin layer
of mono-poly is applied to protect the paint underneath from
being disturbed by the monomer.
The collarette, which is a circular area or star-burst found
around the outside border of the pupil, is painted. The collarette
is usually a lighter and/or a brighter color than the body of the
iris. In brown eyes, the collarette is absent or may not be vis­
ible. Another very delicate ring of color, possibly brighter than
the collarette itself, is commonly found around the outer edge
of the collarette. This ring blends or disappears into the body of
the iris.
429
Finally, the limbus is added. This is the area around the
outer edge of the iris at the junction of the iris and the sclera.
The limbus can be described as a dark ring which blends into
the sclera. The color of the limbus varies from eye to eye, but it
usually is a combination of grays and iris body color. In the
natural eye, it can appear as a shadow from the overlapping
sclera, covering the edge of the cornea (Figure 9-75).
An arcus senilis, or “old age ring”, is commonly found in
elderly patients and seen, at first, superiorly and inferiorly along
the corneal periphery, sometimes forming a complete ring (cir­
cus senilis). It appears as a cloudy, milky ring around the edge
of the cornea, covering part or all of the limbus. The color of an
old age ring varies in each individual, but it will usually re­
semble a translucent, creamy grayish-white.
Fig. 9-75.
Iris painting is
b e in g c o m ­
pleted.
Scleral painting With completion of the limbus and ar­
cus, the second-stage iris painting is finished and our attention
is now drawn to the scleral painting. The natural sclera has veins
present that are usually apparent in both the nasal and temporal
comers of the eye. Red cotton fibers are used to replicate the
veins in the sclera (Figure 9-76). The fibers are separated and
cut from commercially available thread. The vein patterns of
the natural eye are copied by tacking the fibers to the sclera
with a brush and monomer. Note that excessive use of the fibers
can result in the appearance of a red or irritated eye. Once the
veining is finished, the sclera is recoated with mono-poly.
The colors found in the sclera are usually yellow and blue,
or combinations of these. Greens and browns can also be present.
In people of color, the sclera can be a mottled brown. The scleral
painting begins with the application of a wash of yellow com­
parable to that found on the patient’s natural eye. Next, blue is
added, which is usually located inferior and superior to the iris.
A small amount of red is added to the nasal comer to simulate
the caruncle. Finally, any characteristic details present in the
natural eye are added. Once complete, a coat of mono-poly is
applied to the sclera. The iris and scleral painting is compared
with the natural eye and final corrections are made. The pupil is
applied using one of the previously mentioned methods. A final
coat of mono-poly is added to the finished painting and pupil
and allowed to dry.
430 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Final processing The eye is now ready for the final pro­
cessing, the application of a layer of clear acrylic resin. A small
amount of heat cured (type I, class I) clear polymer and mono­
mer is mixed in ajar. The original molds are recoated with a tin
foil substitute and permitted to dry. The eye is placed into the
tissue side of the mold, anterior curvature facing up. The acrylic
resin dough is placed on the painted surface and the 2 halves of
the flask are united (Figure 9-77). Trial packing is not neces­
sary. Once the doughy resin is placed on the painted surface,
a the flasks should be assembled immediately; otherwise, the
acrylic resin dough can soften the painting, resulting in the paint
being moved or displaced when the flasks are pressed together.
The resin is processed as previously described. Processing time
can be reduced, since there is less bulk of resin to be cured.
Twenty minutes in boiling water usually suffices.
After processing, the flask is cooled and the ocular pros­
thesis retrieved from the mold. Hash and irregularities are re­
moved from the surface of the eye. The surface is smoothed
with a fine white stone and polished with flour of pumice.
b
Fig, 9„7e
Delivery and precautions The prosthetic eye is washed
a and b: Red cotton fibers used to replicate veins with soap and water and placed in the socket A drop or 2 of an
in sclera. ophthalmic lubricant on the surface of the prosthesis will facili­
tate insertion. The fit of the artificial eye and the lid configura­
tions of both eyes are evaluated, and adjustments are made as
necessary. The iris position and gaze are evaluated for proper
alignment. Small corrections can be made at this time, using
the techniques used in developing the wax pattern. It is possible
Fig. 9-77. to reposition the upper and lower lids slightly by reshaping the
Layer of clear acrylic resin anterior curve or borders of the eye. This is done by reducing
placed on painted surface small amounts of the clear layer, being careful not to grind into
and flask closed. the painted surface. Once you and the patient are satisfied with
the results, the prosthetic eye is polished, using a paste of tin
oxide and water. The prosthesis is cleaned and placed into the
socket (Figure 9-78). The method used for insertion and re­
moval of the prosthesis are demonstrated to the patient.
The wearing period for an artificial eye varies with each
individual. Most people can wear an eye for a month without
removing it—some much longer—while others remove their
artificial eye daily. Reduced tear production, such as found in
the elderly, may require the eye to be removed more often for
cleaning. Mild soap and water followed by rinsing with water
is all that is necessary to clean the eye. Yearly follow-up and
repolishing of the prosthesis is advisable. Some patients will
require the use of artificial tears to improve comfort and in­
crease the wearing time of the prosthesis. Artificial tears come
in various viscosities and are available without a prescription.
Weather conditions, such as wind or the lack of humidity, can
dry the surface of an artificial eye, and may adversely affect the
b
Fig. comfort of the prosthesis. Artificial tears can improve comfort
■ a and b: Finished prosthesis. under these conditions. If the eye is removed and not worn for
 Restoration o fFacial Defects: Etiology, Disability, and Rehabilitation
any period of time, it should be immersed in water. The clear
layer of acrylic resin can become clouded if the resin is exposed
to air for a prolonged period.
All materials used in the construction of the eye prosthesis
must be clean and free from foreign particles and debris. Intro­
ducing foreign particles, such as an eyelash, a small fleck of
wax from sculpting, or even the powder from examination
gloves, into the socket can cause discomfort and inflame the
conjunctiva. Trays should be soaked in a sterilizing solution
and thoroughly rinsed before use. If gloves are used, they should
be washed to remove the powdered coating. When removing a
wax pattern or an artificial eye, a commercially available rub­
ber suction cup* may be used, instead of fingers, to contact the
surface.
Patient instruction The methods of inserting and remov­
ing as well as caring for the prosthesis are demonstrated to the
patient. The prosthesis should not be allowed to come into con­
tact with alcohol or solvents of any kind, as this could cause
crazing of the acrylic resin. If the eye should become scratched,
it must be returned for polishing.
Modification o f a stock eye prosthesis A stock eye is selected
with the correct iris size, color, and approximate sclera shape.
The peripheral and posterior surfaces are reduced 2 to 3 mm,
and retentive grooves are cut into the posterior surfaces. A small,
straight stick is secured with sticky wax over the pupil, perpen­
dicular to the plane of the iris. This stick will act as a handle and
also guide for aligning the prosthesis in the correct relationship
to the natural eye.
A small amount of irreversible hydrocolloid is mixed with
warm water and placed on the posterior surface of the prosthe­
sis. With the patient looking straight ahead at a distant spot, the
prosthesis and impression material are fitted between the lids
and seated in the socket. Care must be taken to avoid trapping
air between the impression material and the tissue surface. The
handle is used to bring the prosthesis into correct alignment
with the natural eye and the lids are checked for opening and
contour.
The impression is removed and excess impression mate­
rial is trimmed appropriately. The stick handle is removed from
the anterior surface of the prosthesis. The prosthesis and im­
pression are invested in the lower half of a flask. After the stone
has set, 2 small projections of autopolymerizing acrylic resin
are attached to the canthus areas of the prosthesis. These pro­
jections will hold the prosthesis in the upper half of the flask,
retaining the correct relationship between the prosthesis and the
mold during the packing and processing procedures. Using a
separating medium on all exposed stone surfaces, the top half
of the flask is poured. The packing, processing, and finishing of
the prosthesis are accomplished as previously described.
American Optical Corp., Southbridge, MA.
Section on restoration of orbital defects written in collaboration with Michael O. Hamada.
431
Restoration of Orbital Defects**
Fabrication of esthetic orbital prostheses is a most difficult
challenge. Because conversation with others is often initiated
with eye contact, slight discrepancies in the position of the eye,
lid contour, or color of the prosthesis are immediately noticed
by the observer. In some patients, it may not be possible to du­
plicate the appearance and contour of the remaining normal eye
and adjacent orbital structures. In orbital defects in particular,
an unesthetic prosthesis creates more psychological trauma for
the patient than does no prosthesis at all143.
Preoperative consultation is valuable for informing the
patient of the nature of the defect and the choices available for
restoration. Unfortunately, many patients are under the impres­
sion that the prosthesis will move and function in concert with
the remaining eye. Photographs of prostheses restoring similar
defects are helpful in eliminating this misconception. In most
patients, it is not necessary to obtain preoperative photographs
or impressions, for they are of little value in fabricating the post-
surgical prosthesis.
Surgical resection of orbital tumors is dependent on the
nature and extent of the tumor. Resections that are confined to
removal of the orbital contents result in defects that are easier to
restore esthetically (Figure 9-79). As the surgical margins ex­
tend beyond the confines of the orbit, prostheses are less es­
thetic because of the inability to camouflage the lines of junc­
ture between skin and prosthesis. Additionally, as the prosthe­
sis extends beyond the orbit, movable tissue beds may be en­
countered, resulting in further exposure of the lines ofjuncture
(Figure 9-80).
The surgeon should be instructed to line the bony walls of
the orbit with skin. In most instances, attempts should not be
made to occlude the orbit with local or distant tissue flaps. After
such reconstructions, little room remains for placement of a
suitable orbital prosthesis. Moreover, recognition of recurrent
tumor may be delayed because the margins of the resection are
not clearly visible.
Impressions Accurate impressions of orbital defects are diffi­
cult to obtain because the periorbital tissues are easily displaced.
It is particularly difficult to avoid tissue displacement when
dealing with patients who have had a total maxillectomy as well
as an orbital exenteration, since the cheek area is no longer sup­
ported by bone (the zygoma is included in the resection). In
these patients, the definitive obturator must be fabricated, ap­
propriately contoured, and properly positioned and adjusted
before proceeding with impressions of the orbital area.
The purpose of the facial impression is to record the orbital
and periorbital tissue bed as accurately as is possible (Figure 9-
81). To do so, the patient must be placed in a semi-upright posi­
tion, and extreme care taken not to displace the tissue bed. Prior
to obtaining the impression, undesirable undercut areas should
432 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

be blocked out with petrolatum gauze. The field is isolated and

a thin layer of light body polysulfide impression material is ap­
plied to the defect and adjacent tissues (Figure 9-81 a,b). Un­
folded gauze is then embedded within the material, followed
by a thin layer of adhesive (Figure 9-81 c,d). Several thin layers
of fast-setting impression plaster are applied until sufficient sup­
port has been provided (Figure 9-83 e,f). The impression is then
removed (Figure 9-8 lg). During the procedure, the patient
should close the remaining eye in a relaxed manner. This will
prevent undesirable contraction of residual lid musculature on
the defect side and prevent distortion of the defect A cast is
then fabricated in dental stone. A hole should be drilled through
the posterior orbital wall to facilitate movement and adjustment
of the ocular portion of the prosthesis (Figure 9-8 lh).

Sculpting A stock ocular prosthesis that closely approximates

the color and size of the iris and sclera of the remaining eye is
selected. Usually, the ocular prosthesis must be reduced in size
superiorly so that it will fit easily into the orbital defect in the
b appropriate position. An orientation arrow is ground into the
Fig. 9-79. a and b: Resections confined to orbital contents backside of the stock eye, since this will greatly aid the techni­
are far easier to restore. Contours of adjacent tis­ cian during processing (Figure 9-82). Wax is used as the sculpt-
sues undisturbed.

Fig. 9-80. a: Orbital defect with total maxillectomy. Support lacking for tissues of the middle third of the face, creating signifi­
cant midfacial asymmetry. Obturator prosthesis provides support and restores most contours, b: Resection extends
beyond orbital area, distorting the brow, and extends into mobile tissues laterally and inferiorly. c: Lids were re­
tained. As a result, there is insufficient space to properly position orbital prosthesis, d: Orbital defect filled with flap.
Orbital prosthesis is impossible.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 433

Fig. 9-81.
Orbital impression, a: Field isolated, b:
Thin layer of impression material applied,
c: Layer of gauze, d: Layer of adhesive,
e and f: Several layers of impression plas­
te r applied to support the impression
material. First layer is kept thin to avoid
distortion of impression, g: Completed im­
pression. h; Master cast.
g h

Fig. 9-82. a: “Stock” eye reduced

in size so it will fit within
confines of cast, b: Note
arrow carved on poste­
rior surface, c: S tock
eye positioned in wax
on master cast, d: Eye
positioned on patient.

434 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
ing medium. The ocular prosthesis is lodged in the wax and the
entire apparatus is transferred to the patient. The patient should
be standing in a relaxed position with the remaining eye fo­
cused on a distant point. While a colleague holds the prosthesis
in place, the clinician evaluates ocular positioning. A reference
mark is placed at the midline and either a tongue blade, or a
Boley gauge can be used to verify mediolateral placement. The
pupils can be used as reference points in this evaluation. In pa­
tients with orbital exenteration defects that do not affect the
contours of the orbital rims or adjacent cheek, the mediolateral,
anteroposterior, and inferior-superior positioning of the ocular
prosthesis should mimic the position of the normal eye; that is,
if a successful prosthesis is to be fabricated. Discrepancies in
gaze and in superior-inferior position must be avoided. If the
patient also has had a total maxillectomy, a better esthetic result
may be achieved by moving the ocular prosthesis slightly me­
dially and posteriorly. Otherwise, it may appear proptoptic.
Before accepting what appears to be an appropriate ocular po­
sition, verification should be made by additional observers (Fig­
ure 9-83).
Fig. 9-83. Tongue blade used to assess position of ocular
prosthesis.
Fig. 9-84.
a: Lid and surrounding tissue
contours have been completed,
b: Lines of juncture are placed
behind eyeglass frames, c: Mar­
gins contoured to blend with ad­
ja ce n t skin, d: S ynthetic eye
lashes are positioned and lid
contours reverified. Lashes are
removed for processing, but are
replaced when the prosthesis is
completed.
'f t
At the next appointment, sculpting of the periorbital tis­
sues is effected. To ensure appropriate lid contour of the normal
eye, the sculpting should be performed during the middle of the
day. The patient should be rested and relaxed, for fatigue and
anxiety will affect lid contours dramatically in many patients.
Lid contours and periorbital tissues should mimic those of the
normal eye as closely as is possible. When the clinician has
completed the sculpting, he or she is advised to attach the syn­
thetic eyelashes selected previously to the underside of the up­
per eyelid. These lashes cast a shadow and occupy some space,
and their presence will impact on lid opening and contours. Fi­
nal adjustments to lid contours can now be made. All details
must be faithfully reproduced (Figure 9-84a). The lines of junc­
ture should be feathered and ended beneath the eyeglasses or
the shadows cast by them. Without the use of eyeglass frames,
the lines of juncture are quite apparent. Best results are obtained
in older patients with numerous lines and fissures of the perior­
bital tissues. If possible, the lines of juncture should not extend
beyond the area covered by the eyeglass frames, for such mar­
gins are difficult to camouflage. Plastic eyeglass frames are usu­
ally preferable to metal frames because they cast larger shad­
ows under which the lines of juncture can be positioned (Figure
9-84b). In addition, the orbital prosthesis can be attached more
easily to plastic frames, as compared with metal ones, if de­
sired. When completed, the wax sculpting is luted at both the
front and the back of the cast. Care must be taken to ensure that
the wax pattern effectively engages any useful undercuts.
Processing Fabrication of the mold begins by flowing stone
through the hole in the back of the cast, making sure to care­
fully engage the indicating arrow on the back side of the stock
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 435

eye (Figure 9-85b). The cast is then invested in a flask in the
usual fashion (Figure 9-26c). When the stone has set, the flask
is separated and the stock eye is secured to the index (Figure 9-
85 d,e). Silicone or another preferred material is then injected
into the flask and allowed to polymerize (Figure 9-85 f,g).
The prosthesis is processed in the favored material and
tinted either intrinsically, extrinsically, or both. Prosthetic eye­
lashes are attached to the upper lid prior to reinsertion of the
acrylic resin eye. We prefer to use commercially available syn­
thetic eyelashes, which are connected to the upper lid with ad­
hesive, making them easily replaced when they become dirty
or lose their shape, as opposed to sewing lashes into the silicone
(Figure 9-86). Since the lower lashes are quite scanty, they can
be simulated with a few vertical lines of extrinsic painting on
the lower lid. Eyebrows, if necessary, can be simulated either
by painting with eyebrow pencil or with a custom-made pros­
thetic eyebrow (Figure 9-87). A completed prosthesis is shown
in (Figure 9-88). Tinted lenses enhance the effectiveness of the
prosthesis.
Retention Tissue adhesives and/or engagement of undercuts
provide suitable retention for most defects. If the resection ex­
tends onto the cheek and movable tissues, the use of
osseointegrated implants is preferred (Figure 9-89). When eye­
glass frames are worn, care must be taken by the optometrist to
prepare the lens over the prosthesis so it is optically identical to
the lens covering the normal eye; otherwise, asymmetrical dis­
tortion of the prosthesis will be perceived. The patient should
be instructed to turn his or her head and direct the gaze of natu­
ral eye straight ahead rather than vary the gaze of the natural
eye. In this manner, the lack of eye movement of the prosthesis
will not be as noticeable.

e f g
Fig. 9-85. a: Cast reduced for flasking. b: Stone is poured through back side to engage posterior surface of ocular prosthesis.
c: Master cast is flasked. d: Flask separated. Note stone index engaging posterior surface of ocular prosthesis, e:
Ocular prosthesis attached to index, f: Silicone poured into mold, g: Polymerized prosthesis.

Fig. 9-86. Synthetic eyelashes attached to underneath sur- Fig. 9-87. Eyebrow painted onto prosthesis,
face of upper lid with adhesive.
436 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Craniofacial implants

Restoration of facial defects is a difficult challenge for the

a b
Fig. 9-88. a: Completed prosthesis, b: Lens are identical
bilaterally. Shaded lenses make prosthesis more
effective. Prosthesis was retained with skin ad­
hesive.
3HCPV
prosthodontist. In the past, prosthodontic restorations had dis­
tinct limitations due to movable tissue beds, lack of retention of
large prostheses, and the patient’s acceptance of the prosthesis.
The use of osseointegrated implants has eliminated some of
these problems. The retention provided by the implants makes
it possible to fabricate large prostheses that rest on movable
tissues. Patient acceptance is significantly enhanced because of
the quality of the retention. This enables the prosthodontist to
concentrate on esthetics and fabricate thin margins in silicone
which blend and move more effectively with the mobile pe­
ripheral soft tissues.
The same is true for posttraumatic and congenital defects,
especially of the external ear. The use of osseointegrated im­
plants has made it possible to produce effective bone-anchored
ear prostheses which the patient will accept. The prosthodontist
must consider the special problems of this group of patients,
such as the nature of the defect, the attitude of the patient and
their family, the management of ear remnants, as well as the
overall treatment of what may be a complex congenital syn­
drome.
Benefits derived from implant-retained prostheses include:
(1) improved retention and stability of the prosthesis, (2) elimi­
nation of occasional skin reaction to adhesives, (3) ease and
enhanced accuracy of prosthesis placement, (4) improved skin
hygiene and patient comfort, (5) decreased daily maintenance
associated with removal and reapplication of skin adhesives,

a b
(6) increased life span of the facial restoration (when skin adhe­
sives are used for retention, they must be removed and reap­
plied each day, leading to loss of colorants at the margin of the
prosthesis and, eventually, rendering the prosthesis unaccept­
able), and (7) enhanced esthetics of the lines of juncture be­
tween the prosthesis and skin. When an implant-borne prosthe­
sis is fabricated, its margins can be made thinner, and positive
pressure can be developed by the margins of the prosthesis with
the movable peripheral tissues.

Treatment planning Pretreatment planning should involve all

Fig. 9-89.
a and b: Osseointegrated
implants were required to
retain this large orbital pros­
thesis (c).
c the fate of tissue remnants. With microtia, ear remnants will
members of the treatment rehabilitation team. If the patient is
scheduled to lose a facial part secondary to resection of a neo­
plasm, consideration should be given to placing implants dur­
ing the same surgery as the tumor resection. This practice spares
the patient an additional anesthetic, expedites the process, and
reduces the overall time of rehabilitation. We recommend this
practice in patients who will have a planned postoperative course
of radiation, as well. The supraorbital rim is an exception be­
cause the loss of implant fixtures is about 50% following radia­
tion therapy in this location (see Chapter 4).
In patients with congenital ear defects, the major issue is
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation
vaiy in size, shape, and position, and they may need to be re­
moved. Before these remnants are resected, all possible options
for habilitation must be presented, explored, and discussed with
the patient and their family. In some patients, it may be desir­
able to reconstruct the ear canal. If so, this procedure can be
performed during the same surgery as the implant placement
(Figure 9-90).
The implants must be positioned within the confines of the
proposed facial prosthesis. In most patients, it is desirable to
sculpt a wax replica of the future prosthesis, and to use this
replica to fabricate a surgical template (Figure 9-90 b,c). This
template is sterilized and used as a guide at surgery to ensure
the proper position and angulation of the implants. We recom­
mend that the prosthodontist be present in the operating room
so that he or she may advise the surgical team on the location
and angulation of the implants.
Once the facial prosthesis has been designed, the number
and arrangement of the implants required to retain and stabilize
the prosthesis is determined and the possible bone sites evalu­
ated. In routine acquired defects, radiographic studies usually
are not necessary. In large, extensive acquired defects, or in
Fig. 9-90. a: Patient presents with microtia. Attempts made
to reconstruct the auricle, but the results were unsatisfac­
tory. Reconstructed ear was removed and implants placed, b
and c: Surgical template was used to help properly position
the implants (d). Reconstructed ear was removed and ear
canal was reconstructed during this surgery.
437
some congenital defects, CT scans (Figure 9-91) and perhaps
3-D models, fabricated steriolithographically144(Figure 9-92),
may be valuable aids in evaluating potential bone sites and ad­
jacent structures. For example, in some patients with congeni­
tal ear defects, the position' of the facial nerve canal and sig­
moid sinus, the level of the middle cranial fossa, the size of the
mastoid, and the configuration of the mastoid air cell system
may need to be determined. With rhinectomy defects, the posi­
tion of the roots of the teeth heed to be evaluated radiographi-
cally. CT and 3-D models also help to determine the volume
and density of bone available at these or other potential implant
sites.
The skin and soft tissues overlying the proposed implant
sites also require careful examination. The health of the soft
tissues circumscribing osseointegrated implants is easier to
maintain if these tissues are thin (less than 5 mm in thickness)
and attached to underlying periosteum. If the skin and soft tis­
sues overlying the implant sites contain hair follicles, scar tis­
sue, or tissue remnants of past reconstructive procedures, these
tissues should be considered for removal and replacement with
a skin graft.
Fig. 9-91. CT scan used to evaluate pos­
sible implant sites in this patient
with microtia.
Fig. 9-92. Stereolithographically fabricated
3-D model used to assess im­
plant sites.
438 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Surgicalplacem ent Craniofacial implant fixtures** are fabri­
cated commercially from pure titanium (Figure 9-93). They are
available in either 3 mm or 4 mm lengths and with a 5 mm
diameter flange. The threaded portion has a diameter of 3.75
mm. These short lengths are designed to permit placement in
areas with limited available bone. The flange facilitates initial
stabilization of the implant and prevents undue penetration into
interior compartments. In uneven surfaces, a countersunk area
may be prepared. In some locations, where bone volume is
greater (e.g., nasal floor), these implants may be used in combi­
nation with longer dental implants.
Fig. 9-93. Titanium implants used in craniofacial defects.
A 2-stage surgical procedure, similar to the procedure used
intraorally, is employed145. Surgical placement can be conducted
with regional anesthesia, but sterile conditions must be provided.
A full thickness flap is reflected and potential implant sites evalu­
ated with the help of a surgical template prepared from the
presurgical diagnostic casts. The implant sites are prepared and
tapped in the usual atraumatic manner. A titanium cover screw
is placed to prevent ingrowth of soft tissue during the healing
period. In the mastoid, a healing period of 3 to 4 months is
required. The nose, orbit, and irradiated cases require a mini­
mum of 6 months.
In the mastoid area, a curved incision is made approxi­
mately 30 mm posterior to the external auditory canal. A peri­
osteal flap is raised to expose the bone of the mastoid crest.
Two sets of 2 fixtures are usually placed: one for the left side in
the 1 o’clock and 3 o’clock positions, and the other for the right
side in the 9 o’clock and 11 o’clock positions; both sets are
typically placed 15 mm to 18 mm posterior to the external audi­
tory canal. The aim is to place the retention tissue bar under the
antihelix portion of the prosthesis. For anchorage of an external
ear prosthesis, 2 fixtures are usually sufficient. If an additional
fixture is to be placed for anchorage of a bone-conduction hear­
ing aid, it usually is placed above and posterior to the area that
will be occupied by the prosthesis. The sites for the fixtures are
marked with a small, round bur. The depth of the hole is ex­
tended, avoiding penetration of the dura mater or the wall of the
sigmoid sinus. Mastoid air cells may occasionally be encoun­
tered, but fixtures may be inserted provided the walls of the
preparation are sufficiently solid. The same applies to surgical
* Section on surgical placement of implants contributed by Peter Moy.
** Bud Industries, Tonawanda, NY, and Nobelpharma USA, Chicago, IL.
sites in contact with the dura, but those that penetrate the sig­
moid sinus should be plugged with muscle and abandoned. The
site is widened to the final diameter using a 3.0 mm twist drill,
with a countersink on its top to accommodate the flange neck
of the fixture. This countersink also acts as a safeguard to avoid
deepening the hole beyond the desired depth. The site is then
threaded using a titanium tap. All drilling and tapping is per­
formed under copious irrigation with sterile, normal saline to
avoid overheating the bone. The tapped hole is carefully rinsed
and the flange fixture is inserted. The final tightening of the
fixture is done with a manual wrench to prevent overtorquing
of the fixture. A cover screw is placed in the internal hole of the
fixture and the skin-periosteal flap is closed in 3 layers (Figure
9-94). A mastoid pressure dressing is placed and maintained for
at least 48 hours. The nonresorbable sutures are removed 7 days
later2146.
In the orbital area, the lateral portion of the supraorbital
rim, the lateral rim, and the malar body are the preferred sites.
They offer the best combination of bone volume, density, and
blood supply. A skin incision is made either circumferentially
around the orbit, or in sections, and a periosteal flap is reflected.
Occasionally, an incision within the orbital cavity is necessary.
If the bone volume is sufficient, 4-mm-long fixtures are used.
Three fixtures are ideal to retain an orbital prosthesis, but the
higher incidence of fixture loss in this site, and the high per­
centage of patients who will have received radiation therapy,
dictates the insertion of spare fixtures. Five is a reasonable num­
ber in most cases. Special care must be taken to place the im­
plant fixtures in the proper position and angulation. There should
be 10 mm to 12 mm of space between the implants to allow
access for hygiene. The implants and the substructure must not
effect the contours of the orbital prosthesis. Therefore, the im­
plants should not be angled facially as they may will interfere
with the contour of the orbital prosthesis (Figure 9-95).
In the nasal area, a number of sites can be considered for
placement of fixtures. If the patient is edentulous in the anterior
maxillary area, the bone thickness is generally sufficient for the
vertical placement of the fixtures in the anterior nasal floor. Two
4 mm fixtures or longer dental implants may be placed in this
area. When roots of teeth are present, the lateral wall of the
pyriform aperture can be selected for horizontal placement of 1
fixture on each side. Placement of implants into the glabella
area may be considered, provided that the nasal bones have been
resected, but our results with a limited number of implants has
been inconsistent2.
Implants should be placed in the anterior portion of the
nasal floor, about 8 mm to 10 mm apart (Figure 9-96), so that
the implants exit in attached, immobile tissues. If implants exit
through the mobile tissues of the lip, the incidence of soft tissue
reactions around the implants is increased. If implants are placed
too far posteriorly, access for hygiene is compromised (Figure
9-97).
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 439

Fig. 9-94. Implant placement in mastoid bone, a: Auricular defect, b: Wax sculpting fitted to identify proper implant position, c:
Surgical template, d: Flap reflected, e and f: Template used to locate proper implant positions, g: Mastoid exposed
and sites prepared for 3 implants. Note countersink, h: Implant fixtures placed into prepared sites, i: Wound closed
in 3 layers.

At the second surgical stage, a transcutaneous titanium
abutment cylinder is attached. The surgeon should carefully thin
the tissue flap over the implant sites prior to placement of the
abutments. This procedure will lead to the formation of epithe­
lial cuffs around the abutments, facilitate hygiene maintenance,
and promote healthy peri-implant soft tissues. Although abut­
ments longer than 4 mm are available, their use suggests inad­
equate soft tissue reduction. The stage II suigical exposure pro­
cedure is performed 3 to 4 months after the first stage in auricu­
lar cases. Healing time is extended to 6 to 8 months when the
total length of the fixture was not seated completely within cor­
tical bone or in orbital, nasal, and irradiated cases. Stage II pro­
cedures may be performed with general anesthesia or local an­
esthesia with conscious sedation. A split or full thickness skin
graft is required when there is inadequate tissue or when skin
containing hair follicles is overlying the implant sites.
440 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 9-95. a and b: Three implant fixtures placed in lateral portion of supraorbital rim. Note dense cortical bone at this site and
countersink, c: Note position and angulation of fixtures.

a b e

Fig. 9-96. a: Ideal fixture position, b: These implants emerge through thin, attached, keratinized tissue, c: Access for hygiene
is excellent.

Fig. 9-97.
a: These implants exit through
mobile lip tissues, increasing the
risk of periimplantitis. In addition,
they are positioned incorrectly,
making the nasal prosthesis too
wide at the nostrils, b: These im­
plants are positioned too far pos­
teriorly, making access fo r hy­
giene difficult.
For the mastoid area, a thin skin flap is raised when the
skin overlying the fixture sites is free of hair follicles. The inci­
sion is made at the same site used for the stage I procedure. A
second flap of subcutaneous tissue and muscle is then raised
supraperiosteally, leaving the periosteum intact. The fixtures
are located and exposed using a punch blade knife. All subcuta­
neous fat, muscle, and connective tissue in the second flap is
excised, provided that the fixtures are secure. The margins of
the non-reflected tissue closest to the reflected flap is thinned
by removal of subcutaneous tissue. This permits the thinned
dermal layer to be sutured to the periosteum without tension.
Prior to suturing, the cover screws are removed and positions
of the fixtures are identified with the flap pulled back into posi­
tion. The margin of the flap is sutured to the underlying perios­
teum with subcutaneous, resorbable sutures. The skin layer of
the flap is then sutured to the surrounding skin margin with
nylon sutures. The fixtures are located by palpation, and the
flap is perforated with a punch blade knife designed to engage
the top of the implant fixtures. The appropriate length of
transepithelial abutment is selected and connected to the fix­
ture. Wide healing caps are inserted onto the abutments, and a
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 441

strip of ribbon gauze is soaked in polysporin (Terracortryl ear
suspension) ointment and wrapped around the abutments to
provide tissue compression. This packing keeps the
reapproximated soft tissue immobilized and prevents the for­
mation of a subdermal hematoma. The compression dressing is
reapplied at weekly intervals until healing is complete (in about
1 month) (Figure 9-98).
If hair follicles are present in the skin covering the im­
plants, the same incisions are used, but the flap is removed and
replaced with a free, split thickness skin graft or a carefully
thinned full thickness graft of excised remnant tissue. The graft
is sutured over the fixtures in the same fashion as a pedicle flap.
A tie-over compression dressing or vaseline gauze pressure
dressing is usually required with both the flaps and grafts. Al­
ternative suigical approaches are sometimes required when ear
remnants are scheduled to be removed or a tragus reconstructed.
For the orbital area, the exposure procedure is similar to
the technique described for the mastoid region. Use of free skin
grafts is rarely necessary for the orbital rim region. For the na­
sal area, the stage II procedure is similar. The major goals in the
stage II procedure are to reduce as much tissue bulk as is pos­
sible, in order to obtain a non-mobile tissue bed, and to place as
short an abutment sleeve as is possible.
A single stage surgical procedure has been advocated for
uncomplicated ear and hearing aid cases in adults, but this re­
quires experience and care147. There are significant risks of soft
tissue necrosis, so prosthesis construction should be delayed
for at least 6 weeks.
Prosthetic procedures
Auricular defects Approximately 6 weeks are required
for healing of the soft tissues following second-stage surgery.
The impression site is prepared as described previously, except
that impression copings, designed to be imbedded within the
impression, are attached to the abutment cylinders. If space limi­
tations dictate the use of the UCLA abutment technique148, the
abutment cylinders are removed and impression copings are
connected directly to the implant fixtures. A thin layer of light
body polysulfide impression material is applied to the impres­
sion copings and the tissues of the defect. Gauze, plus a thin
layer of adhesive, is applied, followed by succeeding layers of
impression plaster, as described earlier, to provide support for
the polysulfide impression material. Care must be taken to main­
tain access to the screws holding the impression copings in place,
for they must be loosened to permit removal of the impression.

Fig. 9-98. a: Implants being exposed, b: Tissues flap is thinned and per­
forated over implant sites, c: Abutment cylinders attached, d:
Healing caps secured, e: Pressure dressing applied, f: One
week later, pressure dressing removed, g: Sites healed 4
weeks following exposure.
442 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

using the UCLA abutment technique, should be used148. If the

UCLA abutment technique is used, the impression must be made
at the implant fixture level.
Several attachment systems have been used to retain facial
prostheses, such as bar-clips, magnets, and the O-ring types. In
auricular defects, we favor the bar-clip systems because they
provide superior retention124. The wax pattern for the bar is fab­
ricated in the usual fashion. Stability of the prosthesis will be
enhanced if the bar is shaped in the form of an arc, as opposed
to a straight line. The pattern is invested and cast with a gold
a
alloy*- The cast bar is taken to the patient in segments, each
segment is attached to the implant fixtures or transcutaneous
abutment cylinders with guide pins, and a solder relation record
is made with cyanoacrylate**. The bar is removed and imbed­
ded within a thin matrix of improved dental stone. The water-
powder ratio of the stone prepared for this template must be
measured carefully. The bar is soldered and the fit is verified on
both the stone template and the patient (Figure 9-101).

Fig. 9-99. Impressions, a: Impression copings are secured Fig. 9-100.

to implant fixtures, b: Thin layer of rubber base a: Wax sculpture posi­
impression material applied, c: Thin layer of gauze tioned and notches cut
imbedded in impression material, d: Plaster back­ into master cast, b and c:
ing. e: Impression with abutment analogues at­ Silicone template fabri­
tached. f: Master cast. cated. as an aid to fabri­
cate retention bar. In this
case, implants were posi­
After the impression has been removed, abutment analogs or tioned perfectly.
fixture analogs are secured to the impression copings imbed­
ded within the impression. The master cast is prepared in the
usual way (Figure 9-99). The wax sculpting of the prosthesis is
prepared and tried on the patient, checking that the pattern faith­
fully restores contour and symmetry and is properly oriented.
The operator is now ready to fabricate the retention bar
mechanism. Several factors should be considered when design­
ing this apparatus. First, it is desirable to connect all the im­
plants with a rigid bar149. In this way, the stresses delivered to
the implants will be distributed equitably among the implants.
Second, the retention bars must fit in a passive manner. Third,
the retention apparatus must fit within the confines of the pros­
thesis without affecting contour or symmetry. Fourth, retention
must be sufficient to eliminate accidental dislodgment of the
prosthesis.
The wax sculpture is positioned on the master cast, and a
template of silicone, or other suitable material, is fabricated to
aid in the design of the retention bar (Figure 9-100). If the space
available for the retention apparatus is insufficient, then either
shorter transcutaneous abutment cylinders, or the bar fabricated
500 SL, Leach and Dillon, Attleborough, MA.
Zapit, MDS Products Inc., Anaheim, CA.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 443

Fig. 9-101. Fit of bar is verified on patient.

The clear acrylic resin substructure housing the retentive

plastic clips is designed and fabricated using the same silicone Fig. 9-102.a: Acrylic resin substructure to be imbedded within
template as a guide (Figure 9-102a). The substructure should silicone prosthesis, b: Plastic substructure con­
extend into the body of the silicone prosthesis and possess suf­ tains retentive elements.
ficient surface area so that the bond between the substructure
and the silicone prosthesis will not fail during insertion or re­
moval of the prosthesis. Perforations in the plastic substructure
will increase the surface area and improve retention (Figure 9-
102b).
The auricular wax pattern is flasked in the customary man­
ner. Following wax elimination, the bar and acrylic resin sub­
structure are attached to the master cast, silicone material is
injected, and the flasks are closed and placed in a dry heat oven.
Intrinsic and extrinsic coloration are added as previously de­
scribed, the retentive clips are placed into the acrylic resin sub­
structure, and the prosthesis delivered (Figure 9-103). The pa­
tient is instructed in the proper use of appropriate hygiene aids,
such as superfloss, proxybrushes, cotton tip applicators, and end- Fig. 9-103.a: Extrinsic coloration added to silicone prosthe­
tufted brushes. All patients should be placed on a 3 months re­ sis. b: Clips placed into substructure, c: Prosthe­
call schedule for the first year. At follow-up, irritation of the sis delivered.
skin surrounding the implants will be seen occasionally (Figure
9-104). Most skin problems are reversed with removal of accu­
mulations of keratin, sebaceous secretions or other debris, and
improved home care compliance4,147.

Nasal defects Fabrication of an implant-retained nasal

prosthesis is similar to that described for an auricular prosthe­
sis. Impressions of the implants and adjacent facial structures
are made as previously described, and a master cast is retrieved.
In most rhinectomy patients, sites for 2 implants will be avail­
able in the floor of the nose. Our success in the glabella region
of the frontal bone has been poor (0 for 7), so we no longer
place implants in this site in patients with conventional
rhinectomy defects. As with auricular defects, a bar and clip
retention mechanism is preferred. Our experience with mag­
netic retention systems has been mixed. The retention achieved Fig. 9-104.Note erythematous zone around each implant.
is satisfactory, but the defect must be engaged somewhat in or­ This resolved with improved hygiene.
der to prevent accidental lateral displacement of the prosthesis
444 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
(Figure 9-105). A combination of clips and magnets has been
used (Figure 9-106). The magnets provide retention and the
single clip enhances the retention and resists lateral displace­
ment. However, corrosion of the magnets may limit the life­
span of prosthesis, especially in the nasal area because of the
humidity. Our preferred design is a bar and clip with one bar
segment arranged vertically and another horizontally. This de­
sign provides adequate resistance to lateral displacement and
excellent retention (Figure 9-107). An acrylic resin substruc­
ture housing the plastic retentive clips is designed and fabri­
cated, and the nasal prosthesis is completed as previously de­
scribed.
The prosthesis is delivered and hygiene instructionis pro­
vided. Soft tissue complications have been less frequent with
implants placed in the floor of nose, probably because the im­
plants are more easily seen by the patient, and are more acces­
sible for hygiene150.
Fig. 9-105.Magnetic retention, a: One implant retained this bar. Bar engaged hex atop implant fixture to prevent rotation of bar
and loosening of screw, b: Posterior surface of nasal prosthesis. Note magnetic attachments, c: Bar engaging
prosthesis, d: Prosthesis in position.
Orbital Defects Techniques for fabrication of implant-
retained orbital prostheses are similar to those described for au­
ricular and nasal implant-retained prostheses. Impressions are
made (Figure 9-108) and a master cast retrieved. The wax sculp­
ture is completed (Figure 9-109), a silicone template is con­
structed, and the retention bar designed and fabricated. We pre­
fer magnetic retention in conventional orbital exenteration de­
fects. The ease of insertion of magnetically retained prostheses
outweigh the negative aspects, such as corrosion of the mag­
nets and decreased retention. The retention bar should be de­
signed to interface with 3 or 4 magnets arranged in a triangular
or circular fashion (Figure 9-110). In large defects, an acrylic
resin substructure, housing the magnetic attachments, is pre­
pared (Figure 9-111). In small defects, where space is limited,
the magnetic attachments may be secured to the ocular portion
of the prosthesis (Figure 9-112). The ocular portion is then im­
bedded within the silicone prosthesis. The prosthesis should be
Fig. 9-106.
Combination bar-clip and mag­
netic retention, a: Bar with 1 hori­
zontal clip to facilitate magnetic
retention and resist lateral dis­
placement. b: Posterior surface of
nasal prosthesis. Note magnetic
attachments and single, vertically
positioned clip, c: Prosthesis in
position.
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 445

a b e d e

Fig. 9-107.Bar-clip design, a and b: Bars with vertical and horizontal components, c: Posterior surface of nasal prosthesis.
Clips are embedded in acrylic resin substructure within prosthesis, d: Bar engaging prosthesis, e: Completed pros­
thesis in position.

perforated (Figure 9-11 If) to perm it aeration o f the defect. In­

structions for hygiene and maintenance o f the prosthesis are
provided at delivery (Figure 9-113).
Hygiene procedures are more difficult to perform for pa­
tients with orbital defects. Compliance suffers, so these patients
demonstrate a higher rate o f skin irritation around their im­
plants131. These patients have monocular vision, so their com­
promised depth perception makes it difficult to visualize the
plane o f the implant bar. In addition, many o f the patients are
elderly and have compromised manual dexterity. Therefore, they
may have difficulty manipulating the hygiene aids properly. Most
elderly require glasses for close vision and the glasses’ pres­
ence, overlying the defect, complicates access. Therefore, it is
advisable to train a spouse or a friend to clean the bar and im­
plants. These patients should be placed on a strict 3-month fol­
low-up because severe infections can result if good hygiene is
not maintained (Figure 9-114).

Results The success o f osseointegrated implants used to re­

store craniofacial defects generally has been quite good, par­ Fig. 9-108.a: Impression of orbital defect. Note abutment
ticularly for auricular sites. Success rates for the auricular sites analogues, b: Master cast.
has exceeded 95% in m ost studies2145 (Tables 9-9 and 9-10) and
only few complications have been encountered. Minimizing the
thickness o f the peri-implant tissues will keep soft tissue com­
plications to a minimum. The skin and overlying tissues in de­
fects secondary to trauma or tum or resection usually are thin,
and the overlying skin is adherent to the underlying periosteum.
This provides ideal sites for skin-penetrating implants. In con­
trast, patients with congenital malformations o f the ear region
often present with thick, mobile tissues at the proposed implant
sites. Frequently, these patients have been subjected to multiple
surgical reconstructions aimed at restoring the auricle. Soft tis­
sue complications are kept to a minimum by careful thinning of
the flap at second-stage surgery, or by placing a split thickness Fig. 9-109.Wax sculpting of orbital-facial prosthesis.
skin graft over the implant sites.
446 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 9-110. a: Completed retention bar. b: Note arrangement of magnetic attachments.

Fig. 9-111.
a: Retention bar secured to master cast, b: Acrylic resin substructure. Magnetic
attachments are housed within substructure, c: Substructure is seated. Ocular
prosthesis secured to stone index, d and e: Silicone casting. Note magnetic at­
tachments. f: Note perforation of inner canthus, providing aeration for skin around
implants, g: Completed prosthesis in position. It engages retention bar and mag­
netic attachments associated with the maxillary obturator.
g
 Restoration o f Facial Defects: Etiology, Disability, and Rehabilitation 447

Fig. 9-112.
a: Retention bar. Note arrangement of magnetic attachments, b: Magnets are in­
corporated within ocular portion of prosthesis, c and d: Note how ocular portion
interfaces with retention bar. e: Bar and ocular portion placed in mold and ready
for silicone, f: Completed silicone casting and ocular prosthesis. Ocular portion
designed to fit within silicone casting and engage bar. g: Completed prosthesis.

b
Fig. 9-114. Poor hygiene led to accumulation of
113.a: Implants placed in supraorbital and infraorbital keratin, and debris. Local infections
rims. Note retention bars; they are not connected. eventually lead to removal of implants,
b: Completed prosthesis. Patient was not irradiated.
448 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Success rates of the floor of nose sites are between 85%

and 90%; almost as good as the auricular sites and about the
same as oral implants placed in the premaxillary segment2,150,152.
Most patients in this group have undergone total or partial
rhinectomy secondary to resection of malignant neoplasms.
There have been fewer soft tissue complications associated with
implants placed in the floor of nose site, regardless of whether
they penetrate mucosa or skin, as compared to other sites (Tables
9-9 and 9-10). The implants should not exit the mobile tissue of
the lip and/or nasolabial fold region. Space for the retention bar
may be insufficient for good hygiene, so the implants are sub­
Fig. 9-115. Implants placed in irradiated bone. Note exposure ject to a higher rate of soft tissue complications. Implants placed
of implant flanges 36 months post implant inser­ too far posteriorly into the nasal passage will compromise ac­
tion. cess for hygiene and predispose to soft tissue problems.
The success rates of implants placed in the frontal bone
Table 9-9. UCLA Craniofacial Implant Results. and around the orbit have been disappointing, especially when
these sites have been irradiated. Litde long-term data is avail­
Fixtures Inserted between 1987-1993 able for this site, but the failure rates appear to be 3 to 4 times
greater than that seen with the auricular and floor of nose sites
Defects Fixtures Inserted Lost
(Tables 9-9 and 9-10). Of particular interest is the glabella re­
Ear 57 0
gion or the midline area of the frontal bone between the 2 or­
Frontal Bone 47 19
bits. In the UCLA series, all 7 glabella implants, ranging from 4
Hearing Aid 11111 0
to 10 millimeters in length, have eventually failed. However,
Floor o f Nose 23 2
these results are at variance with the South Wales experience2.
Total 130 16 The success rates are diminished if the implant sites have
previously been irradiated, particularly for implants placed in
the frontal bone. In the Nishimura report, the success rate for
implants placed in the irradiated orbital rim was 33%150. The
Table 9-10. South Wales Craniofacial Implant Results. dosages delivered to the implant sites ranged from 4500-6000
cGy. Of particular interest is the fact that, of the implants still
Defects Fixtures Inserted Lost present, all were showing signs of impending implant failure,
Ear 117 1 such as flange exposure, severe soft tissue reactions, and obvi­
Orbit 40 8 ous bone loss (Figure 9-115).
Hearing Aid 15 1 There appears to be a direct correlation between the level
Nose 10 2 of hygiene compliance and soft tissue reactions with all sites.
Nishimura reports that orbital sites were the most difficult for
Total 182 12
the patients to clean and had the highest rates of peri-implant
tissue reactions151 (Table 9-11). The floor of nose sites were the
easiest to clean and had the lowest rate of soft tissue reactions.
Auricular sites were between these 2 extremes. For all sites,
Table 9-11. Soft Tissue Response— Craniofacial Implants when hygiene improved, the inflammatory soft tissue reactions
by Site. subsided or were eliminated. Therefore, as with oral implants,
patients with skin penetrating implants in the facial skeleton
Auricular Nasal Orbital need proper hygiene instruction and should be followed closely.
Grade #Visits #Visits #Visits Patients tend to forget the necessity for good implant and reten­
0 70 65 34 tion bar hygiene, so hygiene instruction must be reinforced con­
1 41 8 19 tinually during periodic recall visits.
2 6 1 11 The mastoid appears to be analogous to the mandible in
3 7 2 5 terms of success with osseointegrated implants. By contrast,
4 3 0 2 the nasal floor is part of the maxillae, so it should be expected
Total 127 76 71 that the implant experience should be similar. However, there
are several fundamental differences; since the fixtures are shorter,
 Restoration o f Facial D efects: Etiology, D isability, and Rehabilitation
the loads on them are less, and they are mostly skin penetrating
rather than exiting through mucosa.
Orbital fixtures appear to have the poorest results— even
in non-irradiated tissues. This may be related to the poor blood
supply and slow remodeling o f bone at this site. In irradiated
cases, there is increasing and encouraging evidence that hyper­
baric oxygen therapy before and after fixture insertion can im­
prove the success rates of fixtures placed in the orbit and other
sites153.
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450 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
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silane crosslinked silicone for facial prostheses. J Prosthet
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Prosthetics. Transactions of The Academy of Dental Materials.
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102 Veres EM, Woofaardt JF, Becker PJ: An evaluation of the
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103 Firtell DN, Donnan ML, Anderson CR: Light weight RTV
silicone for maxillofacial prostheses. J Prosthet Dent.
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104 McMordie R, King GE: Evaluation of primers used for
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105 Polyzois GL, Frangou MJ, Andreopoulos AG: The effect of
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106 Chen M, Udagama A, Drane JB: Evaluation of facial
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107 Tam V, Faulkner MG, Woofaardt JF: Apparatus for the
mechanical testing of maxillofacial prosthetic adhesives. J
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108 Woofaardt JF, Tam V, Faulkner MG, Prasad N: Mechanical
behavior of three maxillofacial prosthetic adhesive systems.
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109 Koran A, Powers JM, Lepeak PJ, Craig RG: Stain resistance
of maxillofacial materials. J Dent Res. 58:145; 1979.
110 Yu R, Koran A, Craig RG, Raptis CN: Stain removal from a
pigmented silicone maxillofacial elastomer. J Dent Res.
61:993;1981.
111 Yu R, Koran A, Raptis CN, Craig RG: Stain removal from a
silicone maxillofacial elastomer. J Dent Res. 60:1754; 1981.
112 Yu R, Koran A, Powers JM: Effect of processing temperature
on the properties o f a polyvinyl chloride maxillofacial
elastomer. J Dent Res. 62:98; 1983.
113 Yu R, Koran A, Raptis CN, Craig RG: Cigarette staining and
cleaning of a maxillofacial silicone. J Dent Res. 62:853; 1983.
114 Ma T, Johnston WM, Koran A: The color accuracy of Kubelka-
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115 Johnston WM, Robinson JC, Ma T: Optical interactions among
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116 Johnston WM: Colorant form ulation o f elastom eric
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117 Koran A, Powers JM, Raptis CN, Yu R: Reflection
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118 Goldberg A, Craig R, Filisko F: Polyurethane elastomers as
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119 Seluk LW, Yu R, Koran A: Stability of ceramic pigments for
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120 Sweeney WT, Fischer TE, Castleberry DJ, Cowperthwaite GF:
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121 Beumer J, Calcaterra T: Prosthetic restoration of large
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122 Marunick M, Harrison R, Beumer J: Prosthetic rehabilitation
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128 Parr GR, Goldman BM, Rahn AO: Surgical considerations in
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150 Nishimura R, Roumanas E, Moy P, Sugai T, Freymiller E:
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R etrospective study o f osseointegrated skin-penetrating
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Maxillofac Implants. 7:523;1992.
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in irradiated tissue: Benefits from hyperbaric oxygen. Inti J
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maxillofacial materials. J Dent Res. 54:1216; 1975.
155 An K, G o nzalez JB , C ha, EY: S tan d ard izatio n o f a
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44:338; 1980.
Chapter 10
Cranial Implants
John Beumer III and Nicholas J. Mankovich
Cranial defects resulting from trauma or disease have been
described since antiquity. A variety of techniques have been
employed to restore these defects. These techniques and their
materials will be described in this chapter. However, computer
modeling techniques have been refined so that, today, preformed
cranial implants that are extremely accurate and require little or
no adjustment at surgery can be fabricated prior to reconstruc­
tive surgery. In our view, techniques based on computer model­
ing will replace conventional methods currently used by most
neurosurgeons and prosthodontists because they are simpler,
provide better cosmetic and functional results, and require less
operating time (thus are cost effective).
Etiology of Cranial Defects
Trauma accounts for the majority of cranial defects. First,
during'repair of compound skull fractures or penetrating wounds
of the brain, significant portions of the skull may require re­
moval. Successful management of these fractures necessitates
repair of the scalp and dura, but not necessarily restoration of
cranial integrity. Second, in some patients, a bone flap reim­
planted during elective craniotomy may become infected and
require removal. Third, excision of osteomas, hyperostosing
meningiomas, and other benign locally invasive lesions may
require extensive resection of the cranial vault. Repair of cra­
nial defects secondary to malignant tumors is usually delayed
or not performed in order to assure control of disease. Fourth,
cranial defects may result from surgically planned external de­
compression craniectomies as treatment of intractable intracra­
nial hypertension (post traumatic cerebral edema, pseudomotor
cerebri, metabolic encephalopathies, and so forth). Cranial de­
fects that result from congenital malformations, such as menin-
goencephalocele, occur less frequently, but they require repair
in selected patients. Last, craniectomy debridement of calvarial
osteomyelitis, occurring either as hematogenous bone infection
or from contiguous sinus infection, may result in a significant
cranial defect requiring later repair, after control of the disease.
Indications for Cranioplasty
The major indications for cranioplasty are disfigurement
and mechanical vulnerability. Small defects (2 to 3 cm in diam­
eter), which are located immediately above the orbital rim or at
nasion, may require repair entirely for cosmetic reasons (Fig­
ure 10-1). Larger defects (8 to 10 cm in diameter) may require
repair almost entirely for brain protection (Figure 10-2). How­
ever, most cranial defects will have some variable proportion of
cosmetic and mechanical requirements, and the decision regard­
ing cranioplasty must be influenced by the patient’s age, prog­
nosis, activity level, and the specific conditions of the scalp and
calvarium. In some patients, who may be poor candidates for
surgery, an external prostheses can be fabricated as an integral
component of a wig, thereby providing some cosmesis and pro­
tection (Figure 10-3).
Local discomfort at the site of the cranial defect may be an
indication for cranial repair. Discomfort can result, particularly
in large defects, upon rapid movement or following periods of
exertion, and could be precipitated by intracranial tissue com­
ing into contact with the bony margins of the defect. Vibration
and pulsation of the brain tissues not confined by bone may
also be disconcerting to the patient. Some clinicians believe
that the cranial implant “splints” the brain, decreases its mobil­
ity and thereby relieves symptoms1,2’3. Vertigo and seizure ac­
tivity cannot be consistently controlled with a cranial prosthe­
sis. These symptoms are usually related to an initial trauma or
other factors, and restoring the skull defect will not result in
relief. In adults, there is no good evidence indicating that an
unrestored cranial defect leads to progressive neurologic dete­
456 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
rioration4. There is disagreement on whether a cranial defect
will directly precipitate symptoms, such as generalized head­
ache, irritability, fatigue, and other problems often associated
with posttraumatic or post-concussion syndrome (syndrome of
the trephined)4,5. Also, there is disagreement on whether cranio-
plasty will relieve these symptoms6.
A disfiguring defect alone is grounds for cranioplasty. No­
ticeable cranial defects often are interpreted by the public as
signs of mental disturbance or retardation and, consequently,
many patients may be inhibited from carrying out traditional
psychosocial functions. Such patients may become reclusive
and consider themselves totally disabled. Additional anxiety is
precipitated by the fear of injury to the unprotected brain. Inse­
curity resulting from being considered an incomplete individual
may interfere with rehabilitation and necessitate surgical cor­
rection.
Immediate repair of cranial defects is discouraged by most
clinicians. Most neurosurgeons believe that, in the presence of
overt or latent infection, cranioplasty should be delayed 6 to 12
months4,7. In the interim, suitable protection can be afforded
with external prostheses (Figure 10-3). Even in the absence of
infectious complications, 2 to 3 months is required for appro­
priate organization and revascularization of scalp flaps5. The
rationale is to allow the tissue bed to mature so that the brain
will not be compromised further during cranioplasty, and to
ensure the absence of infection. On occasion, some surgeons
attempt primary repair of a cranial defect resulting from removal
of benign, local neoplastic disease if the size of the defect is not
excessive.
I b
Fig. 10-1. a and b: This frontal defect involved orbital rim
and was repaired for cosmetic reasons.
Full thickness well-vascularized scalp flaps are important
to the success of cranioplasty. Thin scalp flaps may preclude
cranioplasty altogether. Wide, thin, or poorly vascularized scars
may require removal prior to closure of a cranioplasty. Thin
scalp flaps, or those covered with split thickness skin grafts,
should be removed and replaced with pedicle flaps4or free vas­
cularized flaps8.
Suigical repair of cranial defects in children less than 2
years of age is avoided by neurosurgeons because these chil­
dren possess a capability for osteogenesis. In these patients, bone
regeneration can occur from the outer layer of dura, which is
covered with periosteum. When the dura is lost or replaced with
a fascia lata graft, spontaneous repair should not be expected4.
If laige defects persist, cranioplasty is deferred until age 3 to 5
years, after which growth of the skull slows9. Spontaneous re­
pair in older children is rarely seen because, after age 5 to 6
years of age, the cranial tissue loses most of its osteogenic po­
tential.
Methods of Cranioplasty
The art of trephination has been practiced by several civi­
lizations through history. Artifacts indicate that ancient Britons,
Incas, Asians, South Sea Islanders, and North Africans had the
skills for removing portions of cranial bone successfully, with
evidence of attempted repair5. The ancient Egyptians, noted for
cranial surgery, attempted implants and other protective cover­
ings for defective calvaria10. Gold, which has been used for cen­
turies for cranial repair, was found in the remains of Neolithic
Peruvians11, and also was used by Fallopius in the 17th cen­
tury12. Numerous methods of cranioplasty exist today, and many
have strong adherents among neurosurgeons. Two basic meth­
ods have evolved: (1) osteoplastic reconstruction and (2) resto­
ration with alloplastic implants.
Fig. 10-2. This occipital-parietal defect was repaired in or­
der to provide brain protection.

Fig. 10-3. a: Age and advanced cardiovascular disease precluded restoration of this patient’s cranial defect, b: An external
prosthesis held in position with tape provided acceptable protection from injury, c: Wig provided patient with a
normal appearance.
Osteoplastic Reconstruction
Autogenous Bone
Autogenous bone offers a number of advantages, includ­
ing (1) its radiodensity, allowing for normal radiographic diag­
nostic studies, (2) that it becomes a viable part of the host and
hence is not susceptible to infection, and (3) that it may be ben­
eficial psychologically to restore the defect with the patient’s
own tissue. Adequate vascularity of the scalp flap, presence of
the dura and its outer layer of periosteum, and the absence of
infection all contribute to a successful result.
The principle disadvantages of autogenous bone are (1)
possible absorption and loss of contour, (2) difficulty in obtain­
ing acceptable cranial contours, (3) availability of sufficient graft
material for large defects, and (4) susceptibility to fracture. In
addition, 2 incisions are necessary: 1 to remove the donor ma­
terial and 1 for the cranioplasty.
A composite autogenous graft composed of the outer table
of the calvarium and its pericranium may be used to close small
through and through defects. This procedure is well-described
by Gurdjian and Thomas13. The scalp is reflected and the defect
prepared by removing a few millimeters of the adjacent outer
table, thus forming a lip around the defect. The osteoplastic flap
is seated on this lip. With the aid of a template patterned from
the newly contoured defect, a section of the outer table of bone,
with its pericranium attached, is removed from another area of
the skull and sutured in place in the defect. This osteoplastic
Cranial Implants 457
flap proceeds to organize rapidly and form new bone. Obvi­
ously, the size of a defect that can be repaired with this method
is severely limited because of the partial defect resulting at the
donor site.
Free autogenous grafts, using rib or iliac crest, are used by
some neurosurgeons. Ribs are most commonly used because
they are readily available and easily retrieved with little result­
ing deformity. If its periosteum is not removed from the ribs’
normal position, the ribs will regenerate, thus insuring an al­
most endless supply of autogenous bone. Splitting the ribs can
make adequate bone available for even large defects. To use the
rib, the defect is exposed, the bony margins are freshened, and
a ledge is created around the defect to receive the graft To in­
sure good bony union, spaces or gaps should not be present
between the ribs and the defect. Gaps should be filled with
marrow or bone chips. Some clinicians prefer to hold rib grafts
in position by a snugly repositioned scalp flap12-14, whereas oth­
ers secure each rib to the cranium with stainless steel wire4’15.
Blocks of iliac crest are used less often because of the lim­
ited bone available and the morbidity associated with removal
of bone from this source. Although the outer table of ilium has
been used, the inner table is usually selected because its con­
tour aids reconstruction of the defect, resulting in less func­
tional and cosmetic deformity of the ilium. Iliac crest is not
used in children because of the possibility of disrupting local
growth centers. Other sources of autogenous bone that were
employed in the past, such as sternum, tibia, and scapula, are
not often used today.
458 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Use of cancellous bone obtained from the ilium for resto­
ration of cranial defects was first advocated by Carmody16. Be­
cause of the consistency of this autogenous material, it does not
have the ability to maintain contour in large defects. Habal at­
tempted to overcome this problem with a mesh of polyurethane
terephthalate, shaped to the proper configuration, to restore con­
tour and confine the cancellous bone and marrow while osteo­
genesis was completed17.
The incidence of infection or resorption with autogenous
grafts is small. Hancock, in a review of 44 patients, reported
that only 1 rib graft demonstrated advanced resorption, but no
grafts were compromised because of infection18. Longacre and
de Stefano14and Longacre" reported similar successful long­
term results with rib grafts. Korloff presented data from 55 pa­
tients with cranial defects restored with autographs19. Of 46 rib
grafts, 50% were thought to have normal contour in the graft
area, 25% appeared to have slight unevenness, and 3 patients
demonstrated marked depression of the grafted area. One graft
had to be removed 3 years after surgery because of infection.
Of the 9 iliac crest grafts employed, 6 resulted in normal con­
tour and, in 3, there was a slight depression in the defect area.
None of the iliac crest grafts became infected. These authors
recommended that rib grafts be used to restore major skull de­
fects and that iliac crest grafts be reserved for smaller defects
(up to 4 by 5 cm).
Autogenous bone prepared by freeze drying, autoclaving,
or freezing produces less reliable results. In one series, 31 out
of 78 reimplanted autogenous bone flaps were lost secondary
to resorption or infection18. The physical and chemical charac­
teristics of bone are changed by the preserving process and,
because of the change, this material reacts in a manner similar
to homogenous or heterogeneous bone (Figure 10-4).
Fig. 10-4. Following a traumatic episode, bone flap was
removed, freeze dried, and stored. Six months
later, it was reinserted. Note resorption.
Cartilage, Fat, and Dermis
Diced cartilage has been used by some clinicians to repair
cranial defects20. This material is packed into the defect and
contoured like wet sand. The spaces between the shavings fill
in with connective tissue, with each piece becoming individu­
ally encapsulated. Each fragment of cartilage is braced by the
others with which it is in contact, allowing little contraction as
the graft tissue matures; the contours are therefore maintained.
After healing, active chondrocytes have been observed to be
surrounded by a matrix of normal cartilage. Some bone has
been observed, also. A significant drawback to this technique is
the unavailability of adequate amounts of graft material. In ad­
dition, the graft remains soft and provides little protection to
the underlying brain.
Other autogenous materials, such as adipose tissue and
dermis, have been used primarily in frontal sinus defects. Suc­
cess depends greatly on the size and the location of the defect.
These graft materials have a tendency to contract with matura­
tion and, therefore, they may compromise the cosmetic result21.
Obviously, these grafts do not provide adequate protection from
traumatic injury.
Alloplastic Implants
Metals
Numerous metals and alloys have been employed histori­
cally for restoration of cranial defects. Ideally, the metal should
be light in weight; strong enough to resist trauma, yet suffi­
ciently malleable to allow easy alteration at surgery; inertable
so as not to provoke tissue reactions; and moderately radiolu-
cent to permit normal radiologic examination.
The most popular metal employed has been tantalum. In a
series of more than 400 cranioplasties performed in the military
and at Veterans Administration Hospitals during and afterWorld
War II, more than 90% were accomplished with tantalum22.
Tantalum is inert and malleable. It is available in 0.015-inch
perforated sheets, which can be shaped to the desired contour
and cut with shears to the appropriate dimension. For small de­
fects, tantalum can be easily shaped during surgery with the aid
of a ballpeen hammer and a wooden block, or by the use of cast
iron metal dies, which have been described by Matson9.
For larger defects, an impression of the defect and the sur­
rounding area is obtained and a stone cast is prepared. The cast
is then contoured and used as the positive side of a die. It is
lubricated and a negative or counter die is poured in dental stone
directly over the positive half. No space is necessary between
the two halves of the die inasmuch as the tantalum is used in
thin sheets. When the stone is hard and cleaned, the tantalum
sheet is placed between the positive and negative halves of the
die and shaped with pressure. Crimps in the metal are ham­

mered out. The shaped sheet is trimmed, allowing for a 3 mm
rim beyond the edge of the defect that will be used to attach the
implant to the cranium. Any required perforations are made,
the borders are rounded, the implant is polished, and then the
implant is immersed in nitric acid to remove contaminants prior
to sterilization23. The implant may be inlaid into a ledge (which
has been created by removing a thickness of the outer table of
adjacent skull equivalent to the thickness of the tantalum sheet).
The tantalum implant is then secured in position with tantalum
points. Tantalum implants have also been onlaid and fastened
with screws or wires over a skull defect.
Titanium has been used in fashioning cranial prostheses24.
This metal, strong yet light, is soft enough to be swaged in a
die-counter die system. Moreover, it can be strain hardened,
thus becoming stronger with manipulation. Sheets of 0.61 mm
thickness are adequate and titanium’s radiodensity permits most
radiographic studies. After the metal is shaped, trimmed, and
polished, tissue acceptance of the implant is enhanced by anod­
izing it in a solution of 80% phosphoric acid, 10% sulfuric acid,
and 10% water34.
Most stainless steel products are not acceptable implant
materials because of tissue incompatibilities. However, 316
Austenite stainless steel * implants, which contains iron, chro­
mium, and nickel, have been used to restore cranial defects25.
Its properties are similar to tantalum with regard to tissue toler­
ance and malleability, but it is much less expensive. The thick­
ness used for cranioplasty allows sufficient penetration of X-
rays to permit some radiographic studies. Manipulation is simi­
lar to that described for tantalum. However, a rather high rate of
failure, requiring removal of implants, has been reported25.
A number of other metals have been proposed for use in
cranioplasty, but they have not achieved wide acceptance.
Vitallium, successfully used for implantation at other sites, has
not worked well with large cranial defects because its hardness
makes it difficult to manipulate at surgery. Ticonium is light,
but is too soft to afford adequate protection from trauma.
There are a number of disadvantages associated with metal
cranial implants1,26. Their high thermal conductivity may pre­
cipitate headaches and other neurologic symptoms. Their elec­
trical conductivity precludes accurate interpretation of
electroencephalograms. Some metals, particularly tantalum, are
radiopaque and may prevent interpretation of routine radio-
graphic studies. The metals that are most popular are those that
are quite malleable and permit easy adjustment at surgery. How­
ever, these malleable metals are subject to deformation second­
ary to trauma and may not provide adequate protection, par­
ticularly in large defects. Because metal implants are thin, they
only cover the defect and leave a space beneath; into which the
brain occasionally herniates. The rate of infection, although not
high, does appear significant. In one series 12% of 130 tanta­
lum plates required removal because of infection27. In the resto­
ration of frontal sinus defects, significant numbers of sites be­
* Austenal Products Laboratories, Chicago, IL.
** Cranioplast, Codman and Shurtless, Inc., Randolf, MA.
Cranial Implants 459
came infected (see discussion of frontal bone defects later in
this chapter). In another series, however, in which tantalum was
used for cranioplasty in over 100 children between the ages of 3
and 13 years, fewer than 5% required removal9. When infection
does become associated with an implant, removal is recom­
mended by most clinicians4,28. Thompson attempted to salvage
exposed implants by rotating local flaps, however, successful
coverage was obtained in only 1 out of the 4 in whom metal
implants were exposed28.
To summarize, the principle advantages of the metals en­
joying the greatest use are (1) their malleability, enabling the
clinician to shape them to any configuration, (2) they require
only 1 incision because there is no donor site, (3) operating
time is significantly reduced compared to that needed for cran­
ioplasty with autogenous materials, and (4) most of the metals
are readily available. In recent years, with the evolution of acrylic
resins, metals have been used less than was formerly the case.
Autopolymerizing Acrylic Resin
Since World War n, the use of autopolymerizing acrylic
resin has become increasingly popular among neurosurgeons
because of its tissue compatibility and ease with which it can be
manipulated at surgery. It enjoys a number of advantages over
the metals just described. Autopolymerizing acrylic resin is rela­
tively inert, strong, noncarcinogenic, radiolucent, readily avail­
able in sterilized premeasured packets of monomer and poly­
mer**, and has poor thermal and electrical conductivity.
To develop an appropriate contour, the bony margins of
the defect are exposed. The monomer and polymer are mixed
together and, when the’resin becomes doughy and looses its
tackiness, it is applied to the defect and molded. In small de­
fects, it can remain in place until polymerization is complete.
Heat of polymerization is controlled with steady saline irriga­
tions and moist cottonoids29. In larger defects, when the resin
begins to harden and produce heat, it is removed until polymer­
ization is completed. Some clinicians prefer to mix the mono­
mer and polymer together in a polyethylene bag, and then ap­
ply the bag to the defect1. Using a bag to mix the resin facili­
tates handling and prevents monomer contamination of the dura.
The polymerized resin is trimmed and smoothed with rotary
instruments. Numerous perforations are drilled into the pros­
thesis prior to securing it into position. Fibrous connective tis­
sue proliferates through the holes, thereby enhancing stability
of the implant. In addition, fluid that may accumulate beneath
the implant can pass to the surface and into the subgaleal space.
If the prosthesis is contaminated during the procedure, it can be
sterilized in an autoclave, but only when necessary, as heat may
distort the resin.
The incidence of complications related to autopolymerizing
acrylic resin in cranial prostheses appears to be slightly less
than is the case with tantalum or other metals. In a series re-
460 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
viewed at Walter Reed Army Hospital, 417 patients underwent
cranioplasty with autopolymerizing acrylic resin7. Follow-ups
ranged from 6 months to 13 years. Seven (1.7%) of the original
group developed complications requiring surgical intervention.
In this series, if the cranial defect occurred secondary to a com­
pound fracture, or if the local site was infected, the cranioplasty
was delayed for at least 1 year. In another series, 33 patients
were followed from 1to 15 years after implantation of a cranial
prosthesis of autopolymerizing acrylic resin29. None required
postoperative surgical intervention. Cranial radiographs did not
indicate any evidence of sclerosis or resorption of bone adja­
cent to the defect. In still another series, 37 patients received
implants of autopolymerizing acrylic resin 6 to 12 months fol­
lowing traumatic skull fractures30. None required removal.
The principle disadvantages of the direct application of
autopolymerizing acrylic resin are the heat of polymerization
and the presence of free monomer. Residual liquid monomer
has been implicated as the cause of local tissue reactions31, but,
apparently, monomer toxicity is short lived26. Also, there may
be some difficulty in contouring an implant that encompasses a
significant curvature of the cranium.
Elkins has proposed an alternative method of using
autopolymerizing acrylic resin32. Following reflection of the
scalp flap and exposure of the bony margins, an impression is
obtained of the defect and a cast of dental stone is prepared. The
cranial prosthesis is formed on the cast and inserted at the same
operative sitting. This technique reduces contamination of the
tissue bed by monomer and eliminates exposure of the tissue to
the heat produced by polymerization. However, operating room
time is increased by about 90 minutes.
Combination Metal andAutopolymerizing Acrylic Resin
A combination of autopolymerizing acrylic resin and stain­
less steel mesh has been proposed as a suitable means of form­
ing a cranial implant, particularly in children with thin crani-
ums33. Alone, neither tantalum nor stainless steel mesh provides
suitable protection for active children. The harvest of autog­
enous grafts can produce significant morbidity at the donor site,
and the graft material may be difficult to contour in large de­
fects. The thinness of autopolymerizing acrylic resin implants
makes them susceptible to fracture. The stainless steel mesh
(.028 inch wire, 16 wires per inch*5is trimmed and contoured to
the defect, with a small extension overlying the bony margins.
The mesh is removed, the autopolymerizing acrylic resin is
mixed, and, while it is still a thick vicious fluid, the resin is
poured onto the mesh, allowing the excess to drip off. The resin
is then contoured and adapted with a wet, gloved finger. After
polymerization is complete, the implant is removed, trimmed,
perforated, and attached to the cranium. During a 2-year pe­
riod, 11 such cranial implants were inserted with no complica­
tions reported33.
United Surgical Supplies Co., Inc., Port Chester, NY.
Heat polymerizing Methyl Acrylic Resin
The use of this material requires presurgical fabrication of
the implant. Heat-processed methyl methacrylate enjoys many
of the favorable properties of autopolymerizing methyl meth­
acrylate and, when appropriately fabricated, the heat-processed
resin facilitates reproduction of contours. In addition, the tissue
bed is not exposed to the heat of polymerization or a free mono­
mer and the heat-processed resin is 50% stronger than the
autopolymerizing resin. The result is a stronger, more inert cra­
nial implant
Beumer reported on 46 patients who were treated with pre­
formed heat-polymerized acrylic resin cranial implants at
UCLA34. All defects were confined to the bony cranium and
involved at least 40 square cm of calvarium. These defects were
caused by trauma (24), tumor resection (11), infection of rein­
serted bone flaps (10), and congenital deformities (2). Defects
in the frontal bone secondary to frontal-ethmoidal sinusitis were
not included in this study. All patients were followed at least 2
years. One implant was removed almost immediately after in­
sertion because of a hematoma. It was reinserted 2 weeks later
and has since remained in place free of complications. A sec­
ond cranial implant, restoring a temporal-parietal defect, be­
came loose 6 months following insertion. A portion of this im­
plant was placed beneath the temporalis muscle (this muscle
had been sutured to the implant). This implant was exposed,
removed, readapted to the defect with a lining of
autopolymerizing acrylic resin, and resutured into position (Fig­
ure 10-5). A third implant was lost secondary to a second trau­
matic incident. Interestingly, the heat-cured acrylic resin cra­
nial implant did not fracture. However, the adjacent calvarium
was fractured, necessitating removal of the implant and adja­
cent bone fragments. Another implant was removed 16 years
after insertion to treat a cerebral vascular accident. Following
completion of the procedure, the cranial implant was reinserted.
None of the remaining 43 implants has required removal.
Polyethylene
Polyethylene, a straight-chained, aliphatic hydrocarbon, has
been used in the fabrication of cranial implants and possesses a
number of desirable properties. When it is free of additives,
such as colorants or plasticizers, it is inert and compatible with
tissue. It exhibits high tensile strength, is lightweight, is some­
what flexible, has a low thermal and electrical conductivity, and
has a high resistance to fracture. Polyethylene can be molded to
any shape and is easily adjusted at surgery. It is thermoplastic
and, between 350° to 375°F, becomes a clear, amorphous, and
moldable material that will retain its shape upon cooling10.
This material requires prefabrication of the implant. An
impression of the defect and the surrounding tissues is made
and a master cast retrieved. A wax pattern is then developed on

the cast to proper contour, lubricated, and flasked. A suitable
amount of polyethylene, which is available in sheets, is cut from
a pattern and placed in the mold. Both halves of the open flask
are placed in a dry heat oven and the temperature brought to
375°F. When the material becomes translucent and moldable,
the flasks are closed under pressure, with wet cellophane used
as a separating medium. After 2 to 3 minutes, the mold is re­
opened and excess material is removed. The entire apparatus is
reheated, then closed with pressure until cooled. The solid im­
plant is removed from the mold, trimmed with rotary dental
instruments, perforated, and polished with pumice.
Polyethylene must be sterilized with ethylene oxide be­
cause excessive heat will cause distortion. Aeration time, fol­
lowing exposure to the ethylene oxide, should be prolonged for
the gas is released quite slowly from this material. If quickness
is important, the implant is scrubbed with phisophex, rinsed in
sterile distilled water, and immersed in benzalkonium chloride
for 72 hours10,35. Discrepancies noted at surgery may be cor­
rected with a scalpel. The implant is wired or sutured into posi­
tion. The largest series in the literature reported no complica­
tions associated with 17 polyethylene cranioplasties. Average
follow-up was 37.5 months10.
Fig. 10-5. a: This cranial implant became loose 6 months
after insertion. It was removed, then relined with
auto polym e rizin g a c ry lic resin, b: Im plant
resecured into position.
Cranial Implants 461
Silicone
This popular implant material has been used only occa­
sionally to restore cranial defects. It is tissue-compatible, but its
flexibility may compromise protection in large defects. Medi-
cal-grade implantable silicone is available in 3 forms: (1) blocks
that can be carved to the desired shape, (2) heat-vulcanizing
form, and (3) room-temperature-vulcanizing form. The latter
two forms are cured in a prefabricated mold. Silicone has been
used most often in the frontal sinus, malar, and chin defects,
where reestablishment of contour and not protection is the chief
objective. To gain protection, some clinicians have suggested
incorporating stainless steel mesh within the implant5,36.
Prefabricated Cranial Implants
Prefabricated cranial implants offer a number of advan­
tages for large cranial defects. First, as compared to direct tech­
niques, contours can be perfectly restored, resulting in superior
cosmetic results. This is especially important for large defects.
Second, operating room time is reduced, since less time is re­
quired for insertion of the implant. Use of computerized tomo­
graphic scans produce accurate casts of the defect, which should
result in well-fitting prostheses that can further reduce operat­
ing room time. Third, prefabricated cranial implants reduce the
possibility of intraoperative contamination.
Two methods may be used to fabricate cranial implants.
The first technique uses impressions and conventional radio­
graphs to develop a plaster cast of the cranial defect on which
the implant is fabricated. The second employs computerized
tomography and stereolithography to fabricate a resin model
on which the cranial prosthesis is fabricated.
Conventional Method
An impression is necessary to fabricate a plaster cast on
which a cranial implant can be made. The scalp should be com­
pletely shaved for an impression for large cranial defects. For
smaller defects, a shaved border of 5 cm around the bony mar­
gin is adequate if there is a sufficient number of landmarks to
determine appropriate contours. The outer bony margin is then
palpated and outlined in indelible pencil on the skin (Figure 10-
6). When possible, the clinician should attempt to palpate and
mark the margin of the inner table of bone (Figure 10-7). Lo­
cating the inner table will aid in determining the angle neces­
sary for contouring the cast to form a margin that will fit the
defect. This technique is particularly useful when formulating
an implant for the frontal area, where close adaptation and proper
contour are necessary for the best cosmetic results. Overlying
muscle, edema, or accumulations of cerebrospinal fluid may
prevent accurate palpation of local areas (Figure 10-8). In these
situations, the margins can be determined with the use of con-
462 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 10-6. This patient lost a large portion of frontal bone
secondary to trauma, and was referred for con­
struction of prefabricated inlay-type cranioplasty.
All margins were easily palpable. Skull radio­
graphs verified that margins had been located
correctly, and few revisions were necessary at
surgery.
Fig. 10-7. Inner table of defect is identified and marked
for this patient.
Fig. 10-8. Margins of this parietal-temporal defect were dif­
ficult to delineate by palpation. That portion be­
neath the temporalis muscle was impossible to
palpate; this section was outlined with use of
lateral skull film.
Silastic 3116, Dow Chemical Co., Midland, MI.
ventional radiographs. Deferring impressions until the latter part
of the day, when the patient has been erect for a time, may alle­
viate fluid accumulations and facilitate palpation of bony mar­
gins.
The patient is placed in an upright position and draped so
that the impression material will not soil clothing (Figure 10-
9a). Exposed hair, particularly eyebrows and eyelashes, is coated
with petroleum jelly, which will prevent interlocking into the
impression. When difficulty in controlling the flow of the im­
pression material is anticipated, a dam can be made with dental
boxing wax or wet paper towels. A local landmark should be
included in the impression for reference when using a dam.
A number of impression materials can be utilized. Irrevers­
ible hydrocolloid, when mixed with cold water, is appropriate.
The cold water will delay the chemical reaction of the material,
allowing for more working time without adversely affecting
the physical properties of the impression material. Increasing
the amount of water used by one-third will increase the flow of
the material and reduce the chance of entrapping air bubbles.
Ten measures of powder, as provided by most manufacturers,
will usually be adequate for a large impression. Vigorous mix­
ing of the powder and water is accomplished in a large rubber
bowl, using a stiff spatula for 45 seconds. The mix is then poured
onto the desired area, starting at the highest point to allow the
mixture to flow downward and thus avoid trapping air. Cotton
gauze or paper clips are partially embedded on the surface be­
fore the impression material sets. Once the impression material
has set, it is covered with several layers of quick-setting plaster
of Paris (Figure 10-9b). Two or 3 layers may be required to
achieve the desired 1 cm thickness (Figure 10-9c). The plaster
will lock into the paper clips or gauze and reinforce the irre­
versible hydrocolloid. When the plaster sets, and the heat of
reaction becomes uncomfortable for the patient, the impression,
with its plaster of Paris reinforcement, is removed as a unit (Fig­
ure 10-9d). Although the indelible pencil mark is transferred to
the impression, it should be retraced to insure its transfer to the
plaster cast. Casts of dental stone may be used, but they are
more difficult to prepare than those of plaster.
Some silicones are well-suited as impression materials.*
They are advantageous because their viscosity enables the cli­
nician to control the flow of material more easily. In addition,
the indelible pencil markings are more clearly delineated in the
impression. In irreversible hydrocolloid impressions, the pen­
cil markings often diffuse widely into the impression material.
Bony margins, which are not readily palpated (Figure 10-
10), can be located with cranial radiographs. These radiographs
should be taken at right angles to the area in question with a
technique that minimizes enlargement. Tracings from the ra­
diographs of selected portions of the defect are transferred to
the cast by keying them to palpable portions or landmarks (Fig­
ure 10-11).

Fig . 10-9.
a: Patient draped to prepare for impression. Polysiloxane material was used, b: Plaster backing applied,
c: Completed impression, d: Impression of cranial defect. Note the indelible pencil marking.
F ig . 10-10. This lateral skull radiograph was necessary to
delineate the defect, since its margins extended
beneath temporalis muscle. Tracing was made
and transferred to cast. Only that portion of the
defect resting against film when radiograph is
made should be transferred. Multiple radio^
graphs may be necessary to accurately delin­
eate a large portion of the cranial defect.
■Pf ........ .....
' ]J|h H
— ate curvature in large parietal defects, extending inferiorly to
Fig. 10-11. Thickness of scalp prevents precise palpation
of bony margins. Anterior margin beneath the
temporalis muscle was determined with radio­
graphs and transferred to cast with tracing pa­
per.
Cranial Implants 463
Prior to preparation of the cast, the neurosurgeon should
be consulted and the design of the cranial implant should be
discussed (Figure 10-12). Some clinicians prefer to inlay the
implant into the defect (Figure 10-13a), whereas others prefer
to create a thin lip that rests on the unaltered outer table around
the margins of the defect (Figure 10-13b). We prefer the use of
the inlay technique. In our experience, alteration of the implant
at surgery is easier with this design. It requires less operating
room time and results in a stable, well-supported implant.
To fabricate an inlaid cranial implant, the cast should be
prepared to mimic the bony margins of the defect. The margins
of the cast are prepared at approximately a 45° angle, sloping
inward from a line delineating the outer edge of the defect (Fig­
ure 10-14). This angle may be altered in local areas where both
the inner and outer table are palpable, permitting a more accu­
rate estimate of the angle of the bony margin. If in doubt, one
should overextend the margins of the implant, for it may be
readily reduced at the time of surgery.
The contour of the implant must be exact. If the prosthesis
is too flat, it cannot be seated without exerting excessive pres­
sure on the brain. If the implant is inappropriately contoured on
the inner surface, allowing a space between the brain and the
implant, infection can occur or unwanted fluid can accumulate.
In addition, over-contouring creates obvious asymmetry and
cosmetic deformity. The inner contour of the implant is devel­
oped by altering the cast, and the outer contour by sculpting the
wax pattern. In large defects, those areas that are excessively
concave should be brought to the appropriate contour on the
cast, with the addition of plaster of Paris. To develop appropri­
the squamous portion of the temporal bone or the greater wing
of the sphenoid bone, the cast should be deepened (Figure 10-
14b). If the defect extends beneath the temporalis muscle, it is
advisable to make the wax pattern thicker than the correspond­
ing calvarium of the region (Figure 10-14c). This allows the
operator to account for discrepancies in the curvature in this
region by removal of material either from the superior or infe­
rior surfaces of the implant during surgery. During preparation
464 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

of the cast and wax pattern, a dried skull is useful in verifying

Fig. 10-12. Prefabricated cranial implant can be designed
as an inlay (a) or with a thin lip extending onto
unaltered cranium all around the defect (b).
Fig. 10-13. a: Cranioplasty designed and fitted using inlaid
technique, b: Cranioplasty designed and fitted
using a slight overlay of normal cranium.
appropriate contour and thickness. In some defects, the wax
pattern can be tried on the patient to help verify contour and
extensions (Figure 10-14d).
A bony margin is not always easily palpable. Another
method of determining the margin is to use a radiograph of a
grid superimposed over the skull37. A tentative wax pattern for
the implant, with a quarter-inch wire grid imbedded in it, is
developed on the cast. The grid and wax pattern are removed
from the cast and placed in the appropriate position on the
patient’s shaved scalp. Radiographs of the areas in question are
taken at right angles to the grid. The relationship between the
grid and the defect are determined from these radiographs and
transferred to the cast. Where the margin crosses the grid, dots
are placed on the cast, thereby outlining the defect.
When the wax pattern is complete, it is invested in a suit­
able flask. For large implants, custom-made flasks are used. A
surgical-grade monomer and polymer, without plasticizers or
inhibitors, is mixed and processed. When the implant is no
thicker than a denture, processing with heat in a water bath at
160°F for 3 hours, followed by boiling for 1 hour and slow
cooling, is adequate. If the implant has thick sections, curing
should be performed at a lower temperature, 150°F, for 9 to 20
hours before boiling. The lower temperature is necessary, as the
reaction of polymerization is exothermic. The added heat of
polymerization in thicker sections can boil away the unreacted
monomer, leaving spaces that appear as porosities in the fin­
ished prosthesis. After curing, the implant can be trimmed and
polished with rotary instruments. Wheels should not be used
because the grit from the abrasive wheel may become imbed­
ded in the implant. The implant should be perforated (Figure
10-15). As previously mentioned, these perforations prevent
accumulation of fluid beneath the prosthesis and allow for in­
growth of fibrous connective tissue to assist its stabilization.
The holes also provide a means of securing the cranioplasty

a b c

Fig. 10-14. a: Cast should be prepared to mimic outline and contour of defect. Cast is cut, forming a 45° angle at the edge of
the indelible pencil outline, b: To produce proper contour in temporal and sphenoid area, this portion of the cast
needed to be deepened, c: Wax pattern. Contours must be carefully made to reproduce those of the skull, d: It is
sometimes helpful to verify contours by trying the wax pattern on the patient.
466 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

F ig . 10-17. a: Bony margins of defect are clearly exposed. Note bevel, b: Cranial implant is removed from sterile package. A
hemostat and suture are attached to prevent mishandling, c: Cranial implant tried into defect, d: Adjustments are
made with a dental lathe or other suitable rotary instrument, e: W hen adjustments are complete, the implant is
carefully cleaned, f: Prosthesis held in position while being secured with sutures. The re should be a smooth
transition between implant and adjacent cranium, g: Miniplates were used to secure cranioplasty to cranium in this
patient, h: Presurgical cranial defect secondary to a traumatic incident, i: Prefabricated inlay-type implant of heat-
polymerizing acrylic resin was successfully inserted, providing protection against injury and restoring bony con­
tours.

may be required for adequate fixation. If wires are used, their
twisted ends should be tucked into the perforations on the edge
of implant. Counter sinking the holes will aid in this process. In
extremely large defects, in which the brain droops over the edge
of the bony margins, sutures from the dura to the prosthesis will
hold the dura in proper position, thereby eliminating unwanted
spaces under the implant. The patient with a completed cranio­
plasty using this technique is shown in Figure 10-17 (h,i).
Fig. 10-18. a: Large parietal-frontal skull defect, b: Cranial
im plant was not w ell-adapted, c: S terile,
autopolymerizing acrylic resin was mixed and
added to implant, d: Note improved adaptation.
Cranial Implants 467
Occasionally, brain swelling during surgery will prevent
appropriate seating of a properly contoured implant. The anes­
thesiologist can either hyperventilate the patient or administer a
hypertonic agent (urea or mannitol). If these measures do not
allow seating of the implant, it may need to be recontoured with
autopolymerizing acrylic resin. This is a rare occurrence; in the
100 cranial implants completed at UCLA during the last 22 years,
only 1 implant has required alteration because of this problem.
If the implant is short in an area critical to esthetics, such as in
the frontal region, discrepancies can be filled in with
autopolymerizing acrylic resin (Figure 10-18).
CT—Stereolithography Method
Three-dimensional (3-D) modeling is revolutionizing cran­
ioplasty. Detailed and accurate reproductions of the human skull
can be fabricated using computed tomography (CT) and
stereolithography, and these models can be used to make pre­
formed cranial implants that are extremely accurate39,40. The
concept of using 3-D models, generated from CT scans as a
planning aid for neurosurgical procedures, was introduced in
the mid 1980’s. Mankovich described how 3-D models could
be used to fabricate preformed cranial implants41. The models
in these early reports were generated from a milling machine,
or by stacking a series of life-sized skull outlines in 2-mm-thick
plates on top of one another in order to form a 3-D model (Fig­
ure 10-19). These first models were rather crude and produced
significant “stairstep” distortions. The margin of the skull de­
fect was reasonably well-delineated and the contours of the ad­
jacent bone nicely reproduced, but cranial implants made from
these models still required some adjustment at surgery in order
to achieve proper seating of the implant. Nevertheless, the time
spent adjusting the implant in the operating room was reduced
by about one-half. In recent years, more sophisticated model-
making techniques have evolved. These models no longer ex­
hibit the “stairstep” defects of earlier generations and have an
accuracy of >99.6%42(Figure 10-20).
Fig. 10-19. Early generation model of cranium with cranial
defect. Note “stairstep” distortions.
468 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 10-20. a and b: Models made by stereolithography pro­
cess. These models have an accuracy of 99.6%.
Fig. 10-21. Schematic diagram of process, from patient
scan to fabrication of a plastic, life-size model
of patient anatomy, using stereolithography.
Solid model is a mathematical description of
bone surface, as represented by 500,000 to 1
million triangles, each being < 0.5 mm on a side.
Integration with support structure is necessary
to avoid model distortion while in initial stages
of polymerization.
Fig. 10-22. CT projection image of patient with large cra­
nial defect. Note that this scan-positioning-im-
age encompasses entire defect.
Imaging the Facial Skeleton—CT Imaging and
Reformation
The process (Figure 10-21) begins with a CT scan of the
affected and adjacent areas (Figure 10-22). CT produces closely
spaced axial slices of patient anatomy that, when rejoined in the
appropriate manner, fully describe a volume of tissue. Each CT
slice image is composed of tiny picture elements or pixels. Each
pixel, in turn, is actually a small volume element or voxel of
patient tissue sampled by the CT scanner, with each voxel be­
ing as small as 0.4 x 0.4 x 1.0 mm. A voxel intensity represents
the average tissue x-ray attenuation in that small region of
anatomy by assigning a number ranging from 0 to 4095. In a
properly calibrated scanner, these intensities can be read out in
Hounsfield numbers (H, also called CT numbers). This normal­
ized x-ray attenuation scale defines the attentuation for pure
water at 0 H (Hounsfield numbers) and dense bone at approxi­
mately 1000 H43. The digital CT image produced by the CT
scanning computer is composed of a square matrix of x-ray
attenuation numbers, with 512 voxels in the x-dimension and
512 voxels in the y-dimension, providing a single CT slice with
262,144 voxel values. Atypical CT study is made up of20 to 50
of these slices collected in a 15 to 30 minute CT examination. If
the patient remains still during scanning, the slices will be in
excellent alignment with larger anatomical structures spanning
many slices. If the CT slices are collected contiguously, we can
think of the collection of CT images as representing a 3-D im­
age volume. A collection of pixels or voxels in a small area or
volume (e.g., a 3 x 3 x 3 cm voxel region) is often called a
neighborhood.
If imaged with 3-D protocols, CT can be thought of as ex­
haustive patient tissue samples (3-D image volumes). The col­
lection of 1 to 10 mm thick axial slices in a patient study can be
reformatted in the computer into any combination of coronal,
sagittal, oblique, or arbitrarily oriented slices that the prosth­
odontist and surgeon might find useful44’45. This multiplanar re­
formatting (MPR) of the original slices can be done on the scan­
ner or on an independent 3-D workstation, with most systems
providing these new views on film or allowing the computer
operator to dynamically slice through the 3-D volume under
mouse or track-ball control46,47. These interactive sessions are
quite valuable for mentally assembling structures and under­
standing complex 3-D relationships48. Common 3-D reformat­
ting allows CT image reconstruction to follow the curvature of
the spine or the arc of the cranium, or a standardized sectional
view, such as a mandible image reconstructed to slice longitu­
dinally through the mandibular body. The use of curved lines of
reconstruction allow the viewer to clearly see the course of nerve
and vascular structures.

Three-Dimensional Reconstruction
Beyond the simple reformatting of CT images into new
views, 3-dimensional reconstruction provides a new way of
viewing the anatomy of the patient. These derived images go
beyond simple reformatting to provide a view that integrates
across slices to produce snapshots of entire organs or bones.
The process of extracting an object from an image or stack of
images (image volume) is called segmentation. As commonly
applied to maxillofacial surgery, there are 3 types of 3-dimen­
sional reconstruction, including contour-based methods, volu­
metric methods, and shaded surface methods (Figure 1023).
Contour-based methods were among the first used to pro­
duce 3-D-like displays49,50’51,52. In general, each slice in a CT
series is processed to produce an outline of the structure of in­
terest. This can be an operator-drawn outline or, more com­
monly, a computer-generated contour following a single CT
image intensity value (isovalue), much as a topographic map
line follows a particular elevation. In the case of CT contour­
ing, this value might represent the threshold for cortical bone,
resulting in an outline of all cortical bone in a slice. Other meth­
ods of slice-wise collection of tissue borders rely on relatively
sophisticated mathematical models designed to take into ac­
count larger neighborhoods of pixels, often relying on adjacent
homogeneity of tissue and defined boundaries at those places
where disparate homogeneous areas abut53’54’55,56.
In the process of 3-dimensional reconstruction, the collec­
tion of all contours in a slice combine with adjacent slices to
form a topographic map-like wire frame of the 3-dimensional
structure (Figure 10-24). More commonly, the wire frame is
transformed into a surface by connecting adjacent slice contour
segments to form simple polygons (either triangles or quadri­
Fig. 10-23. Computer-generated shaded surface display of
right calvarium, showing large bone defect span­
ning frontal, parietal, temporal, and sphenoid
bones. Computer display allows visualization
prior to sending bone surface data to stereo-
lithographic machine for life-size model fabrica-
tion.
Cranial Implants 469
laterals)57. The collection of polygons comprise a surface that
forms the basis of 3-D display in a process called surface ren­
dering, a type of computer processing of geometric objects that
relies on the basics of illumination, reflection, shadowing, and
so forth to produce the impression of a 3-dimensional ob­
ject58,59’60,61. The assumed properties of light interaction, called
the lighting model, when applied to a surface representation,
becomes a 3-dimensionally rendered scene.
In general, contour-based processing is computationally
simple, and it can be refined to produce good 3-D displays. The
transformation from contours to surfaces is more problematic,
often requiring operator guidance in connecting adjacent-slice
contours57,62. More sophisticated use of contouring employs
methods adapted from computer graphics to blend adjacent
contours into a solid surface; a process similar to the now-popular
graphics process called morphing. This shape-based interpola­
tion, when combined with a good lighting model, results in 3-D
images that are both detailed and realistic63.
More sophisticated methods of 3-dimensional surface ex­
traction use the full 3-dimensional nature of the tomographic
data to directly produce a geometric surface description64,65. In
its simplest form, the data are treated as a true volume of image
information. This image volume can be processed by simple
threshold-following to produce a list of all voxels comprising
the surface of an object; or a broader, solid-segmentation algo­
rithm might include voxels at or above the specified threshold.
Rendering can then proceed by any number of methods, in­
cluding the rendering of the faces of each voxel64, the creation
of simple polygons from adjacent voxel information66,67, or the
direct projection of voxels onto a display screen or film. The
most detailed surfaces are often constructed by interpolating
the surface elements at sub-voxel resolution. Surfaces derived
from true 3-dimensional thresholding are extremely realistic.
The demands of representing the entire surface can require ei­
ther a large amount of computational power or extreme sophis­
tication in the data organization and handling.
Fig. 10-24. A complete generated series of contours based
on several CT slices.
470 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Both contouring and 3-D surface extraction can extend their
voxel inclusion methods well beyond simple thresholding. Be­
cause of the difficulties in deciding and applying a strict thresh­
old for bone68, the actual mechanism of deciding if a particular
voxel is part of the surface or not can be quite sophisticated. It
can take into account neighboring pixel (voxel) values, or it can
base its decision on some combination of contour (surface) cur­
vature, absolute threshold, and neighborhood differences.
All of the aforementioned methods have the drawback of
representing only surfaces. That is, all other details of the origi­
nal image are lost during the surface extraction (segmentation)
process, and the final surface, when rendered, is simply an
“empty eggshell”; cut into it and you see the inside of the oppo­
site side of the shell. Many 3-D computer systems provide meth­
ods to integrate the original CT image data back into the sur­
face representation. This is done by post-processing both the
surface rendering and the data volume so that, when the surface
is cut by user-controlled planes, the appropriate image intensity
values are projected back onto the cut surface69. This composite
view provides the surgeon with both external (or bony) land­
marks and internal detail.
The final method of 3-dimensional reconstruction avoids
the need to recombine surfaces and image volume data. Volu­
metric imaging provides 3-D displays with a continuum of sur­
face and image intensity data70,71,72,73,74’75. Put simply, volumet­
ric techniques produce the appearance of 3-dimensional sur­
faces without the computer having to explicitly define a geo­
metric surface. By cleverly combining image volume projec­
tion, gradient intensity mapping, and lighting models, the user-
selected parameters of volumetric imaging can produce images
that range in appearance from conventional projection x-rays
to shaded surface displays. Tissue types are selected and
colorized based upon user-selected intensity ranges, and voxels
that might contain 2 types of tissues are visualized as smooth
color blends of the possible tissues. More details of this process
can be found in Udupa61.
Creating Custom Models and Cranial Implants
The creation of anatomical models can directly improve
patient care when the radiological images alone prove insuffi­
cient to the planned surgical procedure. Tomographic images
can be used to create molds or stamping dies for fabricating the
custom implants that function as presurgical planning tools. Slice
contouring for tissue delineation provides a reliable method of
segmenting tissue. However, the preferred method uses 3-D
image information to directly construct an interpolated solid
object As mentioned previously, contours can be collected au­
tomatically by a computer program, tracing the isogrey levels
on adjacent tomographic slices. Often, tissue demarcation proves
difficult, especially in soft tissues or when there is significant
image degradation, as is the case when metal implants create
CT artifacts. In these cases, operator-guided contouring or di­
rect image digitization from film images is necessary to pro­
duce an accurate depiction of an anatomical region.
Rapid prototyping technologyfor cranioplasty Until recently,
patient anatomical model fabrication has been limited by the
physical constraints of numerically-controlled machine tools.
Namely, model fabrication proceeded as a removal process by
carving away material from the outside of a solid block or sheet
of foam, plastic, wax, or metal. Unfortunately, the use of an
external cutting bit severely limits the ability of the machine to
create intricate structures, especially when there is a high de­
gree of internal complexity, as is found in human cranial
anatomy.
During the late 1980’s, the introduction of rapid prototyping
.technologies (RPTs) offered new possibilities for medical mod­
eling41,42-76’77,78-79,80. Developed primarily for the automotive and
aerospace industries to shorten the time between design and
construction of prototype parts, an RPT actually creates the
model layer-by-layer, and it does not rely on surface cutting.
This naturally tomographic approach lends itself readily to the
free-form sculpture present in human anatomy. There are many
variants of RPT but the 3 dominant technologies include: (1)
stereolithography, which uses a ultraviolet laser to solidify a
liquid plastic layer by layer40,78, (2) laser sintering, which uses a
laser to selectively fuse a thin layer of powdered plastic or metal
to previously fused layers, and (3) laminated object manufac­
turing, which successively laminates thin sheets of material and,
with a laser, cuts and destroys material, leaving behind a solid,
laminated part In each of these techniques, the layers added
can be thinner than 0.5 mm, with a vertical wall thickness of as
low as 0.2 mm.
In the fabrication of a patient model, the steps include: (1)
patient scanning with CT or MRI, (2) image processing to en­
hance edges or create cubic voxels from elongated voxels (op­
tional), (3) segmentation to delineate and extract the surface as
triangles or polygons, (4) model preprocessing to produce a
support framework that often relies on sophisticated ray-trac­
ing algorithms, (5) model slicing of a merged model and sup­
port structure, and (6) model fabrication. Figure 10-22 diagrams
the steps involved. Occasionally, patient motion during scan­
ning presents problems that can be corrected before fabrica­
tion, and a computer-generated 3-D display allows visual de­
tection of these problems. Prior to sending the triangulated data
for stereolithography fabrication, the computer produces vari­
ous views of the segmented anatomy as a realistic rendering of
the bone on a color computer display (Figure 10-23).
Typical patient cranial models, such as those shown in Fig­
ure 10-21, are composed of approximately 800,000 triangles,
each less than 0.5 mm on a side. Once in the hands of a prosth­
odontist, the model can be used to fabricate custom implants of
heat-polymerizing acrylic resin. Alternatively, models can be
472 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 10-27.
a: Resin model of large coronal
d e fe c t d e v e lo p e d w ith CT-
Stereolithography method, b: Sur­
gical defect. Note the model re­
produces detail of defect, c: Cra­
nial im plant secured to defect.
Note marginal adaptation.

Three patients are presented which illustrate the signifi­
cant advantages offered by this new technique. The first patient
presented with a large frontal bone defect secondary to resec­
tion of a large neoplasm. The entire supraorbital rim had been
resected. A large cranial bone flap, raised to facilitate access to
the tumor, was repositioned, but much of it had resorbed. The
resultant defect was extensive and cosmetically displeasing.
Restoring such a defect with conventional methods would have
been extremely difficult, if not impossible. However, with the
CT-stereolithography method, restoration was simple and ef­
fective. Aresin model made with CT-stereolithography is shown,
and an acrylic resin cranial implant was fabricated which re­
stored the frontal-supraorbital rim defect in Figure 10-28 (a,b).
The implant required almost no adjustment at surgery and was
attached with wire sutures (Figure 10-28c). Frontal bone and
supraorbital rim contours were effectively restored.
The second patient illustrates the value of the CT-
stereolithography method for restoring extremely large cranial
defects that extend beneath the temporalis muscle and have
complex contours. The defect was caused by resection of a large
meningioma (Figure 10-29a). This defect could have been re­
stored with conventional methods, but a number of skull radio­
graphs would have been necessary in order to fabricate the im­
plant, and extended intraoperative time would have been nec­
essary to properly fit the implant to the cranium. A CT-
stereolithography model was fabricated to which a cranial im­
plant was fabricated. The bony margins of the cranial defect
were exposed and the cranial implant was found to be adapted
perfectly to the defect. As a result, operating time was signifi­
cantly reduced for this elderly patient.
The third patient suffered extensive cranial injuries in an
automobile accident. During surgery, a large cranial bone flap

Fig. 10-28. Complex cranial defects restored with C T-stereolithography

method, a: Tumor resection resulted in loss of supraorbital rim
and parts of frontal bone, b: Cranial implant overlaid areas defi­
cient in contour and replaced missing structures, such as supraor­
bital rim. c: Implant secured in position. Little adjustment was re­
quired. d: Normal contours are restored. d
 Cranial Implants 473

F ig . 10-29. a: Large cranial defect involving parietal, temporal, and frontal bones.
Defects of this size and curvature would be difficult to restore with
conventional techniques, b: Cranial implant on master model, c: Im­
plant secured to cranial defect. No adjustments were required during
surgical placement.

Frontal Bone Defects

was removed but not immediately reinserted. It was freeze-dried
and replaced 6 months later. Subsequently, much of the rein­
serted bone flap resorbed, creating a large frontal-parietal de­
fect. Portions of the bone flap recalcified, creating a highly un­
usual defect (Figure 10-30). Only about 10% of the bony mar­
gin of the defect was palpable clinically. A CT-stereolithography
resin model was fabricated. Note the presence of calcified areas
within the defect (Figure 10-30b). A cranial implant was fabri­
cated which restored the defect and overlaid the calcified areas.
A mirror-image model was made stereolithographically to aid
development of proper contours for the overlay portion of the
implant (Figure 10-30c). Consistent with our previous experi­
ence with the CT-stereolithography method, the implant was
found upon surgical exposure to be almost perfectly adapted to
the bony margins of the defect (Figure 10-30 d,e); Only mini­
mal adjustments to the implant were required.
At UCLA, we have restored 15 patients with the CT-
stereolithography method. All were very large and most encom­
passed complex contours. All were fabricated of heat-polymer-
izing acrylic resin. All implants required little or no adjustment
during surgery. CT-stereolithography is a simple, cost effective,
timesaving technique which, in our view, is destined to become
the standard of care when restoring lame cranial defects with
Defects associated with the frontal sinuses are difficult to
restore, particularly if they were precipitated by infection. The
failure rates are exceedingly high for alloplastic implants placed
in this area21. The risk of infection remains indefinitely—even
after an apparently successful autogenous graft. The reason for
this high failure rate is the presence of residual mucous mem­
brane lining the frontal sinus. Prior to restoration of a frontal
sinus defect, all of the mucosal lining must be removed. (Prolif­
eration of residual mucous membrane under an implant leads to
recurrent infections, which, in some patients, can be life-threat­
ening.) The risk of failure remains high, as residual mucosa
may often be undetected at surgery and proliferate later. For
these and other reasons, alloplastic implants have not gained
universal acceptance in the restoration of frontal defects. Many
clinicians rely on autogenous fat or dermis to obliterate frontal
defects. Though the result is less predictable, the incidence ol
infection is reduced.
Congenital Cranial Defects
Patients presenting with congenital anomalies, such as
Pfeiffer’s, Apert’s, or Crouzon’s syndromes, may exhibit mul-
tinle bonv and facial defects, including flat or dished out fore-
474 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig . 10-30. a: Radiograph of patient. Note calcifications within defect, b: CT-stereolithographic model of patient. The model
accurately portrayed the calcifications seen on radiographs, c: Cranial implant design to restore defect and over­
lay partially calcified areas, d: Surgical exposure, e: Cranial implant secured with mini bone plates.

bital rims, or irregular attachments of the origin of the temporalis References

muscle. Surgical repositioning and recontouring of this portion
of the facial complex affords these patients considerable cos­
metic improvement82. However, in some patients, further im­
provement can be made by augmentation of the frontal orbital
area with an acrylic resin onlay implant. A CT-stereolithographic
model of the defect is obtained, and a wax pattern is developed
to the desired contour. The wax pattern is then processed into
heat-polymerizing acrylic resin, as described earlier. The im­
plant is fashioned to be placed surgically beneath the perios­
teum directly on frontal bone.
After the scalp flap has been reflected and the cranium ex­
posed, the prosthesis is placed into position and contoured as
needed. Necessary additions are made with autopolymerizing
acrylic resin. The margins of the implant should be finely ta­
pered to smoothly blend with adjacent bony surfaces. In most
instances, sutures are not needed to attach the implant to the
cranium, as tension from the securely repositioned scalp flap is
sufficient.
1 Spence WT: Form fitting cranioplasty. J Neurosurg.
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2 Tabadder K, LaMorgese J: Complications of a large cranial
defect: Case report. J Neurosurg. 44:506; 1976.
3 Fodstadt H, Ekstedt J, Friden H: CSF hydrodynamic studies
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28:514;1979.
4 Timmons RL: Cranial defects and their repair. In: Neurological
Surgery, 2nd Ed. Youmans JR, ed. Philadelphia, 1982; W.B.
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5 Shaw RC, Thering HR: Reconstruction of cranial defects.
Clinics Plast Surg. 2:539; 1975.
6 Small JM, Graham MP: Acrylic resin for the closure of skull
defects. Brit J Surg. 33:106; 1945.
7 Hammon WM, Kempe LG: Methyl methacrylate cranioplasty.
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8 Schwartz W, Banis J: Head and Neck Microsurgery (p. 109).
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9 Matson DD: Neurosurgery of infancy and childhood, 2nd Ed.
Springfield, 1969; Charles C. Thomas,.
10 Sabin H, Karvounis P: The neurosurgeon-dentist team in
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11 Longacre JJ: Deformities of the forehead scalp and cranium.
In: Reconstructive Plastic Surgery. Converse JM, ed.
Philadelphia, 1964; W.B. Saunders Co.
12 Millard R, Tates BV: Practical variations of cranioplasty. Amer
J Surg. 107:802;1964.
13 Gurdijian EJ, Thomas LM: Operative Neurosurgery, 3rd Ed.
Baltimore, 1970; Williams and Wilkins Co.
14 Longacre JJ, de Stefano: Reconstruction of extensive defects
of the skull with split rib grafts. Plast Reconst Surg.
19:186; 1957.
15 Shaw RC, Thering HR: Reconstruction of cranial defects.
Clinics Plast Surg. 2:539;1975.
16 Carmody JTB: Repair of cranial defects with special reference
to the use of cancellous bone. N Engl J Med. 234:393; 1964.
17 Habal MB, Leake DL, Manscalo JE: A new method for
reconstruction of major defects in the cranial vault. Surg
Neurol. 6:137; 1976.
18 Hancock DO: The fate of replaced bone flaps. Neurosurg.
20:983; 1963.
19 Korlof B, Nylen B, Rietz K: Bone grafting of skull defects. A
report of 55 cases. Plast Reconst Surg. 52:378;1973.
20 Dancev I: Reconstruction of the frontal bone of the skull with
cartilage implants. Brit J Plast Surg. 18:288; 1965.
21 Blatt IM, Failla A: Acrylic implants for frontal bone defects.
MilitMed. 137:22;1972.
22 White AE, Jablon S: A following study of head wounds in
World War II. V.A. Medical Monograph. Washington, 1961;
U.S. Government Printing Office.
23 Chalian V, Drane J, Maroon J, Matalon V, Standish M: Cranial
and facial implants. In: Maxillofacial Prosthetics. Chalian V,
Drane J, Standish M, eds. Baltimore, 1971; The Willliams and
Wilkins Co.
24 Gordon DS, Blair GA: Titanium cranioplasty. Brit Med.
2:478; 1974.
25 Scott M, Wycis HT, Murtagh F: Long-term evaluation of
stainless steel cranioplasty. Surg Gyn Obst. 115:453;1962.
26 Sessions RB, Jolfe SK, Moiel RH, Cheer WR: Wire mesh
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84:1020;1974.
27 White JC: Late complications following cranioplasty with
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28 Thompson HG, Munro IR, Birch JR: Exposed cranial implants
a salvage operation. Plast Reconst Surg. 59:395;1977.
29 Cabanela ME, Coventry MB, Maccarty CS, Miller EW: The
fate of patients with methyl methacrylate cranioplasty. J Bone
Joint Surg. 54A:278;1972.
Cranial Implants 475
30 White RJ, Yashon D, Albin MS, Wilson D: Delayed acrylic
reconstruction of the skull in craniocerebral trauma. Trauma.
10:780; 1970.
31 Grasso P: Long term effects of plastics. Food Cosmet Toxicol.
10:567; 1972.
32 Elkins CW, Cameron JE: Cranioplasty with acrylic plates. J
Neurosurg. 3:199;1946.
33 Galicich JH, Hovind KH: Stainless steel mesh acrylic
cranioplasty. Neurosurg. 27:376; 1967.
34 Beumer J, Firtell D, Curtis T: Current concepts in cranioplasty.
J Prosthet Dent. 42:67; 1979.
35 Polisar RS, Cook HW: Use of polyethylene in cranial implants.
J Prosthet Dent. 29:310; 1973.
36 Laub DP, Spohn W, Lash H, Weber J, Chare RA: Accurate
reconstruction of traumatic bony contour defects of
. prefabricated silastic. J Trauma. 10:472;1970.
37 Firtell DN, Moore DJ, Bartlett SO: A radiographic grid for
contouring cranial prosthesis. J Prosthet Dent. 25:439; 1971.
38 Schupper N: Cranioplasty prosthesis for replacement of cranial
bone. J Prosthet Dent. 19:594;1968.
39 Mankovich NJ, Samson D, Pratt W, et al.: Surgical planning
using three-dimensional imaging and computer modeling.
Otolaryng Clin NA. 27:875;1994.
40 Nishimura R, Gagnon F, Roumanas E, Mankovich N:
Alloplastic craniofacial implants fabricated from computer
tomographic-scan generated casts. In: Proceedings of First
International Congress on Maxillofacial Prosthetics. Zlotolow
I, Esposito S, Beumer J, eds. New York, 1995.
41 Mankovich N, Curtis D, Kagawa T, et al.: Comparison of
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conventional techniques. J Prosthet Dent. 55:606; 1986.
42 Mankovich NJ, Yue A, Ammirati M, et al.: Solid models for
CT/MR image display: accuracy and utility in surgical
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44 Glenn W Jr, Johnston R, Morton P, et al.: Image generation
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45 Fishman, E.K., Magid, D., Mandelbaum, B.R., et al.:
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Chapter 11

Maxillofacial Trauma
Jonathan P. Wiens and Alan J. Hickey

General Considerations ceeded intentional fatalities (51,147) by a factor of 2:1, but de­
fects associated with self-inflicted injuries have risen dramati­
Traumatic injuries of the oral-facial region vary from lo­ cally in recent years. In the last 20 years, suicide and attempted
calized injuries to extensive avulsion of soft tissue and bone. suicide have increased 200% among persons 10 to 19 years of
Most injuries result in localized defects, avulsed teeth, alveolar age. In the United States, suicide is the second most common
fractures, loss of alveolar bone, and so forth, which can be re­ cause of death among white males 15 to 19 years of age, and
stored prosthodontically. However, severe oral-facial injuries among the first 5 causes of death for white men 10 to 55 years
can cause continuity defects of the mandible, create large of age. Suicide also has a relatively high incidence for men 85
avulsive defects of the maxilla with extensive loss of adjacent years old and older and for women 45 to 54 years old (46.7 and
soft tissues, and inflict central nervous system deficits that com­ 11.6 per 100,000, respectively). Injury incidence for ages 5 to
promise velopharyngeal and tongue function. The reconstruc­ 44 will exceed all other disease incidences for the same age
tion and rehabilitation of these patients requires careful plan­ group.
ning and close interaction between surgeons, prosthodontists,
and other allied health specialists. Significant advances have
been made in the past 10 years in surgical reconstruction and Table 11-1. Leading Causes of Accidental Death.
prosthetic rehabilitation. Therefore, it is the intent of this chap­
ter to provide background information regarding the etiology Rank Cause 1970 1980 1990
and basic characteristics of traumatic injuries to the oral-facial
region, and to present the latest information regarding the reha­ 1 Moving vehicle accident 54,633 53,172 46,814
bilitation of these patients, with an emphasis on the role of the 2 Falls 16,926 13,294 12,313
prosthodontist. 3 Fires and burns 6,718 5,822 4,175
4 Drowning 6,391 6,043 3,979
Leading Causes of Injuries 5 Poisoning 5,299 4,331 5,803
6 Aspiration of objects 2,753 3,249 3,303
Most maxillofacial traumatic injuries are caused by physi­ 7 Firearms 2,406 ; 1,955 1,416
cal trauma, heat, and electrical and chemical agents. The pros­ 8 Airplane crashes 1,612 J S ,494 941
thodontist is most likely to participate in the care of patients 9 Water transport 1,651 : 1,429 923
who have sustained mechanical impact injuries. Traumatic in­ 10 Electric current 1,140 1,095 670
juries are classified by the International Classification of Dis­
eases as unintentional or intentional. The 10 leading causes of Source: National Center for Health Statistics. Advance
unintentional injury and/or death are listed by order of frequency report on final mortality statistics. Monthly vital statis­
in Table 11-1. In 1980, unintentional fatalities (105,718) ex­ tics report. 32:4-7;1994.
480 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Table 11-2. Abbreviated injury scale (AIS). Injury Descriptions and Statistics

Code Category Motor Vehicle Accidents (MVAs)

0 None Trauma from a MVA is one of the leading causes of death
1 Minor in the United States. MVA fatalities from 1975 to 1984 totaled
2 Moderate more than 500,000. Data developed by the National Center for
3 Severe Health Statistics1and the National Highway Traffic Safety Ad­
4 Serious ministration2indicate that passenger vehicle fatalities are great­
5 Critical est in the 20 to 24 year-old group for men and 15 to 19 year-old
6 Maximum Severity (Fatality)
group for women (48.5 and 18 per 100,000, respectively). There
are approximately 46,000 fatalities and 1.3 million facial inju­
Source: National Highway Traffic Safety Administration.
ries per year from motor vehicle accidents'.
National Accident Sampling System: 1986. Washington,
D.C., 1988; Department of Transportation. H.S. 807296.
Biomechanics o f Injury The MVA is a 2-collision phenom­
enon, such as a car with another object or an occupant with
PE R C E N T
another object, and, at 55 m.p.h., it occurs within 0.07 of a sec­
ond. A higher incidence of fatalities and injuries occur with in­
creased speeds, with fatalities approaching 50% in 50 m.p.h.,
head-on collisions (Table 11-2 and Figure 11-1). Certain types
of vehicles are statistically safer than others (Table 11-3). The
occupant strikes the interior of the car 80% of the time, and he
or she is ejected from the car, or intruded upon by an external
object, 12% of the time. Collisions that involve the top and sides
of the vehicle are more likely to result in occupant ejection.
Intrusion injuries are associated with frontal impacts. Recoil­
ing, such as “whiplash”, may further inflict other “non-contact”
types of injuries 8% of the time. Cervical injuries often result
indirectly from contact and usually are related to frontal and/or
right-sided impacts and roll-overs. Frontal vehicular trauma
CRASH SEVERITY MPH tends to result in anterior anatomical avulsions or defects. How­
Injuries AIS>3 -------Fatalities
ever, forces may be propagated or directed away from the ini­
Fig. 11-1. Fatality and serious injury rate using AIS scale. tial impact, resulting in damage at distant sites, such as the tem­
A direct relationship exists between crash speed poromandibular joint3(Figure 11-2).
and severity of injury.

Table 11-3. Injury Statistics by Vehicle Type.

Accidents (AIS): 6 5 4 3 2 1 Injured

Passenger car 13.6 17.3 17.9 101 233 2205 18.1 %
Light truck/van 3.9 4 5.1 228 62.9 342 18.2%
Heavy truck 1 0.4 0.1 1.5 5.9 48 9.7 %
Motorcycles 0.9 3 6.8 27 41 103 81.9 %
Pedestrian 2 3.8 6 22 44 128 74.7 %
Total 21.4 28.5 36 174 386 2826 19.5%
Young male ejected from an au-
Source: National Center for Health Statistics. Advance report on final mortality tomobile. Patient suffered mul-
statistics, 1980. Monthly vital statistics report. 32:4-7;1984. tiple fractures of mandible and
zygomaticomaxillary complex.
Injury to distant sites is likely.
 M axillofacial Trauma 481

Firearms the trigger hand. A toe may also be used to pull the trigger in­
stead of a finger. Therefore, if the tip of the gun barrel is placed
Trauma from firearms will exhibit innumerable variations, in the mouth and the head is tipped less, greater mid-facial and
and these variations will depend on whether or not the trauma is orbital destruction will result. Also, there is often a last-second
self-inflicted. Fatal firearm injuries in the United States have flinch which may result in unilateral types of wounds.
averaged 33,000 per year, while nonfatal head injuries from The defects caused by these wounds are extensive, making
firearms have been estimated at 100,000 per year4’5. Self-in- them difficult to reconstruct surgically and restore
flicted head wounds account for 30% of all gunshot injuries. prosthodontically (Figure 11-5). Large discontinuity defects of
the mandible are common along with extensive avulsive de­
fects of the maxilla. Overlying skin and soft tissues may be
Biomechanics o f Injury The degree of injury is dependent on lacking and/or damaged. Following initial healing, residual
the type of gun used and the general ballistics of the projectile, maxillary fragments are usually displaced and lack bony at­
such as caliber, velocity, range, and direction, (Table 11-4). tachment to the cranial base. The oral mucosa may exhibit sig­
Gunshot wounds are classified as penetrating (projectile remains nificant fibrosis and scarring, and the volume of the oral cavity
in the body),perforating (projectile exits the body) or avulsive6. is often reduced.
Perforating injuries are characterized by a small entry and a
large, nonlinear exit wound with foreign bodies interspersed
(Figure 11-3). Bullets that are made of lead but are encased
with a copper jacket retain more energy within the projectile at
the point of entry, reducing impact deformation. In contrast,
expanding bullets, such as soft point, hollow nose, dumdum,
and black talon types, tend not to perforate but to fragment and
expand. These characteristics increase internal damage some
distance from the bullets primary pathway. Ultrahigh velocity
projectiles increase damage through extensive cavitation of the
wound. Shotgun wounds, particularly those that are self-inflicted,
produce large, avulsive-type injuries.

Table 11-4. Firearm ballistics.

Weapon B u lle t size V elocity (ft./sec.)

Handgun 0.22-0.45 700-1500
Rifle 0.17-0.46 1200-4500
S hotgun 000-9 1000-1300

Self-inflicted long gun wounds, which are common to the

anterior maxillofacial region, are usually directed in an inferior
to superior direction, with 30% of them to the head7. Rifles are
often the weapon of choice. Due to the length of the trigger
mechanism from the end of the barrel, and the need for the head
to be extended backwards, avulsive, nonfatal wounds often oc­
cur as vital structures are missed. The amount of hyperexten­
sion of the head will determine the amount of damage (Figure
11-4). Thus, the nature of self-inflicted wounds may be, in part, Fig. 11-3. a: Patient shot with a .38 caliber hand gun. There
the product of the distance of the trigger to the end of the barrel were multiple maxillary and mandibular frac­
in relation to the overall length of the gun. Shotguns customar­ tures, with loss of multiple teeth and alveolar
ily have a trigger-to-barrel-end length of 18 inches, while rifles bone, b and c: Closure was achieved, but, upon
have 16 inches. The overall lengths of both gun types vary from healing, there was circumoral scarring and re­
26 to 32 inches. A longer barrel length will require an increase striction, along with constriction of tongue and
in the extension of the head. If the tip of gun barrel is placed flo o r o f m o u th . R e m a in in g te e th d id not
under chin, the destruction will usually be contralateral from intercuspate in a normal fashion.
482 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Fig. 11-4. Structures affected by path of bullet depend on
hyperextension of head. Path C indicates the
most hyperextended position and the least struc­
tural damage. Path A illustrates the least hyper­
extension and the most potential damage.
a The commissure stent provides tension, serving as a scaf­
b Many sports involve physical contact which may cause
Fig. 11-5. a: Self-inflicted gunshot wound with right max­
illa avulsed. b: Right anterior body of mandible
also avulsed and required grafting. (Courtesy:
Eleni Roumanas.)
Falls, Machinery, and Explosions
Most falls and other injuries (outside of a war zone) are of
such a low velocity, or are blunt in nature, that they are usually
less devastating. However, the extent of these injuries will be
dependent upon the basic variables of injury mechanics. The
frequency of nonfatal falls remains unreported. However, fa­
talities from falls have averaged 13,000 annually1. Injuries from
falls and explosions not only result in the loss of dental struc­
tures but also loss of adjacent bone and soft tissues.
Burns
Maxillofacial structures are subject to electrical, thermal,
or chemical bums, as they are exposed and do not have the
protection provided by clothing. Infants are curious, having the
common tendency to put foreign objects into their mouths, or
they may ingest caustic chemicals. Young children may pull
boiling water from the stove over onto themselves. While many
maxillofacial or other body structures may benefit from
prosthodontic intervention for bum injuries, it is bums to the
oral commissure that are most likely to involve the maxillofa­
cial prosthodontist. These bums are usually electrical and due
to the child biting into an electrical cord or plug. Since saliva
and interstitial fluids are excellent electrical conductors, bums
to this area may be extensive, having short- and long-term se­
quelae with both functional and cosmetic implications.
The prosthodontist may be requested to construct an oral
commissure stent to maintain or restore normal oral opening
and width. Many injuries tend to be unilateral, causing asym­
metry of the oral aperture and irregular “pursing” of the lips.
These stents may be retained with orthodontic headgear or orth­
odontic bands with tube brackets. An extra-oral prosthesis may
also be used with an adjustable, stainless steel wire spring frame­
work expansion device.
fold during healing, which tends to reduce scar contracture. For
the best results, the commissure stent should be applied as soon
as possible after the initial trauma. Continuous light tension
should be employed to avoid decubital ulceration. Patient com­
pliance is critical, and children will often require parental assis­
tance. However, it is common to observe more complete heal­
ing in youthful patients. See Chapter 12 (Bum Stents section)
for further details.
Athletic Injuries
locally avulsive injuries to oral structures with displacement
and possible fracture of other adjacent structures. Improvements
in equipment, playing fields, rule changes, and coaching, along
with the increased use of mouth-guards, helmets, and face-

masks, seem to have reduced the incidence of maxillofacial in­
juries in organized sports. However, the emphasis on weight
training, while reducing the number of cervical spinal chord
injuries, along with the improvement in equipment has exacer­
bated other types of injuries. For example, a knee or a zygoma
does not match up well with a hard plastic helmet propelled by
a larger, faster, and stronger body.
Sports medicine, a recognized specialty of medicine, has
evolved from simply a practice, emphasizing the treatment of
sport-related injuries, into an organization investigating the
causes of sport injuries, with the goal of reducing both the num­
ber and severity of injuries. Most college and professional teams
have a physician in attendance. For example, college and pro­
fessional football teams will likely have an orthopedic surgeon,
and hockey teams a plastic surgeon, at games. A dentist is often
asked to custom-fit mouth-guards and to instruct participants
on the importance of faithfully wearing them. Several profes­
sional football teams have a dentist on the sidelines to treat oral-
related injuries.
Unfortunately, many oral and maxillofacial injuries occur
during a less-structured sport activity. The patient depicted in
Figure 11-6 is a good example of an injury sustained as the
result of a baseball bat during participation with limited super­
vision. When injuries of this nature occur, not only are the teeth
(primarily anterior teeth) avulsed, but also a significant amount
of the surrounding bone and soft tissues are lost. At times, the
remaining teeth may exhibit cuspal or other fractures, other teeth
may have undetectable cracks, and the vitality of peripheral teeth
may be questionable. Therefore, the evaluation of the remain­
ing dentition requires both time and persistent observation.
Psychosocial Considerations4
The aforementioned injuries present traumatic emotional
experiences for the patient. The significance of this experience
Fig. 11-6. Localized injury resulting in loss of central inci­
sors.
Section on psychosocial considerations contributed by Ronald Wiens.
Maxillofacial Trauma 483
is accentuated by the loss it represents to the patient. The injury
to the patient must be recognized by the prosthodontist as a
major loss, regardless of how well the prosthesis or the recon­
structive surgery makes the patient function or look to others.
This loss may manifest itself in the form of anxiety, depression,
or a posttraumatic stress disorder8. Prosthodontists should refer
patients with these disorders to a certified psychotherapist. The
complete cycle of loss, grief, and reintegration must be under­
stood by the practitioner in order to properly monitor the patient’s
progress.
Loss
Peretz defines loss as “a state of being deprived of or being
without something one has had and valued”9. The loss of a fa­
cial feature or other body part can be one of the most painful
experiences in life, subordinate only to the loss of a loved one
to death. The prosthodontist must understand that the loss in­
cludes not only the deprivation of the facial feature, or other
body part, but also subsequent deprivation of experiences the
individual might have had. All patients will be subject to pos­
sible rejection by their spouses, friends, business associates, and
so forth. The loss of a maxillofacial feature may mean a loss of
friends, status in a particular group, a career, and a cascade of
other negative experiences. If the patient cannot develop suc­
cessful psychological and physical coping skills, then he or she
will experience severe psychological trauma. Mental disorders
that may develop include anxiety, depression, and posttraumatic
stress disorder.
Grief
Stages of the grief process include (in sequence):
Shock and denial This includes physical changes in sleeping
or eating, depression, and an idealization of the past. The pa­
tient will be at risk for suicide at this stage if their depression is
severe.
GuiU, anger, and a search tofin d ways to make the emotional
and psychologicalpain go away Professionals need to under­
stand that the feeling of anger is really secondary to the driving
feeling of fear of the unknown and unfamiliar. The patient may
be subject to possible substance abuse at this stage.
Adjustment, acceptance, and growth This entails the realiza­
tion that the past had its faults and the future may not be so bad.
With integration of the loss into a healthy adjustment, new life
patterns are developed. Acceptance of the prosthesis will be
possible at this stage.
484 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
At some point in the grief process, the patient must de­
velop a supportive psychological link with another person. Grief
is an adaptive function “to assure group cohesiveness in spe­
cies where a social form of existence is necessary for survival”10.
Our society emphasizes competency, adequacy, and strength.
Unfortunately, this often prevents patients with a loss from shar­
ing their feelings. The prosthodontist should refer patients who
need validation to the trained professional.
Children grieve their losses openly. It has been hypoth­
esized that, because of their immaturity, children are unable to
complete their task of mourning, which will be completed later
as adults. However, this does not signify that they should-avoid
psychotherapy. To the contrary, therapy for children is strongly
indicated in this case. A predominant emotion for children to­
wards a loss is anger. Ineffectively discharged, it can set the
psychological stage for emotional difficulties as adolescents and
adults. Because of their egocentricity, children can often blame
themselves for losses and feel guilty.
Tasks of the Patient and Prosthodontist
The patient will have 4 specific psychological tasks to com­
plete in order to fully integrate with the prosthesis: (1) die pa­
tient will need to accept the reality of the loss, (2) experience
the pain of grief, (3) adjust to an environment without the part
of the body affected, and (4) reinvest in the prosthesis and any
necessary life-style changes. The patient’s family and friends
can provide invaluable support during the time of recoveiy and
adaptation to the prosthesis. The prosthodontist must understand
the concept of grief, support the patient’s expression of feel­
ings, and refer the patient to an appropriate professional, should
the grieving disturb the patient’s mental health.
Prosthodontists who are trained in psychometric testing may
wish to test the patient to clarify the degree of psychological or
emotional impairment, and to confirm the need for a referral to
a psychotherapist. While the Minnesota Multiphasic Personal­
ity Inventory (MMPI) is a comprehensive, full scale test, a va­
riety of other psychological rating scales are available and easier
to administer. Interested practitioners should explore the Sheehan
Patient Rated Anxiety Scale and the Beck Depression Inven­
tory11. Both are quickly administered and provide valuable data
immediately.
Those patients who are victims of self-inflicted trauma have
complicating psychological factors that need to be processed
with a trained psychotherapist. As described earlier, these pa­
tients will need to discuss their loss and grief after they work
towards ameliorating the factors that led to their destructive or
suicidal behavior. Frequently, these patients will have conflict­
ing thoughts over not having completed their destructive task
and accepting their new physical self. Previous thoughts and
feelings that motivated their behavior may still be present and
will need to be dealt with in the presence of a trained psycho­
therapist.
Maxillofacial Injuries
Head and Cervical Injuries
Impacts to the head, such as closed head injuries, may re­
sult in contusions, intracerebral hematomas, cerebral lacerations,
and circulatory deficiencies. These conditions may lead to lo­
calized or general brain ischemia that may affect motor and
sensory innervation, leading to changes in behavioral and cog­
nitive processes. Some patients may experience velopharyn­
geal incompetence, and a palatal lift prosthesis may be needed,
(see Chapter 7, Special Obturator Prostheses section). Tongue
motor dysfunction often accompanies velopharyngeal dysfunc­
tion in these patients, and a palatal speech and swallowing aid
may be useful (see Chapter 5, Palatal Speech and Swallowing
Aids section). The amount of functional improvement will vary
between patients and is dependent upon the extent of the inju­
ries. Closed head injury patients are typically young and many
are injured in motorcycle and automobile accidents. It is impor­
tant, as part of the rehabilitation, for the patient to be able to
communicate as soon as is possible. The retentive requirements
of the prosthesis are greater than normal. The utilization and
maintenance of as many teeth as is possible is important.
Neck injuries are divided into vertebral fractures, disloca­
tions, cord compression, and separations. Fractures in the C-l
to C-3 region generally result in death. Fractures between C-3
and C-5 often result in respiratory difficulties and quadriplegia.
Fractures below C-5 have a range of sequelae from sensory
nerve loss to the upper extremities to paraplegia. One in 5 of all
MVA fatalities include cervical fractures. Cervical injuries are
common in the 16 to 25 year age group as a result of MVA roll­
overs and ejection, causing more than 500 people to become
quadriplegics per year12.
The ability to manipulate a removable prosthesis may be
diminished in the neuromuscularly impaired or physically handi­
capped trauma patient. It may be necessary to educate either a
spouse, friend, or auxiliary personnel to help place, remove,
and cleanse the prosthesis and the dentition. Loss of dexterity
may encourage consideration for an intraoral prosthesis that is
not removable by the patient. However, the ability to perform
oral hygiene will also be reduced and may require the assis­
tance of nursing home personnel or family members. The quad­
riplegic may benefit from the placement of a prosthesis as an
appendage for activities such as writing, keyboard computing,
and painting (see Chapter 12, Mouth Controlled Devices to
Assist the Handicapped section).

Cranial Fractures*
The cause of the trauma is important and can be divided
into low velocity and high velocity trauma. Usually, low veloc­
ity trauma will cause undisplaced fractures, while the latter re­
sults in a much more significant injury. In all cranial fractures,
the significant signs to look for are changes in pupil size and
reaction to light. A fixed dilated pupil may indicate a significant
increase in intracranial pressure unilaterally, or damage to the
optic nerve or ophthalmic artery. Bilateral changes indicate a
generalized increase in intracranial pressure, or damage to both
optic nerves or optic chiasma. The depth of coma is significant
and frequently is associated with other signs which will be dis­
cussed later.
Seizures indicate focal brain involvement or an increase in
intracranial pressure. Limb weakness and hemiplegia is an in­
dication of focal brain damage. Leaking of cerebral spinal fluid
(CSF) from the ear or nose, with associated temporal or ante­
rior skull base fractures, indicates a dural tear. Bleeding from
the ear may also be indicative of fracture of the temporal bone.
All patients with a head injury should be watched and moni­
tored very carefully. Localized signs or evidence of increasing
intracranial pressure are indications for surgical exploration.
A CT scan will provide useful information on fractures,
brain displacement, and brain injury, and these findings will be
important in decisions regarding exploration. An obvious de­
formity, especially when the frontal sinus is involved, is an­
other indication for exploration. Skull x-rays are a useful screen­
ing procedure to diagnose the presence or absence of a skull
fracture.
Exploration and Treatment of Cranial Fractures
On most occasions, a coronal flap is used for exploration
and treatment. This will permit examination of almost all re­
gions, except the occipital area, where a posterior flap is em­
ployed. The only indication for exploring undisplaced cranial
fractures is extradural bleeding. This will occur when a tempo­
ral fracture crosses the canal for the middle meningeal artery.
Burr holes are made and a temporal bone flap is elevated. This
will allow release of the hematoma and cauterization of the ves­
sel. The bone flap is replaced with wires or plates, and the coro­
nal incision is closed with drainage.
Displaced cranial fractures are explored most frequently
with a coronal flap, the loose bone is removed, and the appro­
priate craniotomy performed. This flap will allow exposure of
the area for control of hemorrhage, repair of dural tears, and so
forth. Once these conditions have been corrected, the displaced
bone and the craniotomy are replaced and fixed in the correct
position with wires, miniplates, or microplates. The vast major­
Sections on cranial fractures, orbital fractures, nasal fractures, and soft tissue trauma contributed by Ian Jackson.
Maxillofacial Trauma 485
ity of these patients are given intravenous steroids to reduce
brain swelling, and all are given intravenous antibiotics. After a
suitable period of healing (generally, 1 year), cranial defects
that result from these injuries can be restored with preformed
cranial implants (see Chapter 10).
Anterior cranial fossa fractures, which involve either the
frontal or ethmoid sinus in combination with dural tears, pre­
disposes the patient to meningitis, since the intradural space is
in contact with the nasopharynx. Another complication is long-
range drainage problems associated with chronic sinusitis and/
or mucocele. There are several suggested ways to treat this situ­
ation, such as the removal of sinus mucosa, increased provision
for drainage, and removal of the posterior wall of the frontal
sinus (cranialization). It is necessary to carefully analyze each
situation in order to determine the most appropriate treatment.
When- trauma creates a defect in the posterior sinus wall,
cranialization, with complete removal of sinus mucosa and burr­
ing of the sinus walls with a high speed drill, is the preferred
treatment. When there is also a dural tear, the tear must be care­
fully repaired. This is accomplished by direct closure or by us­
ing a patch of pericranium, deep temporal fascia, or facia lata to
aid in closure. The posterior wall may be removed partially or
totally, or it may be left intact. The sinus mucosa is removed
completely, and the inner aspect of the sinus is burred to re­
move all spicules and crests of bone and open the sinus areas.
The resultant cranial defect can be restored with a preformed
cranial implant or other means (see Chapter 10).
Orbital Fractures
Supraorbital Rim Fractures
These fractures are frequently associated with the frontal
bone, and they are reduced and stabilized at the same time as is
the frontal fracture. The coronal approach allows clear visual­
ization for fixation with microplates or wires. If the orbital roof
is fractured, the fragments are left in position, and defects are
frequently left untreated. These defects can be grafted if bone is
available, but this treatment is usually not essential. Pulsation
of the eye does not occur without an underlying pathology, such
as a posttraumatic, anterior venous aneurysm in the cavernous
sinus.
Orbitozygomatic Fractures
There are 4 main groups of fractures in this category13. Fre­
quently, malar radiographs will allow the diagnosis to be estab­
lished and treatment instituted. However, in high-velocity inju­
ries with significant displacement, a CT scan with axial and
coronal views is advocated in order to complete the diagnosis.
486 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
The trauma may be either of low or high velocity, but the latter
is usually associated with other injuries, such as a LeFort HI
fracture. If there is swelling and bruising around the lid, there
may be vertical or horizontal changes in globe position, de­
creased or double vision, poor eye movement, and trismus or
infraorbital nerve damage14.
Infraorbital Rim Fractures
These fractures result from direct trauma, such as a fall.
The fracture is usually localized, but the force may be transmit­
ted to the orbital floor, and a fracture can result in this area-, also.
Swelling, bruising, infraorbital nerve numbness, diplopia, and
dystopia can occur in association with orbital floor damage.
The diagnosis is established with facial bone x-rays. The frac­
ture is treated with direct exposure, using a conjunctival or lid
incision, and is reduced and fixed with wires or microplates. A
floor fracture is left untreated if it is not displaced.-Displace­
ment requires the same treatment as for a blowout fracture.
Orbital Floor Blowout Fractures
These fractures may occur in isolation or as part of a com­
plex of orbital fractures. The classic blowout fracture results
from injury to the globe or orbital rim in which the force is
transmitted to the floor which then fractures into the antrum.
The clinical signs are enophthalmos, dystopia, diplopia (in up­
ward gaze), and a positive forced duction test. The conjunctiva
is anesthetized, and an attempt is made to rotate the globe up­
wards by grasping the conjunctiva of the lower fornix with for­
ceps. If rotation is impossible, the inferior rectus may be trapped
in the fracture. The diagnosis can be established with a coronal
CT scan, or a sagittal scan taken in the long axis of the orbit. A
PA x-ray of the face may, in large defects, show the “hanging
drop” sign when orbital contents are in the antrum.
Treatment is by exposure of the floor, using a lid or con­
junctival incision, and dissection of orbital contents from the
floor defect. Exploration can be performed safely for a distance
of 4 to 5 cm towards the orbital apex. The floor is reconstructed
with silicone or teflon sheeting, septal cartilage, or a cranial
bone graft. Alloplastic material is favored by a majority of sur­
geons, but septal cartilage is advocated for small defects, and a
split cranial bone graft is advocated for more extensive injuries.
The injury is usually more extensive when the injury of the
floor is associated with other orbital fractures. The cranial bone
graft is usually fixed to the inferior orbital rim with a small,
contoured plate. In very severe injuries, there may be extensive
damage to the medial and lateral orbital walls. In this situation,
it can be difficult to stabilize the reconstruction and, when this
is the case, a floor is created with metal mesh with or without an
onlay bone graft. With these injuries, the incidence of diplopia
is significant.
Complications of Extensive Orbital Fractures
There are 3 reasons why these injuries are significant. First,
there is an obvious deformity, and incomplete reduction of the
fracture is common. Second, enophthalmos is a frequent re­
sidual problem, and complete correction may be impossible.
Third, eye displacement and/or compromised muscle function
may result in diplopia, which is rarely completely corrected by
the subsequent surgery.
Nasal Fractures
Undisplaced nasal fractures do not cause a deformity and,
therefore, treatment is not indicated. It is important, however,
to examine for septal displacement and septal hematoma. Dis­
placed fractures are best diagnosed on clinical examination, as
x-rays are of limited value. The fractures are reduced by instru­
mentation and manipulation, and then stabilized with tape and
a plaster cast. If the septum is displaced, it must be manipulated
into its correct position. Septal hematomas are incised and
drained. Failure to do so may lead to infection, subsequent loss
of the septum, and nasal deformity due to the lack of support
for the soft tissues of the nose.
Soft Tissue Trauma
The soft tissues of the head and neck have an abundant
blood supply so that incisions and lacerations usually can heal
quickly. With proper management, complications are few and
scars are frequently acceptable. Fortunately, it is unusual for
portions of the face to be avulsed or sloughed—even with se­
vere injuries. Should this occur, local skin flaps are used to re­
construct the area. Large defects may require local regional flaps
or possibly a vascularized free flap.
Scalp lacerations are closed in 1 or 2 layers, depending on
the preference of the surgeon. Complications may include the
loss of hair in relation to the scars. If there is loss of a portion of
scalp, a flap can usually be designed to close the defect Avul­
sion of large areas of the scalp may require replacement of the
avulsed part with a vascularized free flap.
Lacerations of the ear are common and are carefully re­
paired. Rarely can avulsed potions of the ear be salvaged, and
they should be discarded. A subtotal or total ear amputation
should be reimplanted with microsurgical anastomosis of ves­
sels. Lacerations of the nose are repaired in layers, and small
skin defects can be reconstructed with local flaps. Rarely can
avulsed portions of nose be salvaged, unless they are large and
have vessels that can be re-anastomosed. The eyelids are very
important functionally and must be carefully repaired in layers.
Any defect of the lids must be reconstructed, especially the up­
per lid, since this lid serves to protect the eye. Local flaps or
portions of the lower lid are used in upper lid reconstruction.

The help of an ophthalmologist is suggested if the eye is dam­
aged in any way.
The lips are an esthetic area with definite contours and a
mucocutaneous junction. Careful closure in layers is indicated
with accurate realignment of the skin and vermilion junctions.
Small lip defects can be corrected by converting them into a
full thickness, wedge-shaped lip defect, and then closing this
defect with care. Large lip defects require closure with local
flap(s). The tongue has an excellent blood supply, so it should
always be repaired—even if portions have only a small pedicle
or seem ischemic. Watertight closure of the oral mucous mem­
branes during initial treatment is strongly advised—even though
this practice may lead to some distortion of oral structures.’
Jaw Fractures*
The surgeon is frequently confronted with the management
of jaw fractures that are inherently unstable and, in addition,
often result in occlusal derangements. It is such cases, the sur­
geon requires the assistance of the maxillofacial prosthodontist
in the designing and fabrication of prostheses to aid in the im­
mobilization of the fractured bones, so that rapid and satisfac­
tory healing can take place. Following satisfactory healing, the
prosthodontist may also be required to refine any resultant oc­
clusal disharmonies, and to restore missing structures, as needed.
Anatomic Considerations
Traditionally, the facial skeleton has been divided into 3
segments (Figure 11-7). The middle third area, frequently called
the mid-face area, comprises a central facial area that includes
the nasal complex region. The lateral portion of this middle third
area is referred to as the zygoma, malar, or cheek area, and should
more accurately be called the zygomaticomaxillary complex
region. The zygomatic arches lie within this lateral component
of the middle third area and often fracture independently. The
upper limit of this middle third area is the supraorbital ridge,
and the lower (inferior) limit is the occlusal plane. The lower
third of the facial skeleton is composed of the mandible and the
mandibular teeth.
The mid-face region is made up of multiple, relatively thin,
fragile bones that tend to absorb the fracturing force, resulting
in multiple fractures of the individual bones. It is the dissipa­
tion of these forces by the fracturing of the facial bones that
tends to serve as a protection to the orbit and intracranial struc­
tures.
Considerable forces are necessary to cause a fracture of
the jaws. But it must be noted that there are certain inherently
weak bony areas of the jaws along which fractures have a greater
tendency to occur. This is especially true in the mandible, and
fractures commonly occur in the region of the impacted man­
dibular third molar and in the region of the mandibular cuspid
Section on jaw fractures contributed by Frank Brady.
Maxillofacial Trauma 487
because of its relatively long root structure. The long, slender
mandibular condylar neck is another area where fractures fre­
quently occur. Li addition, certain pathologic states, such as cysts
when they exist in bone, increase the likelihood of a fracture
either as a spontaneous event or with a minimum of trauma.
Fig. 11-7. Shaded area is shown as middle (or mid third)
of face. Region lying above this is upper third,
and lower third is represented by mandible and
mandibular dentition.
Classification of Fractures
Essentially, jaw fractures are either of the closed (simple)
or open (compound) variety. Simple fractures occur when the
break in the bone is not associated with an open wound. A frac­
ture is referred to as compound when an open wound exists. In
the oral and maxillofacial region, a break in title integrity of the
skin, mucosal lining of the mouth, nasal passages, or associated
paranasal air sinuses constitutes an open wound. It should be
appreciated that any fracture of the jaws that occurs in the tooth-
bearing area is, by definition, compound intraorally, as there is
always some degree of laceration at the gingival crevice.
Fractures in general have been further subdivided to de­
scribe the way the ends of the bones have broken. This is usu­
ally determined by radiographs. A greenstick fracture is one in
which the bone is not broken completely through. Because the
bones of young children are relatively soft and pliable, it is in
this age group that such fractures are generally encountered.
Subcondylar fractures in children are usually of this variety. An
oblique fracture occurs when the fracture extends diagonally
along the bone. This variety of fracture is frequently encoun­
tered in the body and ramus of the mandible. A transverse frac­
ture is one in which the fracture exhibits litde or no separation
488 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
of the broken ends. An impacted fracture is one in which the
broken ends of a bone or bony complex are not separate but are
actually jammed together. This is a common finding in the mid-
maxillofacial region.
General Principles of Jaw Fractures
Fractures can occur singly or in several combinations. A
blow to the chin can cause a fracture at the parasymphyseal
region (so-called “direct fracture”) and the fracturing force may
be transmitted to the opposite condylar area, causing a
subcondylar fracture (so-called “indirect fracture”). Another
commonly seen combination is in an injury to the central part
of the chin, which often does not fracture itself, in which the
force is transmitted to both condylar areas, resulting in bilateral
subcondylar fractures (indirect fractures).
Unlike fractures in the mid-face region, mandibular frac­
tures are frequently influenced by muscular displacing forces.
Whether or not the fragments become displaced by the muscu­
lar forces depends on the direction of the fracture plane. When
it is parallel to the muscular pull, the fracture plane allows dis­
placement of the fragments (unfavorable fracture) (Figure 11-
8a). When the fracture plane is in the opposite direction, the
muscle pull is advantageous (favorable fracture) (Figure 11-
8b). Favorable fractures tend to be self-retaining and facilitate
more rapid healing. While the displacement of the bony frag­
ments may be the result of the direction of the fracturing force,
the degree and severity of the displacement is often greatly in­
fluenced by the direction of the muscular pull. Unfavorable frac­
tures usually require the fabrication and placement of splints to
help maintain the position of the fragments.
Fig. 11-8. a: Unfavorable fracture. Muscular forces are un­
favorable. b: Favorable fracture. Muscular forces
are favorable.
Fig. 11-9. Fracture o f left parasym physeal region and
angle. Note malocclusion.
Fractures of the Mandible
The relative prominence and position of the mandible make
it particularly susceptible to fracture. In the absence of an un­
derlying disease process, significant violence is required to frac­
ture the mandible. External violence, usually in the form of ve­
hicular accidents, sporting injuries, fist fights, falls, industrial
accidents, or gunshot injuries account for the fracturing forces
in most instances. As previously mentioned, the mandibular
angle, parasymphysis, and condylar neck area are the sites most
commonly affected.
Clinical features The most consistent single clinical finding
of a mandibular fracture is a dental malocclusion. Depending
on the nature of the fracture, this malocclusion may be obvious
(Figure 11-9) or it may be subtle. If a patient volunteers the
information that “the teeth don’t meet together properly” after
trauma to the jaw, then a fracture must be assumed until proved
otherwise. The cardinal clinical features of any fracture (i.e.,
pain, swelling, deformity, and loss of function) will be seen to
varying degrees in any fracture of the mandible. The pain is
usually made worse by movement of the fractured segments.
Should the fracture be between the lingual and the mental fora­
men, varying degrees of numbness of the lower lip may be
present. The site and extent of the swelling is obviously depen­
dent on the location and severity of the fracture. In most frac­
tures of the mandible (other than those of the condylar area),
there is evidence of intraoral bruising. A sublingual hematoma
is a consistent finding and an important diagnostic sign. Often,
there are other areas of hematoma and, if the fracture is in a
tooth-bearing area, there is tearing or bruising of the gingivae.
The range of deformity varies with the type and severity of the
fracture, and the loss of function of the mandible is manifested
by inability to chew properly, speech difficulties, dysphagia,
inability to control salvation, and occasional respiratory diffi­
culties. Examination of the patient must include gentle palpa-

tion of the mandible bimanually, with one fmger inside and one
finger outside the mouth. Fracture sites and movements of the
bones can thus be detected. Most fractures of the mandible can
be diagnosed clinically, but radiographs must be obtained to
confirm the diagnosis.
Location (Figure 11-10)
Region o f symphysis The anterior region of the mandible
that extends from a vertical line just distal to the mandibular
cuspid on each side is called the symphyseal region. Fractures
in this area are called symphyseal fractures. Fractures that oc­
cur exactly through the midline are rare, probably accounting
for less than 1% of all mandibular fractures. Fractures in this
region are far more likely to occur on either side of the midline
and are thus often referred to parasymphyseal fractures. Such
fractures are generally oblique and extend in a posteroinferior
direction from the region of the mental fossa to the lower bor­
der of the mandible. Because of the nature of the muscle forces
acting on such oblique fractures, there is frequently an overlap­
ping or telescoping effect of the fragments.
Region o f the body The body of the mandible has been
described as the segment that lies between a vertical line drawn
distal to the mandibular cuspid and a line coinciding with the
anterior border of the masseter muscle. This region, which sup­
ports the mandibular bicuspid and molar teeth, is the thickest
and strongest portion of the bone, but nonetheless it is frequently
involved in fractures. Fractures in this region, which are by defi­
nition compound intraorally, usually exhibit most of the classic
signs and symptoms of fracture of the mandible. Paresthesia or
anesthesia are fairly constant findings in these fractures because
of injury to the inferior alveolar nerve. Should the proximal
Condylar
process
Ramus
Symphysis
Fig. 11-10. Location of mandibular fractures with percentage of incidence of occurrence.
Maxillofacial Trauma 489
fractured segment (i.e., the segment nearest to the temporoman­
dibular joint) be edentulous, and the direction of the fracture is
horizontal and unfavorable (as it frequendy is), then this frag­
ment is pulled upward and medially by the pterygomasseteric
sling of muscles until it impinges on the upper arch or alveolar
ridge. If this proximal fragment has teeth, they will occlude
with their maxillary counterparts (if present).
Anglefractures The region of the angle has been defined
clinically as the area of the mandible enclosed by the
pterygomasseteric sling of muscles. This region accounts for
approximately 20% to 25% of all fractures of the mandible.
The possibility of a subcondylar fracture, or fracture of the op­
posite side of the mandible, should be considered when a frac­
ture of the angle region of the mandible occurs. Although the
pterygomasseteric muscle complex affords good protection to
this area, it is still a common site for fractures because the bone
is thinner here than bone is in the body, and the relatively high
incidence of impacted third molars in this region further weak­
ens the bone. The more posterior the angle of the fracture, the
more likely it is to be splinted by the muscles and thus be
undisplaced. More anterior angle fractures frequently produce
varying degrees of displacement of the proximal fragment, usu­
ally in a superomedial direction.
Ramusfractures Because of the powerful splinting effect
of the pterygomasseteric sling of muscles, fractures in the re­
gion of the ramus are rare and almost never displaced.
Coronoidfractures The coronoid region is well-protected
by muscles and by the bony zygomatic arch, and, thus, isolated
fractures of this region are rare. Fractures of this region gener­
ally occur in conjunction with fractures of other parts of the
mandible.
14%
490 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Condylarfractures Fractures in the region of the head of
the condyle and the slender condylar neck seldom are the result
of direct trauma to the area; they are more likely to be a result of
an indirect injury from a direct blow to the parasymphyseal
region of the opposite side of the mandible. Fractures of the
condylar head are of either the intracapsular, or the extracapsu-
lar variety. Direct trauma to the midline symphyseal area of the
mandible can result in bilateral subcondylar fractures; a clinical
situation that often poses a difficult management problem. Be­
cause of the attachment of the lateral (external) pterygoid muscle
(i.e., to the anterior surface of the condylar neck), fractures be­
low this attachment usually result in an anteromedial displace­
ment of this proximal (upper) fragment. Clinically, this mani­
fests itself in deviation to the affected side on opening of the
mouth, and in frequently altered occlusal relationships.
In bilateral subcondylar fractures, there is a shortening of
the posterior facial height with an anterior open bite (Figure 11-
11). Intracapsular fractures, which by definition occur above
the attachment of the lateral pterygoid muscle, are therefore not
subjected to muscular displacing forces. There is often an oc­
clusal disharmony on the affected side as a result of intracapsular
bleeding, which forces the condyle downward.
If not managed correctly, subcondylar fractures will lead
to a variety of problems. These include anterior open bite, tem­
poromandibular joint dysfunction, and trismus. The younger
the patient, the more likely is the possibility of an ankylosis of
the temporomandibularjoint, especially in an intracapsular frac­
ture.
a the fact that this thin wall of bone (lamina papyracea) is com­
b
Fig. 11-11. a: Bilateral subcondylar fractures, b: Note aper-
tognathia.
Fractures of the Maxillae and Middle Third of the Face
Generalprinciples The commonest facial fracture, and gener­
ally the simplest to treat, is the nasal fracture. However, maxil­
lary fractures, often the most demanding facial fractures to treat,
also he within the same middle third area.
Often, such fractures are misdiagnosed or undiagnosed.
There are several reasons for this situation. The facial bones are
thin and fragile and lie in several planes. Soft tissue swelling
often masks the degree of underlying bony deformity. Because
of the relative density of the cranial bones that lie behind the
mid-facial bony skeleton, even a grossly displaced fracture may
be difficult to demonstrate by conventional radiographic ex­
amination. Therefore, the diagnosis of such fractures is usually
determined by clinical evaluation and/or CT scans.
Fractures ofthe zygomaticomaxillary complex Fractures that
are confined to the lateral middle third area are often made more
confusing by differences in terminology. The most accurate term
to use should bt fracture o f the zygomaticomaxillary complex.
The zygoma (malar or cheek bone) and zygomatic arch are com­
posed of 3 bony entities: the zygomatic process of the temporal
bone, the zygoma, and the short zygomatic process of the max­
illa. All 3 form a part of the zygomaticomaxillary complex. These
names are often used incorrectiy in an interchangeable fashion.
Most important is that most of these bones form part of the
bony orbital cavity and, therefore, many of these fractures fre­
quently involve the orbit and its contents.
Smith and Regan were the first to describe a fracture of
this region that was confined to the orbital floor15. The orbital
blowoutfracture, as it is called, is caused by trauma applied to
the orbital globe that causes a sudden, sharp rise in the intraor­
bital pressure. As previously mentioned, the orbital floor is par­
ticularly thin and fragile and is therefore easily fractured by this
intraorbital compressing force. It is of interest to note that frac­
ture and blowout through the equally fragile and thin medial
wall of the bony orbit is rare, and this is possibly explained by
posed of honeycombed ethmoidal air sinuses, which may help
to dissipate the forces.
Clinicalfeatures Of primary importance in evaluating
suspected fractures of the zygomaticomaxillary complex is a
thorough examination and assessment of the orbit and the or­
bital contents. In the infant and young child, reliance often has
to be placed on the physical examination alone. In the older
child and adult, correlating the signs with the symptoms make a
final diagnosis an easier task. The basic principle of comparing
sides is important. The examining doctor should note any peri­
orbital ecchymosis or edema. Should the eyelids be markedly
edematous, as they frequently are, difficulty may be experienced
in examining the eye adequately. Sterile cotton swabs may prove
 Maxillofacial Trauma 491

extremely useful as an aid to examination. Subconjunctival hem­

orrhage extending to the limbus of the eye is a strong support­
ing sign of a bony orbital fracture. Edema of the conjunctiva
(chemosis) may be seen in many cases. Eye movements should
be carefully evaluated and any diplopia noted. Diplopia restricted Fig. 11-12.
to the upward gaze usually implies a fracture of the orbital floor Note close anatomic relation­
with some degree of entrapment of the inferior rectus muscle. ship of coronoid process and
Careful palpation of the orbital rims (comparing both sides) zygomatic arch.
should be carried out and any “point tenderness” elicited by the
examining finger noted. Such tenderness in the regions of the
frontozygomatic suture, and the zygomaticomaxillary suture
especially, is an important diagnostic sign. In addition, any It must be emphasized that it is a sound policy to seek con­
“steps” in the rims should be noted, as these represent a discon­ sultation from the ophthalmologic service in all cases of frac­
tinuity in the bony contour. Palpation over the zygomatic arch tures involving the bony orbit. Expert preoperative assessment
area for tenderness and any depressions is also important On of the eye is essential if serious problems are to be avoided.
occasion, orbital emphysema can be detected as a crackling This obviously is of major importance should any damage to
crepitation sensation by the examining fingers. This sign im­ the globe itself be suspected.
plies that there is a communication between the nasal passages,
or paranasal air sinuses, and the periorbital soft tissues. The air Fractures of the central middle third of the facial skeleton
passes into these soft tissues, usually as the result of a sudden Classic experimental studies by Rene LeFort broadly subdivided
rise in the intranasal air pressure, which frequently is the result fractures of this region into 3 main groups17:
of blowing the nose sometime after the trauma occurred. This
can be an alarming sign, but it tends to disappear rapidly if simple LeFort I (low level, Guerin type)
measures are carried out16. LeFort II (pyramidal)
If the zygomatic arch is depressed and/or the zygomatico­ LeFort III (high level, craniofacial dysfunction type) (Figure
maxillary complex fracture is rotated, there may be an obvious 11-13)
flattening of the normal cheek prominence. However, the in­
evitable edema that accompanies these fractures often obscures
this flattening, and the appearance may appear deceptively nor­
mal—even though the underlying bony structure may be mark­
edly depressed. Subtle depressions and flattening may be best
appreciated if the patient is examined from behind and above.
Unilateral epistaxsis is often seen in these fractures as the result
of bleeding into the affected maxillary antrum. Because of the
close proximity of the infraorbital nerve to the inferior orbital
rim, fractures in this region are frequently associated with dam­
age to this nerve and its terminal branches. Clinically, this is
manifested by anesthesia (or paresthesia) of the lower eyelid
side of the nose and upper lip. Direct trauma to the prominence
of the cheek may result in a small area of sensory impairment
from contusion of the zygomaticofacial nerve, a small but con­
sistent branch of the maxillary nerve.
On occasion, these fractures are compound intraorally, with
resultant oral bleeding or ecchymosis, and, therefore, no ex­
amination is complete without a thorough intraoral examina­
tion. In addition, the occlusion should not be neglected, as a
downwardly rotated complex fracture can alter the occlusion in Fig. 11-13. Top and bottom: The dotted line (• • •) repre­
certain instances. Trismus and/or restricted lateral excursion of sents level of LeFort I (low level, Guerin type)
the mandible to the affected side may be seen in depressed arch fracture; the broken line (------ ) represents level
fractures. 11118 is easily explained when one considers the close of LeFort II (pyramidal) fracture; and the dotted
anatomic relationship of the zygomatic arch to the coronoid and broken line (— — •) represents level of LeFort
process of the mandible (Figure 11-12). III fracture.
492 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Note that LeFort I and II fractures are both subzygomatic,
whereas the LeFort HI variety is suprazygomatic in nature.
Combinations of any of these varieties may occur. Although
many different bones comprise the facial skeletal framework,
from a practical point of view, fractures should be considered in
reference to large “blocks” of bone rather than to the individual
components.
Clinicalfeatures If a LeFort fracture is suspected clini­
cally, important diagnostic signs to look for are mobility of the
fractured block of bone and teeth in relation to a fixed point. In
a LeFort DI fracture (or high-level fracture), such a fixed point
is the frontal bone area, whereas, in a LeFort I type fracture’, the
nasal apparatus and zygomatic area are unaffected and there­
fore stable relative to the mobile fracture. However, such mo­
bility is not always elicited, especially in impacted fractures,
and considerable experience is needed to detect subtle move­
ments in some cases. LeFort HI fractures should demonstrate
many classic signs. Generalized facial edema is often marked.
Bilateral periorbital hematoma and subconjunctival hemorrhage
are important signs. Again, massive edema may mask the de­
gree of underlying skeletal disruption. In LeFort HI fractures,
the tendency is for the entire middle third complex to be pushed
posteriorly. As the base of the skull assumes an inclined plane
relative to the occlusal plane, such a backward displacement is
accompanied by a downward displacement of the posterior por­
tion. This may be represented clinically as an overall flattening
of the face, which also becomes elongated, and is accompanied
by an anterior open bite. Dysfunction of the middle third facial
complex from the cranial base in the region of the cribriform
plate of the ethmoid bone may result in a tearing of the olfac­
tory nerve elements, with resultant permanent damage to the
sense of smell. Trauma in this area may also be accompanied
by a rupture of the meningeal coverings (dura mater and arach­
noid) of these first cranial nerves, with the resultant escape of
cerebrospinal fluid from the subarachnoid space into the nasal
cavity (cerebrospinal fluid rhinorrhea).
Often accompanying such middle third fractures are frac­
tures of the nasal bones and nasoethmoidal complex. Such com­
pression fractures are usually associated with a widening of the
nasal bridge area and a resultant traumatic ocular hypertelorism.
Radiographic Considerations in Jaw Fractures
Radiographs are invaluable aids to the diagnosis of facial
fractures. They should complement a thorough history and physi­
cal examination, but they do not substitute for such an exami­
nation. Facial radiographs, although important, should not take
precedence over basic life-support measures. When basic life-
support is accomplished, no definitive treatment should be un­
dertaken without an adequate radiographic survey of the facial
bones. Conventional radiography and CT scans may aid in de­
tecting fractures that could not have been suspected clinically.
However, because of the complexity of the facial bony skel­
eton, and because of the overlapping effect of the cranial bones
and spinal column, many conventional radiographs can prove
difficult to interpret, so CT scans may be preferred.
A panoramic view (Panorex, orthopantogram) is extremely
valuable for fractures of the mandible. If this is not available,
right and left oblique views of the mandible, and a Towne view
of the condyles and subcondylar region, will suffice. A man­
dibular occlusal film is valuable in assessing symphyseal and
parasymphyseal fractures. Should the fracture occur in the tooth-
bearing area of the mandible, periapical films of the teeth at the
fracture site should be obtained if possible.
The single most informative conventional radiograph of
the mid-facial region is the occipitomental, or Water’s, projec­
tion. This is a posteroanterior view with the neck, slightly ex­
tended so that structures, such as the petrous temporal ridges
and the mastoid air cells, do not obscure the area to be viewed.
It is often wise to obtain several Water’s views at varying tilts.
A submentovertex view (“jug-handle” view) demonstrates the
zygomatic arches. Lateral and posteroanterior views of the fa­
cial bones also should be obtained. The integrity of the nasal
bones is determined on their lateral and occlusal views. On oc­
casion, it may prove necessary to obtain CT scans in specific
situations, such as in evaluating the integrity of the orbital floor.
Management of Facial Bone Fractures
Early (supportive) management When fractures of the facial
skeleton occur, attention must primarily be directed to basic
life-support measures. First, priority must be given to the estab­
lishment and maintenance of an adequate airway. Blood, mu­
cous, or vomitus should be removed from the oropharynx, ei­
ther manually, or with the aid of a suction apparatus. The tongue
should be prevented from retruding and obstructing the oropha­
ryngeal airway by positioning the head, or by utilizing gentle
traction with a suture or towel clip placed on the tongue. Place­
ment of an oral airway, anasoendotracheal airway, or an endot­
racheal tube may be necessary. Should these measures fail, a
tracheostomy may have to be performed. Should any doubt exist
as to whether to perform a tracheostomy, it is probably best to
do one. Once the airway has been established, attention should
be directed to arresting any hemorrhage.
Once the airway and hemorrhage have been properly man­
aged, attention should be directed to the patient’s general physical
condition and any associated injuries, such as trauma to the chest,
abdomen, and other bones. Adequate fluid intake is essential.
Maintenance of an intravenous line with adequate fluid replace­
ment may prove necessary, as dehydration can easily occur as a
result of inadequate oral fluid intake. Once the patient’s condi­
tion has been stabilized, the nature and extent of the facial inju­
ries are assessed.

As a temporary supportive aid, Barton’s head bandages
may be used. The temporary splinting action can greatly mini­
mize the pain and discomfort. Should it be necessary to sedate
the patient, or to administer a short general anesthetic for as­
sessment purposes, this time should be utilized to obtain im­
pressions of the dental arches. Casts made from such impres­
sions often prove invaluable in accurately assessing the occlu­
sion and the condition of the teeth. In addition, these casts can
be duplicated and utilized for the construction of various types
of splints. Such impressions can be obtained with local anes­
thesia, as well.
In highly unstable fractures, particularly those that might
embarrass the airway due to loss of tongue control, it may prove
necessary to temporarily wire the jaws together, although this
should be avoided unless absolutely necessary. However, a wire
passed around the teeth on either side of the fracture, without
wiring the jaws together, often proves useful as a temporary
measure.
Appropriate analgesics should be administered. Any facial
fracture that passes the socket of a tooth is, by definition, com­
pounded intraorally—even if the fracture is not displaced and
the tooth is firm in the socket. Similarly, fractures that involve
the paranasal sinuses should also be considered compound and,
therefore, all patients with such fractures should receive adequate
antibiotic prophylaxis.
The general aim of treatment is to achieve bone healing
with the best possible dental occlusion in the shortest possible
time. Restoring the bone ends and the proper dental occlusion
maintains appearance and symmetry. As soon as the patient’s
general condition permits, reduction or realignment of the bony
fragments should be carried out. This is then followed by a pe­
riod of immobilization to allow bony healing to take place.
Often, fractured bone ends can be realigned by manipula­
tion of the fragments without direct visualization of the frac­
tured bone ends. This closed method of reduction is usually
employed when the displacement of the fragments is minimal
and a good stable result is anticipated. However, it may prove
necessary in some instances to surgically expose the fracture
site and visualize the bone ends to reduce the fracture. When an
open reduction is performed, the reduced fragments are usually
secured by interosseous (transosseous) wires, plates, or metal
mesh tray systems. Depending on the individual circumstances,
open reduction of a fractured jaw can be performed either via
the intraoral or the extraoral route.
As soon as the general condition of the patient permits,
reduction and immobilization of the fracture should be carried
out. However, it must be emphasized that, apart from an acute
airway problem or profuse hemorrhage (which is surprisingly
rare), fractures of the jaws alone are rarely life threatening. There­
fore, it is generally more prudent to allow time for the patient’s
condition to be stabilized, and utilize this time to obtain satis­
factory radiographs and study casts.
Maxillofacial Trauma 493
Temporomandibular Joint Injuries
Injuries to the temporomandibularjoints are common, with
traumatic forces directed to the anterior mandible and/or from
direct impact on the TMJ. The examination should note the pres­
ence of pain, abnormal sounds, and any limitation of rotary and
translatory movement, as observed during vertical opening and/
or lateral eccentric jaw movements. Evaluation should also in­
clude an assessment of the normal range of border movements,
with consideration for individual patient variations. Compari­
sons should be made between restrictions during right and left
lateral and protrusive jaw movements, with and without tooth
contact. Restrictions to movement may be related to intracaspular
injuries, such as adhesions, displaced discs, intracondylar frac­
tures, and so forth. Extracapsular injuries may be caused by
mandibular-zygoma-maxillary fractures, neuromuscular splint­
ing, or spasms. Deviations will usually occur toward the af­
fected side. The diagnosis is typically supported by restricted
lateral jaw movements (lack of translation) that corresponds to
an ipsilateral deviated protrusive movement. A previous his­
tory of temporomandibular disorders (TMDs) and its treatment
should be carefully noted.
Traumatic injuries may exacerbate a preexisting TMD
whose symptomatology may have been sub-clinical, inconspicu­
ous, and/or long-standing. Initial findings may indicate symp­
tomatology, suggesting subluxation, edema, and sprain of lim­
ited duration that may resolve with rest, soft diet, and applica­
tion of vapocoolant spray with alternating moist heat to the
musculature. It is common to find that the posterior teeth can­
not achieve maximal intereuspation, as determined by articu­
lating ribbon or shimstock, and the anterior teeth may be in
hyperfunction, as indicated by the patient’s awareness and pres­
ence of fremitus. The prescription of nonsteroidal, anti-inflam­
matory drugs or muscle relaxants may be indicated.
Unstable disc complexes can result in reciprocal clicking
(with anterior displaced discs) with or without reduction and
locking. This may indicate a need to provide a stabilizing influ­
ence upon the articular disc, with uniform occlusal contact pro­
vided by inter-occlusal splints. Occlusal adjustments may not
be indicated during the initial stabilization period, as atypical
tooth contacts may resolve with reduction in soft tissue inflam­
mation and muscle spasm, or eliminated with reduction of the
bony fractures. Occlusal adjustments may be indicated when
attempting to eliminate tooth hyperfunction that may lead to
tooth fracture, periodontal injury, and/or migration. After surgi­
cal fracture reduction, occlusal adjustments and/or restorations
may be required to reduce excessive tooth contacts when the
vertical dimension of occlusion has been traumatically increased
and/or decreased from residual malposed bony segments.
Subcondylar neck fractures are a frequent finding, while
intracondylar fractures are less frequent and more difficult to
observe radiographically without tomograms.
494 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Severe trauma may fracture, dislocate, and displace the
condylar head from the capsule, causing a severe unresolving
mechanical obstruction that prevents mandibular movement.
This may necessitate a condylectomy with a resultant disconti­
nuity defect, or other additional surgical correction. Aberrant
tooth contacts will occur causing deflection upon closure and
likely require adjustment. Shortened and flattened cusps may
be necessary to achieve a harmonious or nondeflective occlu­
sion. Reconstructive temporomandibular surgery may improve
function, but limitations of opening and lateral jaw movements
may remain. Consideration may be given to the autogenous
grafting of cartilage from the concha of the ear when the disc
has been obliterated and a painful, bone-to-bone contact exists.
The objective is a pain-free joint that permits adequate func­
tional movements at an appropriate vertical dimension of oc­
clusion with a repeatable and stable position.
Local Avulsive Injuries of Dentition and Alveolar Bone
Often, traumatic avulsion creates partially edentulous ar­
eas which are tooth bound and nonlinear in configuration, with
long expanses of missing teeth. The associated alveolar bony
defects will be more extensive than those that result from rou­
tine extractions from dental disease. These anatomical limita­
tions increase the demands upon the supporting structures, and
they must be considered during treatment planning.
Injuries to the teeth may be categorized into 3 broad cat­
egories: (1) fractures of enamel, dentin, and cementum; (2) ir­
reversible pulpitis; and (3) avulsions and subluxations, result­
ing in extraction and loss of alveolar bone. These injuries may
be found in a 4:2:1 ratio, respectively (Figure 11-14). Frontal
-AVULSED
-PULPAL
■ENAMEL/DENTIN
1 2 3 4 5 6 7 8 910111213141516
Left Right
TOOTH NUMBER
a
Fig . 11-14. a: MVA maxillary tooth injuries frequency chart, b: MVA mandibular tooth injuries frequency chart. (Source: Wiens
JP. Acquired maxillofacial defects from motor vehicle accidents: statistics and prosthodontic considerations. J
Prosthet Dent. 63:172;1990),
MVA impacts may cause significant anterior tooth injuries.
Mandibular anterior teeth are more prone to avulsion, while
maxillary anterior teeth are more likely to fracture and have
pulpal injuries (Figure 11-15). Periodontal defects will be found
when tooth fractures involve cementum immediately adjacent
to avulsed regions and along displaced jaw fractures. The loss
of teeth as well as alveolar structure often requires the use of a
removable prosthesis, or implant-supported prostheses, with
extensive flanges and borders to provide adequate facial sup­
port. The size and configuration of the edentulous area precludes
the use of fixed prosthodontics in most instances.
Principles of Treatment
Preservation of life, maintaining vital functions, and
prioritization of coexisting injuries are the initial concerns. Ef­
fective prosthodontic treatment will require recording the
patient’s history with correlation of the events and the nature of
the trauma. The past medical and dental histories should be as­
certained, noting potentially compromising diseases, medica­
tions, or previous treatments. Mental status, attitudes, and cur­
rent expectations should be observed and investigated with psy­
chometric testing18and counseling19at the appropriate time. The
process of recording the history and examination will be ongo­
ing due to the prolonged nature of multiphasic treatment and
lengthy healing periods. General prosthodontic treatment goals
should be ascertained for each patient and reevaluated during
each treatment phase. A written descriptive treatment plan should
be prepared and reviewed with the patient when possible. Treat­
ment may be divided into initial stabilization, early, intermedi­
ate, and definitive phases.

Fig. 11-15. a: Mandibular anterior teeth are more prone to
avulsion, b: Maxillary anterior teeth are more
likely to fracture, c and d: Avulsion of teeth of­
ten results in the loss of alveolar bone.
Maxillofacial Trauma 495
Treatment Goals for the Trauma Patient
There are several treatment goals for the trauma patient
which may differ from the treatment objectives for postsurgical
cancer and congenital cleft lip and palate patients. These goals
are as follows:
1 Oral Intake
It is important to restore oral integrity as soon as condi­
tions permit, so feeding tubes can be removed and nutrition can
be maintained orally. It is important not only for the patient to
swallow liquids but to masticate and consume a normal healthy
diet, as well.
2 Closure of the Palate
Closure of the hard or soft palate may be accomplished
either surgically or prosthetically. Initially, this objective is usu­
ally achieved with an interim prosthesis which will reestablish
the oral-nasal partition and provide a contacting surface for the
tongue during speech, swallowing, and mastication. Occasion­
ally, the interim prosthesis must also be used to enhance velo­
pharyngeal closure.
3 Mobile-Sensate Tongue
Both the innervation and mobility of the remaining tongue
are vital for adequate function of the tongue during mastica­
tion, bolus control, and speech (see Chapter 5). If the tongue is
immobile, suigical release of any limiting scar bands or adhe­
sions should be considered as early as feasible in the progres­
sion of treatment.
4 Circumoral Competence
Adequate circumoral movement and flexibility of the lips
is essential for control of both saliva and the bolus. Oral access
is also an important consideration for proper hygiene, place­
ment of a prosthesis, and access for necessary dental proce­
dures.
5 Maxillary and Mandibular Realignment
If maxillary and/or mandibular fractures are evident, skel­
etal and dental realignment is essential. Stable occlusal con­
tacts at an acceptable vertical dimension of occlusion are an
important prognostic factors for both the interim and definitive
prostheses.
496 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
6 Appearance
A socially acceptable appearance is the ultimate object of
rehabilitation. Without an acceptable appearance, the chances
of returning the patient as a productive member of society may
be compromised.
The Staging ofTreatment
Initial Stabilization
Severe traumatic injuries may result in an emergency situ­
ation with an immediate need to maintain a satisfactory airway,
control blood loss, evaluate the damage to the nervous system,
and ascertain the status of the thoracoabdominal region. Usu­
ally, the first 2 weeks are required to stabilize the patient and
immobilize the fractured elements. In the initial stabilization
phase, it is important for the maxillofacial prosthodontist to be
involved in the treatment planning with the surgeon(s) who will
be doing the reconstruction, so that a predictable and favorable
long-term prognosis, both surgically and prosthodontically, can
be achieved for the patient. The role of the prosthodontist at this
stage is one of support, by fabricating surgical stents and splints
for grafting and osseous realignment, and by offering consulta­
tive services.
Early Management
Early management will vary from 2 to 8 weeks in length.
During this phase of treatment, it is more likely that a complete
history and examination can be obtained. The initial psycho­
logical status should be evaluated with patient recognition that
a change in body image may have occurred. The emotionally
traumatic experience of severe injuries, possibly involving the
loss of anatomical or facial structures, death of a family mem­
ber or friend, and (for those who feel unduly wronged) litigious
concerns, may result in altered behavior. Attention should be
given to the verbal and nonverbal cues that may signal an un­
derlying problem. Expectations of rehabilitation may be unre­
alistic and require careful counseling. It is important to stress
realistic goals to the patient and not to embellish the prognosis.
The attending physician may delay some treatment proce­
dures until the prognosis is more definitive. The examination
may be difficult in the hospital setting, and the collection of
dental records may be delayed by pain, edema, trismus, recent
suigery, and circumoral restriction, necessitating extraoral ra­
diographs. Diagnostic dental and medical records are obtained,
including photographs, and consultation with appropriate al­
lied health care providers should be requested. Pre-trauma ra­
diographs, photographs, and casts may be available from a pre­
vious dental provider. The clinical examination should include
an evaluation of the maxillomandibularjaw relationships, tem­
poromandibularjoint status, arch configurations, dentition, and
the quality of supporting structures and associated soft tissues.
Sectional impressions may be made and the resulting cast
corrected in the laboratory to achieve a complete-arch diagnos­
tic cast Some delay may be indicated to allow for healing, which
will provide time for securing proper diagnostic records. Dis­
rupted maxillomandibular relationships will require reduction
and fixation with surgical splints, bone plating, and/or inter­
maxillary fixation (IMF). Unfavorable fractures, with antago­
nistic muscle vectors, along with wire ligation with arch bars
may cause rotation of the mandibular segments, placing the
mandibular teeth in lingual version, or result in an apertognathia.
During this phase, dental treatment may be needed for gross
removal of caries, placement of temporary restorations, emer­
gency endodontic extirpation, and control of dental infections
and/or other potential pathogens which may interfere with heal­
ing. Oral hygiene should be instituted and may need to be pro­
vided by a supportive staff member. Manual oral debridement
with cotton swabs or sponge-sticks, bactericidal mouth rinses,
such as hydrogen peroxide or chlorohexadrine, and oral irriga­
tion devices (on low settings) may be indicated to promote heal­
ing, but only with the approval of the attending physician prior
to use.
The prosthodontist may be asked to construct surgical
splints to stabilize bony fragments and stents to support soft
tissues. Splints and stents sometimes require remaking or modi­
fication because of tissue changes. Splints and stents may en­
hance complex multidisciplinary reconstructions and help es­
tablish the proper maxillomandibular relationships through re­
alignment, immobilization, and bracing. They may also obtu­
rate or partition defects, restore deglutition, eliminate feeding
tubes, protect wounds to promote healing, reduce scar contrac­
ture, and restore esthetics. Splints may also be required to main­
tain the position of adjacent or opposing teeth, or other maxillo­
facial bony structures. Occasionally, lip incompetence may re­
sult in drooling or pooling of the saliva. A lower lip stent may
be considered to control saliva by acting as a dam. The con­
struction of surgical adjunctive devices may require that im­
pression-making and other procedures be performed in the hos­
pital setting.
Instruments and equipment If the prosthodontist makes fre­
quent visits to a particular hospital, an instrument and supply
kit can be assembled and maintained in the hospital suigical
area (Table 11-5). If a kit is not feasible, the clinician should
compile a master list of all equipment and materials necessary
for these visits, so the dental assistant can assemble the kit be­
fore each visit. The list for the trauma patient and the potential
maxillectomy patient (see Chapter 6) will be identical, except
for a few items. However, the sequence of treatment may not be
as well-defined for the trauma victim, as compared to the pa­

tient with acquired defects secondary to resection of oral
paranasal sinus cancer.
Since trauma patients tend to be younger and have rela­
tively normal life expectancy, it is all the more important to
salvage most remaining teeth or roots of teeth. Therefore, emer­
gency endodontic supplies and equipment should be included
in the kit, along with temporary restorative cements and instru­
mentation. It is not uncommon for restorations to be fractured
and/or lost as the result of the accident As previously men­
tioned, the impressions for diagnostic casts for the trauma pa­
tient may need to be made segmentally, and the resulting casts
may then be reassembled in the laboratory. For this reason, dis­
posable and modifiable trays, with an appropriate adhesive,
should be included in the kit. Oral access may be limited ini­
tially; therefore, an antibiotic ointment, used as a lubricant for
the lips, will improve patient comfort during these initial im­
pression procedures.
Preparation of individual packets of premeasured impres­
sion materials and water is beneficial. Blood contamination is
likely. Therefore, impressions must be disinfected following
accepted infection-control standards. Proper written entry of the
prosthodontic procedures performed should be made in the
patient’s hospital progress notes, which may include the patient’s
condition before, during, and after the procedure. Also, the lo­
cation, time, and next treatment step should be noted to ensure
proper communication with the attending physician and staff.
Table 11-5. List of Suggested Materials to Have Available in
the Operating Room or Hospital Room.
• Impression materials and accompanying measur­
ing devices
Variety of disposable and modifiable trays with ad­
hesives
Mixing bowls/spatula/pads
Soft block-out wax, cotton-gauze, floss to attach
to gauze packs for retrievability, antibiotic ointment
for lubrication
Temporary restorative cements and appropriate
instrumentation
Emergency endodontic equipment/supplies
Dental mirrors, explorers/probes, tongue blades,
cotton pliers, ruler
Containers or plastic bags with acceptable infec­
tion control materials to place impressions
• Materials for recording interim jaw records or ex­
tending impression trays
• Light source for examination and inspection
Maxillofacial Trauma 497
Fabrication o f splints and stents When a surgical splint is to
be used to stabilize a jaw fracture, impressions must be ob­
tained. Modification of standard techniques are required so that
accurate and useful impressions may be secured. The pain, swell­
ing, trismus, and excessive salivation associated with fractures
and oral-facial injuries make the task more challenging. How­
ever, with careful planning and preparation, good impressions
are obtainable.
In order not to distress the patient further, local anesthesia
should be obtained, using infiltration and block techniques.
Usually, control of pain reduces trismus, facilitating the impres­
sion procedures. Good lighting andhigh-volume evacuation are
essential. The mouth should be gently irrigated and the surfaces
of the teeth should be cleaned. Usually, stock trays must be
trimmed and adjusted to meet individual needs. This is usually
achieved by trimming the lingual flange of the tray, which greatly
facilitates both insertion and removal. During the impression
procedure, care should be taken so that distraction of the frag­
ments does not occur. In most instances, irreversible hydrocol­
loid is the impression material of choice. Impression material
can be deposited into undercut areas, or regions of difficult ac­
cess, with a disposable syringe. If the patient will undergo a
general anesthetic for any other purpose, it is wise to use this
opportunity to obtain impressions.
The prosthodontist shouldbe familiar with the various types
of feeding and breathing tubes and how to perform dental pro­
cedures, such as impression-making, around the tubes without
dislodgment. Trauma may result in the exposure of paranasal
sinuses, nasal and other cavities, or vital structures. Impression
materials may fracture and separate during tray removal, lodg­
ing in small openings, around tubes, or in sinuses, which could
lead to infection or compromise an airway. Dampened or lubri­
cated gauze, secured with floss, is used to block out small open­
ings that are not needed or require protection. Thin, tenuous
extensions of fragile impression materials* such as irreversible
hydrocolloid, are the most likely to fracture upon withdrawal.
The prosthodontist should carefully inspect the impression area
for any remaining fragments of material after making the im­
pression. These fragments are carefully teased from the area.
After the impression is removed, a stone cast is prepared.
The most common surgical splint in use today is the lin­
gual splint. These splints are particularly useful in
parasymphyseal fractures of the mandible because they prevent
the adverse muscular forces from causing lingual collapse and
overlap of the fractured segments. Wire loops, or arch bars alone,
that are applied to the teeth on either side of the fracture line
frequently cannot control this type of collapse. The lingual splint
can also be used to stabilize jaw fragments when bone grafting
is indicated for mandibular discontinuity defects in trauma pa­
tients.
The lingual splint is fabricated on the corrected cast of the
lowerjaw. We advise that the splint for patients with mandibu-

Intermediate Management
The period of intermediate management usually extends
from 2 to 6 months. During this phase, the provisional or treat­
ment prostheses, provided for esthetic and phonetic reasons,
may be used to refine and stabilize the occlusion. These treat­
ment prostheses may reveal other potential prosthodontic prob­
lems, leading to more realistic goals. At the same time, these
prostheses provide a general sense of well-being so that the
patient can anticipate future progress.
Mandibular continuity is reestablished during this period
with appropriate bone grafts and flaps. The soft tissue bed des­
tined to receive the bone graft should be carefully examined. If
there is an insufficient amount of soft tissue to receive the graft,
or its vasculature is deficient, consideration should be given to
supplementing the soft tissues with a flap. Free bone grafts are
preferred for most discontinuity defects. Vascularized free flaps
are advantageous in large combination bone and soft tissues
defects. Both types of grafts provide bone of suitable quality
and quantity for osseointegrated implants (see Chapter 5, Sur­
gical Reconstruction section).
The maxilla also requires careful evaluation. Displaced frag­
ments in unfavorable positions should be repositioned surgi­
cally if possible. Small oral-antral fistulas should be closed.
However, large, palatal defects should be left open, and consid­
eration should be given to lining potential denture bearing and/
or usable undercut areas with a split thickness skin graft. Surgi­
cal closure of large, palatal defects is possible, but it may result
in mobile, bulky, and nonfunctional soft tissues that cannot be
used to effectively support the prosthesis. In addition, the flaps
used to close these defects are often bulky, usually resulting in
unfavorable palatal contours and/or compromises in the posi­
tion of the denture teeth. Consequently, articulation, swallow­
ing, and esthetics may not be restored to optimal levels. In con­
trast, large palatal defects, particularly when lined with skin and
properly engaged with a prosthesis, may enhance the stability,
support, and retention of the prosthesis. Teeth may be properly
positioned and functional palatal contours can be restored. In
addition, support for the lips and cheek can be developed more
effectively if the maxillary prosthesis is stable.
Surgical correction of traumatic disorders of the temporo­
mandibular joints and faulty maxillomandibular relationships
must be corrected prior to definitive prosthodontic treatment.
Discordant maxillomandibular skeletal relationships, if left un­
corrected, will compromise both tooth alignment and future
implant placement, making the prosthodontic prognosis less
predictable. Traumatic injuries may create or accentuate Class
II or Class HI skeletal relationships, resulting in unfavorable
leverages20.
It is critical to determine the definitive long-range maxillo­
facial prosthetic treatment plan during this phase of care and
coordinate this treatment plan with the other treatment being
Maxillofacial Trauma 499
considered. All necessary adjunctive consultations and dental
treatment, such as endodontics, periodontics, and orthodontics,
should be completed prior to definitive prosthodontic treatment.
Often, the maxillofacial prosthodontist must coordinate the care
of these other specialists, since prosthodontic treatment will be
dependent upon the treatment outcomes of their services. The
patient’s ability to maintain oral hygiene, keep recall appoint­
ments, develop adequate dexterity for the placement and care
of a prosthesis is another important factor to be considered. The
potential influence of other bodily injuries and presence and
degree of family support should be assessed. The social worker
is essential in this assessment.
Definitive Management
General concepts The length of this phase is variable, but it
usually extends for at least 6 months and, often, 1 to 2 years is
required to complete the definitive care. The presence of nonvital
or nonrestorable teeth indicated for removal should be referred
to the oral surgeon for extraction. Strategic abutments and adja­
cent supporting tissues, important to definitive treatment, should
be reevaluated. The potential mechanics of the prosthesis must
be calculated prior to definitive treatment if the prosthesis is to
be properly supported, stabilized, and retained. Altered tongue
and adjacent oral musculature may result in unusual vectors of
force in all 3 planes. Residual supporting structures are reduced
in size and may not be fully restored with reconstructive sur­
gery, and the removable prosthesis becomes bulkier. Therefore,
greater movement of the prosthesis should be anticipated, as
larger volumes of tissue require replacement.
The prosthodontist must assess and anticipate the magni­
tude and direction of forces when he or she considers the design
of the prosthesis. In most patients, the loss of large segments of
teeth and contiguous bony and soft tissues results in the need
for a removable prosthesis, supported both by teeth and soft
tissues, and supplemented with dental implants. Support, sta­
bility, and retention provided for the prosthesis will be influ­
enced by the tooth or abutment position within the arch, the
curvature of the arch, the configuration of the alveolar ridges,
and the nature of the mucosa covering denture bearing areas.
The prosthesis may need to address the altered condition of the
lips, tongue, hard and soft palate, and any neuromuscular inad­
equacies or incompetencies associated with these structures. The
use of osseointegrated implants enhances prosthesis support,
stability, and retention, permitting selection of more diverse
prosthodontic options21,22,23’24.
Treatment planning guidelines suggest the need for a clas­
sification system for patients requiring removable prostheses
with differing anatomical alterations. The value of any classifi­
cation is that it invokes a visual conceptualization of impending
need. The Kennedy Classification, while logical, may be mis­
leading, since it is based solely on location of edentulous areas.
500 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

The length of the edentulous span, the loss of bony support, and
the type and condition of the contiguous soft tissues available
for support may be more important than the location of the eden­
tulous span and abutments per se. Prosthodontic treatment may
be different with each trauma patient—even given the same
edentulous arrangement. Therefore, Applegate’s modification
of Kennedy’s classification25is more appropriate, since it is based
upon available support from teeth, implants, and soft tissues.
Obviously, the amount of available support is crucial.
Fixed versus removable prosthodontics McCracken noted
that it is usually preferable to restore a tooth-bound space with
a fixed partial denture (FPD)26. Unfortunately, this axiom does
not always apply for patients with large maxillofacial defects or
deficiencies. The loss of a significant amount of alveolar bone
and adjacent soft tissues may compromise the esthetic and pho­
netic results achieved with fixed partial dentures. Traumatic
injuries may result in the need for longer teeth vertically and
more extensive anterioposterior spans of replacement teeth.
Fixed partial dentures, therefore, may require additional abut­
ments for proper support. Abutment and retainer selection must
be carefully considered for the long-term prognosis.
The effects of traumatic injuries often do not become clini­
cally evident for several years. For example, teeth may become
nonvital and symptomatic, requiring endodontic therapy sev­
eral years after an accident. If a FPD is used, abutments adja­
cent to avulsed regions may be compromised structurally and
require endodontic therapy, cast post and core restorations, and
full-coverage retainers that offer the greatest resistance to pros­
thesis dislodgment. Severely fractured abutments may create a
questionable prognosis relative to long-term support for fixed
prosthodontics. Subsequent fractures of weakened abutments
are common and may lead to failure of the FPD.
Consideration should also be given to the incorporation of
guide planes, rests, and retentive and non-retentive areas. If sub­
sequent abutment failures do occur, the FPD may be sectioned
and removed, and the remaining abutments may be more easily
modified to support a removable prosthesis. When confronted
with nonparallel abutments, fixed partial dentures may also need
solderless connectors-matrix/patrix components to achieve pros­
thesis placement In addition, the restoration of long spans may
be made less complicated by making multiple, smaller fixed
prostheses whenever possible (Figure 11-18). Cement bond fail­
ure also will be less likely by reducing unfavorable leverages.

Fig. 11-18. a: Teeth, #23 through #28, were avulsed secondary to an MVA. b and c: Fixed partial denture was fabricated. Due
to curvilinear nature of restoration, a matrix-patrix connector was used to reduce the potential for cement bond
failure. Note that longer segment contains patrix, while 2 remaining abutments contained matrix. This allowed for
removal of greater span if necessary, d and e: Prosthesis inserted.
 Maxillofacial Trauma 501

Patients with a short lip, high smile-line, or excessive scar­ thesis so that occlusal forces are directed along the long axis of
ring may have greater esthetic needs and functional expecta­ the implants.
tions. These findings generally indicate the need for a remov­
able prosthesis. Inadequate tooth abutments and avulsive de­
fects may also indicate the need for a removable partial den­
ture. In most situations, cross-arch stabilization, as well as ad­
ditional support and indirect retention from abutment teeth which
are remote from the actual defect being restored, is required.
Anterior alveolar ridge defects will require retentive clasp ele­
ments both near the defect and distant from the defect to control
prosthesis movement, especially during incising.

Role of osseointegrated implants Significant benefits may be

derived from the use of osseointegrated implants for total pros­
thesis support. The successes27 and difficulties28 in the use of
osseointegrated implants are well-documented. Implants help
maintain bone and, in some situations, reverse ridge atrophy.
Implants can reduce the need to involve adjacent teeth, and they
may eliminate the necessity for a conventional fixed prosthesis
supported by natural teeth29,3031*32. Extensive soft and hard tis­
sue loss usually requires an implant supported or retained over­
lay prosthesis to obtain adequate facial support and restoration
of oral functions. The retrievability of osseointegrated prosthe­
ses offers the opportunity for future modifications, thus increas­
ing the life span and serviceability of the prosthesis.
A number of issues must be considered when using im­
plants for the trauma patient. b

Fracture sites Healed fracture sites may not be ideal im­
plant sites. Bone volume may be reduced at the fracture site and
the bony defects that are present may be filled with scar tissue.
Old fracture sites that are under consideration for implants are
best evaluated with CT scans.
Fig. 11-19. a and b: Patient suffered gunshot wound to an­
terior mandible. Note multiple metallic frag­
ments. It will be difficult to place implants in this
patient, avoiding these metallic fragments.
(Courtesey: John Beumer.)

Foreign bodies The presence of foreign bodies are a fre­

quent observation following trauma. They range from copper
or lead bullet fragments to chrome, nickel, iron, or stainless
steel wire used for fixation, and, occasionally, alloy from dental
restorations (Figure 11-19). Bone sites containing metallic for­
eign bodies should be avoided if possible because of the elec­
trolytic interaction between the implant and the foreign body,
subsequent corrosion, and unfavorable tissue reaction33,34.

Location, angulation, and number Implant position, an­

gulation, and number placed are dependent on the nature of the
defect, the number of implant bone sites available, and the de­
sign of the prosthesis (implant-supported versus a combination
of implant and mucosa supported, maxilla versus mandible, fixed
versus removable, and so forth) (Figure 11-20). Proper implant Fig. 11-20. Four implants were placed in preparation for a
angulation and position is best accomplished with the aid of a fixed implant-supported partial denture. Note
surgical template that is based upon a diagnostic waxup. Ef­ angulated abutment on left implant.
forts should be made to position implants and design the pros­
502 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Grafting Autogenous bone grafting may enable the use of
longer implants and allow for improvement of bone and soft
tissue contours. In restored discontinuity defects, implant place­
ment should be delayed for 6 months after bone grafting to per­
mit the graft to become vascularized and mature. Soft tissue
grafting procedures to replace poorly keratinized mobile mu­
cosa with attached keratinized epithelial surfaces should be con­
sidered (Figure 11-21).
Fig. 11-21. This mandibular discontinuity was restored with
a bone graft. A dermograft was used to create
attached keratinized tissue at potential implant
sites.
Implant-supported prostheses versus prostheses using a
combination of implant support and mucosal support Pres­
ently, clinical recommendations regarding the number, length,
and configuration of implants required to provide the entire sup­
port for a given prosthesis in a given jaw are based on clinical
reports and are largely anecdotal in nature. The minimum bone
implant interface surface area (bone appositional index) required
to support a given load delivered a specific number of times
over a defined time period has yet to be determined. As previ­
ously stated, in trauma patients, implant sites deemed desirable
from a prosthesis-design perspective may not be suitable from
a biologic-surgical perspective. Therefore, if there is doubt re­
garding the amount of the support provided for the restoration
by the implants (because the number used, or the angulation
and position of the implants is not ideal), consideration should
be given to designing the prosthesis so that the mucosal sur­
faces supplement the support provided by the implants. As pre­
viously stated (see Chapter 6), osseointegrated implants are prone
to bone loss when they are subjected to excessive lateral torqu-
ing forces. Osseointegrated implants have a better long-term
prognosis when occlusal loads are delivered along their long
axis.
When the prosthesis is designed to obtain its support from
both the implants and the oral mucosa, we feel that many of the
basic design philosophies suggested by Kratochvil35 for con­
ventional, extension base, removable partial dentures provide
useful guidance for the clinician, as he or she designs the pros­
thesis (see Chapter 5, Partial Denture Design section). These
principles are (a) major connectors (i.e., implant superstructures)
should be rigid; (b) occlusal rests (i.e., implant bar rests or at­
tachments) must direct occlusal forces along the long axis of
the teeth (i.e., implants); (c) retainers (i.e., attachments) should
be designed so that lateral forces are not delivered to the re­
maining teeth (i.e., implants) during function; and designs should
consider the need for easy cleaning. Other considerations in­
clude wide stress distribution by the use of multiple occlusal
rests and proper denture base extension in edentulous areas.
Fixed versus removable Removable overlay prostheses
are preferred when the patient presents with significant loss of
alveolar process along with the loss of teeth, regardless of im­
plant support. Speech and esthetics are effectively restored with
the removable overlay prostheses, while access for oral hygiene
is decidedly improved (Figure 11-22).
Definitive Prosthodontic Management
Anterior localizedavulsive defects As expected, anterior teeth
are the teeth most commonly avulsed as the result of a MVA
(Figure 11-14). Small defects of the anterior maxilla or man­
dible that involve the loss of 1 to 4 incisor teeth, accompanied
by only minimal alveolar bone loss, can be restored with con­
ventional fixed prosthodontics (Figure 11-23). The number of
abutments on each side of the defect is dependent on the span,
arch form, condition of the potential abutments, and the oc­
clusal relationships. The use of implants becomes more desir­
able as the number of teeth lost increases if the abutments are
compromised, or if the arch form becomes less favorable. Con­
ventional removable partial dentures are used only when the
implant sites have insufficient bone or bone of poor quality, or
when implants are not feasible from a financial perspective.
Removable partial dentures restore speech and esthetics effec­
tively, but they generally provide a less favorable functional
result because mucosal support areas are usually quite deficient
in most patients.
Many patients with local avulsive defects of the anterior
maxilla present with significant loss of alveolar bone and, there­
fore, esthetics and speech are best restored with removable over­
lay prosthesis. Either conventional fixed prostheses (Figure 11-
24) or implant-retained fixed prostheses (Figure 11-22) can be
used to support the removable overlay portion. If fixed implant-
supported partial dentures are to be used, surgical augmenta­
tion of alveolar bone and soft tissues is generally required. In
the mandible, the restoration of speech and esthetics is not so
dependent on the design and contours of the prosthesis and,
therefore, fixed implant-supported partial dentures are more
acceptable (Figure 11-25).
 Maxillofacial Trauma 503

g "
Fig. 11-22. a: Teeth, #5 through #8, were avulsed in a MVA. Note loss of alveolar process, b: Implants in position, c: Master
cast. Note vertical alveolar defect, d: Tissue bar with swivel latch and 2° milled spark erosion platform, e: Com­
pleted prosthesis, f: Underface of prosthesis, g: Bar secured, h: Complete prosthesis in position.

a b
Fig. 11-23. a: Patient avulsed 4 incisors. Alveolar contours were relatively normal and arch form is favorable, b: Completed
conventional fixed partial denture.
504 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

9 h

Fig. 11-24. a: MVA resulted in avulsion of teeth, #6 and #7. Note alveolar defect. There was also an adjacent palatal defect
about 1 cm in diameter, b: Mounted master cast, c: Completed restoration with tissue bar (with Ceka* attachments
incorporated), d and e: Fixed prosthesis with tissue bar cemented, f: Removable prosthesis, g and h: Removable
prosthesis inserted.

a b

Fig. 11-25. a: All 4 mandibular incisors were avulsed. Two implants were placed. Note alveolar defect, b: Completed prosthe­
sis. The alveolar defect was restored prosthodontically. (Courtesy: Arun Sharma)

Attachments International, San Mateo, CA.


Large avulsive defects
Maxilla Avulsive wounds of the maxilla that result in
large palatal defects are difficult to restore. The physical con­
figuration of traumatic palatal defects varies considerably and
is dependent on the nature of the injury. Maxillectomy and
palatectomy resections are planned to achieve 2 primary objec­
tives: (1) resect the tumor and (2) prepare the defect to help
stabilize, support, and retain an obturator prosthesis (see Chap­
ter 6, Alterations at Surgeiy that Improve the Prosthetic Prog­
nosis section).
Palatal defects secondary to trauma differ in several im­
portant ways from planned maxillectomy and palatectomy sur­
gical defects for tumor extirpation. First, they are generally lined
with a combination of pseudo-stratified columnar epithelium,
or poorly keratinized squamous epithelium, as opposed to skin
grafts. These types of mucosal linings are more sensitive and
do not tolerate the physical trauma associated with prosthesis
use, as compared to skin-lined surfaces. Second, in maxillectomy
defects, the lateral wall is divergent, facilitating retention of the
prosthesis. Trauma-induced defects are irregular in size and
shape. In most patients, the lateral wall contracts and is not di­
vergent and thus is not as effective in preventing the prosthesis
from rotating out of the defect. Consequently, additional stress
must be bom by the residual dentition or implants in order to
retain the prosthesis. Third, the soft tissues bordering the defect
are often heavily scarred and cannot be as easily displaced or
recontoured by the prosthesis, as compared with the skin-lined
cheek of a maxillectomy defect. Thus, facial esthetics is often
compromised. Fourth, the residual maxillary segments may be
displaced and lack bony attachment to the base of the skull,
which compromises support and may subject abutment teeth to
unfavorable lateral torquing forces. Last, the arrangement of
mandibular dentition, the mandibular arch form, and the oc­
clusal plane of the mandible may be less than ideal, making it
difficult to establish proper occlusal relationships.
Partial denture design: The basic principles of partial den­
ture design shouldbe followed; namely, major connectors should
be rigid, occlusal rests should direct occlusal forces along the
long axis of the teeth, guide planes should be designed to facili­
tate stability and bracing, retention should be within the physi­
ologic limits of the periodontal ligament, and maximum sup­
port and stability should be gained from the residual soft tissue,
denture bearing surfaces, including the defect. If implants are
used to supplement the dentition, they should be positioned and
the attachments should be designed to direct occlusal forces
along the long axis of the implants36. The challenges encoun­
tered in removable partial design and implant bar design are
similar to those discussed with regard to acquired maxillary
defects, and we, therefore, refer the reader to this section (see
Maxillofacial Trauma 505
Chapter 6, Partial Design Concepts for Maxillary Defects and
Implant-Retained Prostheses for Maxillary Defects sections).
Clinical procedures: Altered cast impressions are made
of the denture-bearing tissues and the defect after the remov­
able partial denture framework has been fitted and physiologi­
cally adjusted. Inappropriate areas on the cast are blocked out
with wax, and tray resin is molded to the framework and the
defect area. The framework and resin extension is checked in
the mouth for path of insertion and removal, tissue impinge­
ment, and so forth. Approximately 1 to 2 mm of space should
exist between the resin base and the peripheral defect tissues.
Scar tissue can be especially unyielding in the trauma patient;
therefore, these areas must be carefully checked for proper clear­
ance. Modeling plastic is added to the tray until the desired ex­
tensions have been achieved. After the modeling plastic is “cut
back”, we prefer to refine the border molded impression of these
defects with a thermoplastic wax, considering the nature of the
soft tissues lining traumatic palatal defects. The soft tissue beds
in the defect are highly variable with regard to epithelial cover­
age and tissue displaceability, and we feel functional impres­
sions will result in better adaptation and fewer adjustments dur­
ing the delivery and follow-up periods (Figure 11-26). The im­
pression is boxed, as previously described, and conventional
prosthodontic methods are followed to complete and deliver
the prosthesis.
Mandible Large, avulsive defects of the mandible sec­
ondary to trauma will challenge the skills of even the most ex­
pert of surgical-prosthodontic teams. Sizable segments of the
mandible can be lost along with its adjacent and overlying soft
tissue; the temporomandibularjoint region can be altered, lead­
ing to trismus and changes in mandibular movement; and
maxillomandibular relationships can be altered.
Discontinuity defects should be reconstructed with a bone
graft as soon as is practical. The goals and principles of bone
grafting discussed earlier, in reference to patients with tumor
resections (see Chapter 5, Surgical Reconstruction section),
apply to patients with traumatically induced mandibular defects.
Grafts should be designed so that they possess a sufficient vol­
ume and density of bone to receive osseointegrated implants.
From a prosthodontic perspective, these defects closely
resemble the acquired mandibular defects described in Chapter
5. Most patients present with anterior-lateral defects, and they
usually have posterior teeth remaining bilaterally, creating the
need for a Kennedy Class TV partial denture. The edentulous
segment will usually display varying degrees of soft tissue scar­
ring, loss of keratinized attached mucosa, obliteration of the
vestibule, and compromised bony support The size and length
of span of the edentulous area will vary considerably. In some
patients, the lack of keratinized attached tissue and obliteration
506 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
f g
of the vestibules may require a vestibuloplasty with either a
skin or a palatal graft (Figure 11-18).
Conventional removable partial dentures for these patients
will improve esthetics, provide support for the lower lip and
cheek, facilitate speech articulation, and enhance control of sa­
liva (Figure 11-27). Compromised support for the extension
denture base usually precludes effective mastication, unless
anterior teeth have been retained. The placement of implants in
the edentulous segment will provide the necessary support for
the prosthesis and should be considered. Implants are especially
beneficial if the patient is edentulous. In edentulous patients,
the plane of the reconstructed mandible is frequently not paral­
lel to the plane of the edentulous maxilla, compromising den­
ture stability. The presence of implants provides the stability
necessary for effective function and also enhances support and
retention.
Partial denture designs must consider the movement of the
extension base portion of the prosthesis. The approach to par­
Fig. 11-26.
a: Large avulsive defect of maxilla sec­
ondary to gunshot wound. Only 1 tooth
remains, b and c: Master impression was
refined with thermoplastic wax. d: Mas­
ter cast from altered cast impression, e:
Completed prosthesis, f and g: Obtura­
to r prosthesis in position. (Courtesy:
John Beumer.)
tial design is similar to that proposed earlier (see Chapter 5,
Defects with Mandibular Continuity Maintained or Reestab­
lished section).
Edentulous patients Discrepancies in edentulous ridge rela­
tions are often encountered in edentulous patients suffering trau­
matic injuries. Diverging alveolar ridges may cause denture base
deflection and lack of base stability. Scarring and the lack of
displaceability of the border tissues may compromise the pe­
ripheral seal of the complete denture (Figure 11-28). Surgical
correction should be the first consideration in these situations.
The position and movements of the residual tongue should be
carefully checked so that the level of the occlusal plane will
favor the least stable prosthesis.
Consideration should also be given to shortening and nar­
rowing the occlusal table by selection of smaller resin teeth.
Posterior teeth may need to be arranged in a “cross-bite” rela­
tionship, or an occlusal platform may be fabricated if mandibu-
 M axillofacial Trauma 5(X.

Fig. 11 -27. a: Patient suffered gunshot wound to face. Only 4 teeth remained. These teeth were restored with porcelain fusee
to metal retainers. Occlusal rests and guide planes were incorporated, b: Completed removable partial dentures
Note full palatal coverage of maxillary prosthesis, c and d: Prostheses inserted, e: Esthetic result.

References

1 National Center for Health Statistics: Advance report on fina

Fig. 11-28. Edentulous patient suffered multiple fractures
in a MVA. Note collapse of arch on left side.
This creates a potentially unstable base. Dur­
ing function, the denture base will tend to be
displaced anteriorly.
lar movements are very imprecise. Occasionally, the vertical
dimension of occlusion may need to be decreased to permit lip
competency and improve denture base stability.
The placement of implants is strongly recommended for
these patients. The presence of implants provides the stability
necessary for effective mastication and also enhances the sup­
port provided and retention for the prosthesis (Figure 11-29).
mortality statistics, 1980. Mon Vital StatRep. 32:4-7; 1984.
2 National Highway Traffic Safety Administration: Nationa
Accident Sampling System, 1986 (HS 8 07 296). 1988
Washington, DC; Department of Transportation.
3 Wiens JP: Acquired maxillofacial defects from motor vehicle
accidents: Statistics and prosthodontic considerations. JProstl
Dent. 63:172; 1990.
4 Jager J, Dietz ED: Death and injury by firearms: Who cares'
JAMA. 255:3143;1986.
5 Sosin DM, Sacks JJ, Smith SM: Head injury-associated death;
in the United States from 1979 to 1986. JAMA. 262:2251; 1989
6 Kelly JF: Management of war injuries to the jaw and relatec
structures. Washington, DC, 1977; US Government Printing
Office.
7 Hickey AJ: Maxillofacial prosthetic rehabilitation following
self-inflicted gunshot wounds to the head and neck. J Prostl
Dent. 55:78; 1986.
8 Bowlby J: Attachment and Loss: Vol. 1. Attachment. New
York, 1969; Basic Books.
9 Peretz D: Development, Object-Relationships, and Loss. In
Loss and Grief: Psychological Management in Medica
508 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 11-29. a and b: Patient suffered multiple facial injuries secondary to MVA. b: Premaxillary area was avulsed. c: Subse­
quently, bone graft from iliac crest was obtained and implants placed simultaneously, d: Implants exposed, e: Note
maxillary tissue bars, f: Maxillary prosthesis, g: Prosthesis in position. Note that anterior mandibular defect was
also restored with implants, h: Radiograph of final results, i: Esthetic result.

Practice (pp. 3-19). Schoenber B, ed. New York, 1970;
Columbia University Press.
10 Averill JR: Grief: Its nature and significance. In: Grief:
Selected Readings (pp. 232-260). Carr, AC, et al., eds. New
York, 1975; Health Sciences Publishing Corp.
11 McGlynn T, Metcalf H: Diagnosis and Treatment of Anxiety
Disorders: A Physician’s Handbook. Washington, DC, 1989;
American Psychiatric Press.
12 Huelke DF, O ’Day J, Mendelsohn RA: Cervical injuries
suffered in automobile crashes. J N euro surg. 54:316; 1981.
13 Jackson IT: A fresh look at the malar fracture: a new
classification. In: Transactions of the VIII International
Congress of Plastic Surgery (Montreal). 26-July 1 (pp 336-
337). Williams HB, ed. 1983; R.B.T. Printing Ltd.
14 Jackson IT, Pellett C, Smith JM: The skull as a bone graft
donor site. A n n P la st Surg. 11:527; 1983.
15 Smith B, Regan WF: Blow-out fracture of the orbit. A m er J
Ophthalmol. 44:733; 1957.
16 Brady FA, Roser SN, Hieshima GB: Orbital emphysema. B rit
J O ral Surg. 14:65; 1976.
17 LeForte R: Etude experimentale sur les fractures de la
machovie superieure. R ev Chir. 23:208; 1901.
18 Eckert SE, Laney WR: Patient evaluation and prosthodontic
treatment planning for osseointegrated implants. D en t Clin N
Am er. 33:599; 1989.
19 Guckes AD, Smith DE, Swoope CC: Counseling and related
factors influencing satisfaction with dentures. J Prosth Dent.
55:78;1978.
20 Desjardins RP: Tissue-integrated prostheses for edentulous
patients with normal and abnormal jaw relationships. J Prosth
D ent. 59:180;1988.
21 Br&nemark PI: Osseointegration and its experimental
background. J Prosth D ent. 50:399; 1983.
22 Bergman B: Evaluation o f the results of treatment with
osseointegrated implants by the Swedish National Board of
Health and Welfare. J Prosth D ent. 50:114; 1983.
23 Adell R: Clinical results o f osseointegrated implants
supporting fixed prostheses in edentulous jaws. J Prosth Dent.
50:251;1983.
24 Zarb GA, Symington JM: Osseointegrated dental implants:
Preliminary report on a replication study. J P rosth D ent.
50:271;1983.
25 Applegate OC: Removable Partial Denture Prosthesis, 3rd ed.
1965, Philadelphia; W.P. Saunders.
26 McCracken WL: Differential diagnosis: Fixed or removable
partial dentures. J A m er D ent Assoc. 63:767;1961.
27 Cox JF, Zarb GA: The longitudinal clinical efficacy of
osseointegrated implants: a 3-year report. I n ti J O ral
M axillofac Im.pl. 2:91; 1987.
M axillofacial Trauma 509
28 W orthington M D , B olender C L, T aylor TD : T he Sw edish
system o f osseointegrated im plants: Problem s encountered
during a 4-year trial period. Inti J Oral Maxillofac Implants.
2:77;1987.
29 Zarb G A, Z arb FL, Schm itt A: O sseointegrated im plants for
partially edentulous patients. Interim considerations. Dent Clin
N A m er. 31:457; 1987.
30 Jem t T, Lekholm U, Adell R: O sseointegrated im plants in the
treatm ent o f partially edentulous patients: A prelim inary study
on 876 consecutively placed fixtures. Inti J Oral Maxillofac
Impl. 4:211; 1989.
31 van Steenberghe D: A retrospective m ulticenter evaluation of
the survival rate o f osseointegrated fixtures supporting fixed
partial prostheses in the treatm ent o f partial edentulism . J
Prosth Dent. 6 1 :217; 1989.
32 • van S teenberghe D , L ekhom U , B o len d er C , e t al.: T he
a p p lic a b ility o f o s s e o in te g r a te d o ra l im p la n ts in th e
rehabilitation o f partial edentulism . A prospective m ulticenter
stu d y on 558 fix tu res. In ti J O ral M axillofac Implants.
5:272;1990.
33 Van Ordan AC: C orrosive response o f the interface tissues to
316L stainless steel, titanium -based alloys, and cobalt-based
alloys. In: T he D en tal Im p lan t (p. 1-24). M cK inney RV,
Lem ons JE, eds. Littleton, M A , 1985; PSG Publishing Co.,
Inc..
34 G eis-G erstorfer J, W eber H , Sauer KH: In vitro substance loss
d u e to g a lv a n ic c o rro sio n in T i im p la n t/N i-C r su p ra—
construction systems. Inti J Oral Maxillofac Impl. 4:119; 1989.
35 K ra to c h v il F J: P a r tia l R e m o v a b le P r o s th o d o n tic s .
Philadelphia, 1988; W.B. Saunders Co.
36 W iens JP: The use o f osseointegrated implants in the treatment
o f patients w ith trauma. J Prosth Dent. 67:670; 1992.
Chapter 12

Miscellaneous Prostheses
Richard J. Grisius and Dorsey J. Moore

Utilizing knowledge of anatomy, physiology, and dental
materials, a dentist can provide innovative prosthetic aids that
will contribute to the total management of the patient. The pros­
theses to be discussed in this chapter are examples of adjunc­
tive appliances that can be fabricated by the dental clinician to
facilitate the treatment and rehabilitation of patients with vari­
ous functional and anatomical deficiencies.
Lip and Cheek Support Prostheses
will aid saliva control and speech, retention of the prosthesis is
difficult because of movements of the mandible and the pres­
ence of saliva (Figure 12-1).
There are a number ofpatients with neurologic impairments
of the lip and cheek who will derive benefit from supportive
removable prostheses. These prosthetic aids can be constructed
following conventional prosthodontic guidelines. They are eas­
ily modified and may be discarded if innervation returns or the
prosthesis proves ineffective.

The lips and, to a certain extent, the cheeks provide the

final valve mechanism for articulation of speech (Chapter 7).
The lips achieve a variety of positions during formulation of
consonant phonemes. A semisphincteric posture is assumed
during the production of the “oo” sound, while a tense and spread
posture is necessary for the “ee” sound. An excellent test for
function of the facial nerve that provides innervation for this
muscle complex is to instruct the patient to alternate between
these two vowel sounds1. Although the cheek is not as involved
in the speech process, the contraction of the buccinator muscle
against the teeth confines the air-sound volume and contributes
to the speech articulation. As evidence of this fact, some com­
promise in articulation will be noted if the cheek is retracted
with a mouth mirror during speech production1.
Robinson and Niiranin suggested, “An intact lower lip is
more important for speech than the upper lip because of [its]
greater potential for movement”2. Clinical experience confirms
this observation. Patients with large midfacial defects (resec­
tion of the anterior maxilla, upper lip, and nasal structures) will
usually exhibit essentially normal speech with a prosthesis
(Chapter 9). In contrast, prosthetic replacements for the lower
lip and cheek are generally unsuccessful for several reasons, Fig. 12-1. a: Lower lip defect, b: Lower lip prosthesis in po­
and surgical reconstruction is usually the treatment of choice. sition. Speech and saliva control were improved
Whereas a prosthesis for replacement of a resected lower lip dramatically. (Courtesy: Eleni Roumanas.)
512 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
Lip supportive prostheses may be beneficial to patients with
facial nerve paralysis. Unilateral facial paralysis can result from
trauma, infection, cerebrovascular accidents, or Bell’s palsy.
Since the facial nerve supplies the motor and sensory innerva­
tion for the buccinator and the circumoral musculature, the loss
of innervation to these muscles will result in sagging of the
affected side of the face. Facial distortion results with drooping
of the eyebrow, cheek, comer of the mouth, and the lip. Unilat­
eral paralysis permits the unopposed muscles of the unaffected
side of the face to exert an abnormal pull on the paralyzed side.
This prolonged absence of antagonists leads to chronic spastic­
ity of the uninvolved muscles3. With the lack of tonus and droop­
ing of the comer of the mouth, saliva control may also be com­
promised. The articulation of speech will be affected in varying
degrees, depending on the neurologic insult and its effect on
other structures involved in the formation of speech.
Lazzarri described the fabrication of a maxillary remov­
able partial denture with an open loop of 8-gauge, half-round
wire attached in the area of the first bicuspid4. The wire loop
was adjusted to protrude from the commissure of the mouth
and was used as a hook to elevate and support the upper lip and
the comer of the mouth (Figure 12-2). After the removable par­
tial denture framework was adjusted, the loop was covered with
baseplate wax, and modifications were made in the wax to de­
velop the desired support for the comer of the mouth. When the
adjustments were completed, the wax was replaced with clear
aciylic resin.
Larsen suggested that, while the loop described by Lazzarri
straightened the lip line, it did not improve facial sag and still
permitted drooling5. He thought the loop was unesthetic and
resulted in distortion of bilabial (“p” and “b”) and labiodental
(“f '1and “v”) speech phonemes. He advocated fabricating a
maxillary removable partial denture framework with a reten­
tive meshwork in the bicuspid area. Modeling plastic was added
gradually to the retentive meshwork to elevate the vestibular
fornix and cheek while speech and esthetic changes were evalu­
ated. When the desired contours were achieved,
autopolymerizing acrylic resin was substituted for the model­
ing plastic.
Fig. 12-2. Open loop of half-round wire attached to buccal
aspect of removable partial denture and cov­
ered with acrylic resin to support upper lip and
corner of mouth.
Laryngectomy Aids
Approximately 4,000 resections of the larynx are performed
annually in the United States, mostly for men over 50 years of
age. Because the incidence of laryngeal cancer is increasing,
and the mortality rate is decreasing, approximately 30,000 la-
lyngectomy patients are now living in the United States6. Most
tumors of the larynx are squamous cell carcinomas and may be
related to the use of tobacco products (Chapter 5).
Surgical removal of the larynx requires that an alternative
airway be provided to allow communication with the tracheo­
bronchial tree. A tracheostomy is performed, creating a perma­
nent stoma in the suprasternal notch area of the neck to provide
air exchange while bypassing the nasopharyngeal airway (Fig­
ure 12-3). Although improved surgical procedures have mini­
mized the problems associated with maintaining an adequate
tracheal opening, a substantial number of patients with laryn­
gectomies may be required to wear a prosthesis, either periodi­
cally or constantly, to prevent stenosis of the stoma.
Fig. 12-3. Permanent stoma in suprasternal notch area of
neck. (Source: Grisius R, et al. Prosthetic treat­
ment of the laryngectomized patient. J Prosthet
Dent. 32:300;1974.)
The standard inflexible silver alloy tracheostomy tube, with
a predetermined diameter, curvature, and length, may cause
problems, such as irritation of the lining mucosa. This irritation
often leads to an increase of mucosal secretions. In addition,
tarnish, difficulty in cleaning, and improper angulation of the
opening may also be evident. More serious sequelae include
wound infection, erosion of the trachea, and formation of tra­
cheoesophageal fistulas3. A metal tracheostomy tube can also
complicate the dosimetry of postoperative radiation therapy.
In an attempt to minimize these complications, tracheo­
stomy tubes have been hand-crafted from several different ma­
terials. Swerdlow suggested tracheostomy tubes be constructed
of glass7, but these tubes require the talents of a glassblower
and have the potential risk of breakage. Acrylic resin has been
used for these prostheses, but it is inflexible and presents prob­
lems in achieving proper anatomical curvature and uniform
opening. A custom-made tracheostomy tube of silicone rubber
can aid in preventing stenosis of the stoma, while minimizing
 Miscellaneous Prostheses 513

Fig. 12-4. a: Standard laryngectomy tube modified as tray, with impression of stoma and surrounding structures, b: Three-
section mold with copper tubing incorporated to provide airway, c: Completed silicone-rubber custom laryngec­
tomy tube. Note modification to deflect air and tracheobronchial secretions away from patient’s face, d: Custom
laryngectomy tube in position to prevent stenosis of the stoma. (Source: Grisius R, et al. Prosthetic treatment of
the laryngectomized patient. J Prosthet Dent 32:300;1974.)

complications and adding to patient comfort8. Silicone rubber the mold. To prevent stenosis of the stoma, the prosthesis should
has many advantages over glass and acrylic resin: it is flexible, be worn constantly for at least 3 weeks. When the stomal open­
inert, and adjustable; and it can be molded to reproduce ana­ ing has stabilized, the prosthesis need only be worn at night.
tomical detail. Also, multiple prostheses can be custom-made An alternate method is to modify a commercially avail­
for the patient from the same mold. able tracheostomy tube. An impression is made o f the
To fabricate a silicone rubber tracheostomy prosthesis, a tracheostoma, utilizing the commercial prosthesis as a base (Fig­
tracheostomy tube is modified to serve as a tray for making an ure 12-5 a,b). A stone mold is fabricated from the impression,
impression of the tracheostoma and surrounding structures. The and wax is adapted to the commercial prosthesis (Figure 12-
tray is formed by adapting baseplate wax to the superior por­ 5c). The customized prosthesis is then modified with either clear
tion of the tube. It is coated with adhesive* to enhance the reten­ acrylic resin, or silicone rubber. A prefabricated plug is avail­
tion of the impression material. able which fits into the prosthesis to obturate the stoma for speech
Suction is used to clear the trachea of secretions and should (Figure 12-5d).
be available during the procedure. Special care must be taken to
keep the tracheostomy tube unobstructed to ensure an adequate
airway during impression procedures. A modest amount of
quick-setting irreversible hydrocolloid impression material is
applied to the special tray to make an impression of the ana­
tomical contours of the depression and the stomal opening (Fig­
ure 12-4a). The impression is removed and poured with artifi­
cial dental stone in stages to create a 3-piece mold. A copper
tube of a gauge comparable to the internal diameter of the stan­
dard tracheostomy tube is incorporated into the mold to main­ a
tain an adequate airway in the finished prosthesis (Figure 12-
4b). If the opening of the tracheostoma is directed toward tlie
patient’s chin, the mold can be modified to incorporate a de­
flector in the finished prosthesis to direct air and tracheobron­
chial secretions away from the patient’s face (Figure 12-4c).
Inert earth pigments can be blended into room-tempera-
ture-vulcanizing silicone rubber** to produce the basic skin shade
before the silicone is packed into the stone mold. Nylon mesh
can be incorporated to add edge strength to the prosthesis. To
c
facilitate retention of the prostheses, fabric tape ties can also be
embedded within the silicone rubber before the mold is closed F ig. 12-5. a: Patient with permanent tracheostoma. b: Com­
(Figure 12-4d). The patient should be provided with duplicate mercial tracheostoma prosthesis, c: Prosthesis
prostheses and instructions for cleaning them with soap and adapted to stone mold of patient and modified
water. Since the laryngectom ized patient w ill have a with wax. d: Customized prosthesis after process­
tracheostoma for the rest of his or her life, it is advisable to save ing. A prefabricated plug obturates the stoma.

Getz Hold, Teledyne Dental, Elk Grove Village, IL.

** A 2186 Silastic, Factor II, Lakeside, AZ.
514 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

C ustom A irw a y TUbe tube is removed, the opening usually heals primarily or is closed
surgically. Occasionally, it is desirable to maintain the patency
Custom-made tubes of silicone rubber* fitted with an in­ of the tracheal stoma. However, the patient’s speech will be
flatable cuff have proven effective in providing a positive pres­ compromised unless the tracheostoma is obturated. Obturation
sure airway (Figure 12-6a). They are superior to the standard may be accomplished by placing a finger over the opening or
wire-reinforced rubber airways, and they may be used for ad­ by wearing a prosthesis to occlude the opening.
ministering oxygen, placing medication, or aspirating patients Harley discussed the fabrication of a tracheostomy obtura­
with tracheostomies (Figure 12-6b). The silicone rubber tube is tor of acrylic resin by duplicating the contours of the metal tra­
constructed with a 90° bend and may be made with a variety of cheostomy tube in a hydrocolloid mold, then filling the mold
lumen sizes. with fluid resin9. The polished resin obturator is held in place
by the same cloth tape used to retain a metal tracheostomy tube.
Rudd and others have also described the fabrication of a stomal
button of flexible resin that effectively obturates the tracheo­
stomy site until closure is feasible10.
The impression is made with a thin mix of irreversible hy­
F ig . 12-6. drocolloid, observing the same precautions for the protection
a: Custom silicone of the airway as described for the laryngectomized patient. Af­
rubber airway with ter the impression is poured in artificial stone, the mold is scraped
inflatable cuff ready to develop a retentive flange on the section that inserts into the
fo r p la ce m e n t in trachea. The prosthesis may be made of acrylic resin or silicone
trachea, b: Custom rubber* and tinted to blend with the patient’s skin tones. The
a irw a y in pla ce . patient is instructed to clean the prosthesis with soap and water
Note oxygen hook­ and to wear it continuously (Figure 12-7).
up ready for deliv­
ering positive pres­ O ro fa cia l Plug
sure ventilation.
The lack of sufficient tissue to adequately develop primary
closure or a postsurgical infection can lead to the formation of
an orofacial fistula (Figure 12-8a). The continuous drainage of
saliva can be controlled by the fabrication of a silicone rubber
b plug, which is to be used until corrective surgery can be per­
formed (Figure 12-8b). An impression of the defect is made in
'Tracheostom y O b tu ra to r irreversible hydrocolloid to develop a stone cast. Judicious scrap­
ing of the cast at the intraoral surface will create a flange in the
A tracheostomy often is performed to provide a patent an prosthesis to ensure an adequate seal. The extraoral surface of
airway when breathing is compromised by infection or trauma. the silicone rubber prosthesis may be tinted to blend with the
When the patient’s condition improves, and the tracheostomy adjacent tissue (Figure 12-8c).

F ig . 12-7. a: Permanent tracheostoma. b: Silicone rubber plug customized to obturate stoma and appear as jewelry, c:
Custom stomal plug in place.

A 2186 Silastic, Factor II, Lakeside, AZ.


F ig . 12-8.
a: Orocutaneous fistu la of
mandibular angle, b and c:
Fistula obturated with silicone
rubber plug.
Obstructive Sleep Apnea
When air flow ceases to pass through the upper airway
with continued diaphragmatic effort during sleep, a pathologic
condition called obstructive sleep apnea (OSA) may be diag­
nosed. Obstructive sleep apnea is now recognized as a common
clinical disorder with potentially life-threatening consequences11.
It is estimated that as many as 5 million American adult males
are affected12. Occupational and motor vehicle accidents have
been attributed to OSA.
Sleep induces relaxation of the musculature in the upper
airway. As a result, the opening of the airway shrinks and breath­
ing becomes more laborious. The most prevalent explanation
of OSA is that the obstruction occurs when the tongue retrudes
back against the posterior pharyngeal wall. Whether the airway
remains patent or collapses depends on the amount of negative
pressure in the airway and the counterbalancing muscle tonus
of the dilators of the oropharynx, particularly the genioglossi.
OSA is more common in men, and it can be strongly sus­
pected if the patient is a middle-aged, overweight, complains of
excessive daytime sleepiness, and has a history of heavy snor­
ing that is punctuated by periodic cessation of breathing. Other
symptoms are early morning headaches which may be due to
nocturnal C 0 2, retention, impaired concentration, depression,
anxiety, hypertension, and impotence13.
Miscellaneous Prostheses 515
Meyer and Knudson have described the various current
modalities of treating OSA14. The conservative methods include
weight loss, changes in sleep posture, drug therapy, nasal con­
tinuous positive airway pressure (CPAP), and a variety of in­
traoral devices. Some of the surgical procedures performed are
tracheostomy, uvulopalatopharyngoplasty (UPPP), and
septoplasty. Orthognathic surgery procedures, which advance
the maxilla or the mandible and the hyoid bone, are considered
for individuals with skeletal deficiencies.
Weight loss is the primary nonsurgical approach in OSA
treatment. A direct relationship has been found between losing
weight and improving the sleep pattern, as well as a reduction
in apnea frequency. The use of medications has not been uni­
formly successful, and can be complicated by undesirable side
effects.
The prosthodontist contributes to the team approach for
OSA treatment by providing and interpreting cephalometric
radiographs to evaluate the degree of airway obstruction and
subsequent improvement following therapy. Mounted diagnos­
tic casts will help determine if a presumed retrognathic man­
dibular position contributes to the collapse of the tongue against
the posterior and lateral pharyngeal walls. In addition, an in­
traoral prosthesis, fabricated of acrylic resin, can serve as a di­
agnostic device as well as a conservative, reversible procedure
which may be sufficient to substantially decrease the number
of apneic episodes.
If the patient has a retrognathic mandible, the prosthetic
device will increase the airway by positioning the mandible in a
more anterior position, thereby increasing the intraoral space
for the tongue and minimizing the potential for airway obstruc­
tion. Once the patient experiences the benefits of this forward
position of the mandible, they may choose to wear the prosthe­
sis routinely during sleep, or to undergo orthognathic surgery,
which will permanently reposition the mandible in this more
favorable position.
Most patients who utilize the intraoral prosthesis have dem­
onstrated a decrease in episodes of apnea, since the device brings
the mandible forward and increases the vertical dimension be­
tween the jaws. The prosthesis is especially helpful for patients
who are medically or financially unable to undergo surgical
correction. Some patients who have chosen the constant posi­
tive airway pressure (CPAP) treatment at home will utilize a
prosthesis when they are traveling so they do not have to take
along the CPAP equipment.
Impressions are made of the maxilla and mandible, and are
poured in stone. The casts are surveyed to record the height of
contour and mounted on a semi-adjustable articulator. A face­
bow transfer to record the patient’s arc of closure is recom­
mended, since the prosthesis will be fabricated at an increased
vertical dimension of occlusion.
The mandibular cast is advanced approximately 5 mm on
the articulator, but not beyond an end-to-end relationship of the
516 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Fig. 12-9. a: Maxillary and mandibular occlusal rims processed in clear acrylic resin for treatment of a sleep apnea patient.
b: Adapted rims on casts. Note increase in vertical dimension of occlusion and protrusive jaw relationship, c:
Completed prosthesis with adequate anterior space to allow patient to breathe freely.

dentition. The vertical dimension of occlusion is increased ap­
proximately 6 to 8 mm between the anterior teeth. Baseplate
wax is adapted to both casts to the height of contour, and a
keyway is incorporated in the mandibular occlusal surface to
maintain the protrusive position. A space of at least 3 mm is
maintained between the wax rims, covering the anterior teeth to
serve as an airway. The wax rims are processed in clear acrylic
resin (Figure 12-9a). An alternate method is to fabricate the rims
in visible light-curing resin*. The individual polished clear resin
rims are tried on the patient to verify adaptation to the dentition.
The keyway can be modified to increase or decrease the protru­
sive relationship. The maxillary and mandibular segments are
united with visible light-curing resin (Figure 12-9b). A bonding
agent is applied to the opposing surfaces before the light-curing
resin is placed and cured. The united prosthesis is removed from
the mouth, cured from the buccal and lingual with a visible
light source, and polished. The completed prosthesis is placed,
making sure that the anterior space is adequate for the^atient to
breathe freely (Figure 12-9c).
Since this prosthesis positions the mandible in a protrusive
position and at an increased vertical dimension, concern has
been expressed that there can be damage to the stomatognathic
system. Yoshida recorded no obvious increase in masseter or
lateral pterygoid muscle activity for patients during sleep after
the appliance was placed15. He found that the prosthesis main­
tained the desired mandibular position without craniomandibular
disorders in 20 patients who wore the appliance for an average
of 55 months.
den and often times total loss of verbal communication. If only
the tongue is removed, compensatory movements of the man­
dible and cheeks may permit some articulation with the use of a
tongue prosthesis16. The large oral cavity created by the loss of
the tongue makes the control of saliva and liquids very diffi­
cult. Fluids tend to pool in the altered floor of the mouth and to
seep around the epiglottis, thus stimulating the cough reflex
and/or leading to aspiration. For immediate surgical reconstruc­
tion of the tongue and adjacent hard and soft tissues, please see
Chapter 5.
An impression of the mandible without a tongue present
can be accomplished by modifying a stock maxillary impres­
sion tray. The palatal section of the maxillary tray is built up
and extended with wax to include a major portion of the floor
of the mouth and to provide support for the irreversible hydro-
colloid impression material.
When the mandibular arch is partially edentulous, the
tongue prosthesis is incorporated into a removable partial den­
ture. The retentive meshwork of the framework is extended into
the defect to provide support for the resin tongue prosthesis.

Tongue Prosthesis
The loss of the entire tongue and related structures, includ­
ing the floor of the mouth, suprahyoid musculature, teeth, and
alveolar ridges, impairs all functions of the stomatognathic sys­
tem (Figure 12-10). The impact of the physical disability is ag­
gravated by the psychological trauma that accompanies the sud­
Triad, Dentsply, York, PA.
Fig. 12-10. Defect created by total glossectomy and resec­
tion of floor of mouth. Note epiglottis (arrowy.
(Source: Moore DJ. Glossectomy rehabilitation
by mandibular tongue prosthesis. J Prosthet
Dent 28:429;1972.)
 Miscellaneous Prostheses 517

The denture base should include the floor of the mouth, extend
well into the oral pharynx, and overlay the epiglottis (Figure
12- 11).
The tentative contours of the prosthesis are developed in
wax and evaluated intraorally prior to processing to verify the
occlusion, ensuring freedom in lateral and protrusive move­
ments, and to check for adequate palatal contact of the tongue
prosthesis during speech and deglutition (Figure 12-12a). After
processing, the denture base is reevaluated with pressure-indi-
cating paste to eliminate undue pressure with the floor of the
mouth during muscular activity (Figure 12-12b). Cine-
radiographic studies have shown that the epiglottis must not be
impeded if proper function and comfort are to be ensured.
For some patients, speech can be improved by adding a
flexible tongue of silicone rubber* to the mandibular prosthesis.
The body of the tongue prosthesis is held in place by develop­
ing a snap-ring and undercut design in the mandibular denture
base at the level of the occlusal table (Figure 12-13). The tip of
the tongue is flexible and elevated 2 to 3 mm above the denture
base (Figure 12-14a). This position permits a positive contact
with the palate during the formation of linguoalveolar sounds
and when the mandible approaches the closest speaking space.
Certain speech patterns usually require that the mandible be
placed in a slightly protrusive position. During closure into cen­ Fig. 12-12.
tric occlusion, however, the silicone rubber tip of the tongue a: Completed dentures on articulated remount casts, show­
prosthesis depresses, allowing for bilateral contact of the poste­ ing relationship of maxillary denture base to tongue prosthe­
rior teeth (Figure 12- 14b). The dorsal surface of the tongue pros­ sis in a simulated lateral chewing stroke, b: Polished surface
thesis is contoured to allow food and fluids to be directed by the of mandibular removable partial denture supporting tongue
cheek musculature into the oral pharynx and shunted into the prosthesis. This surface will contact floor of mouth while al­
esophagus during swallowing. An extension of the denture base lowing for unrestricted movement of epiglottis. (Source: Moore
over the epiglottis and larynx provides a protective cover for DJ. Glossectomy rehabilitation by mandibular tongue pros­
the airway (Figure 12-15). thesis. J Prosthet Dent. 28:429;1972.)

Fig. 12-13. Tongue prosthesis and denture with duplicate

silicone rubber tongues, illustrating method of
retention to denture base.

Fig. 12-11. Waxed mandibular tri.al denture showing hollow,
elevated tongue in 2 sections. Hollow design
minimizes the weight of the prosthesis. (Source:
Moore DJ. Glossectomy rehabilitation by man­
dibular tongue prosthesis. J Prosthet Dent.
28:429;1972.)
A 2186 Silastic, Factor II, Lakeside, AZ.
If the surgery involves the tonsillar fossa, deeper neck struc­
tures, or soft palate, or if the surgery necessitates the placement
of extensive skin grafts, the prognosis for improvement of func­
tion with a tongue prosthesis is poor. A partial mandibulectomy
(Chapter 5) may complicate rehabilitation if the remaining man­
dibular segment is deviated toward the defect side.
518 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

mum contact is developed with the floor of the mouth during

swallowing (Figure 12-16 b,c). After the wax pattern of the
tongue prosthesis is perfected, it is processed in acrylic resin.
The modified maxillary denture replaces the tissue volume lost
by the glossectomy and will assist the patient in swallowing.
However, speech and salivary control may be improved on an
individual patient basis.

Fig. 12-14. a: When mouth is at “closest speaking position”,

tongue tip can make light contact in rugae area
of maxillary denture, b: With teeth in contact,
tongue tip folds into space created under tongue.
(Source: Moore DJ. Glossectomy rehabilitation
by mandibular tongue prosthesis. J Prosthet
Dent. 28:429:1972.)

Fig. 12-15.
Lateral radiograph showing
radiopaque outline of man­
dibular removal partial den­
ture extension over epiglottis.

Fig. 12-16. a: E dentulous p a tie n t fo llo w in g to ta l

As a result of primary closure following glossectomy, there
may be little remaining alveolar ridge in an edentulous patient
due to the loss of vestibular depth (Figure 12-16a). The treat­
ment of choice in this situation is to suspend a tongue prosthe­
sis from the maxillary complete denture. Impression wax that
softens at mouth temperature* is added to the palate of a maxil­
lary denture. The wax is then modified intraorally until maxi-
Adaptol, J.F. Jelenko and Co., Inc., New Rochelle, NY.
glossectomy and tenting of floor of mouth to
close surgical site. Note lack of alveolar ridge,
b: Existing maxillary denture was modified with
tongue bolus developed in mouth-temperature
impression wax. c: Closed mouth position illus­
trates ability to establish intimate contact be­
tween modified denture and floor of mouth. This
aids swallowing and formation of certain speech
sounds.
 Miscellaneous Prostheses 519

Esophageal Prosthesis
The loss of the cervical portion of the esophagus from ab­
lative surgery or radiation necrosis presents a difficult and chal­
lenging rehabilitation problem. Infection or complications from
radiation necrosis may delay surgical reconstruction. Until con­
tinuity of the esophagus is restored, the patient will be unable to
swallow effectively or control his or her secretions*7. A custom
cervical esophagus of silicone reestablishes the continuity of
the esophagus, permitting swallowing and control of secretions.
Fabrication begins with an impression of the anterior neek re­
gion. The head should be in a slightly extended position when Fig. 12-17. Impression of residual cervical esophagus, in­
the impression is made. A moist gauze plug is attached to a cluding pharyngostoma and esophagostoma,
length of dental floss or suture material and inserted about 25 and made with irreversible hydrocolloid.
mm into the esophagostoma to dilate the lumen and restrict the
flow of the impression material. The patency of the airway is
protected during the impression procedure.
Irreversible hydrocolloid impression material is mixed with
one-third more water to facilitate the flow of the material, and
the mixture is loaded into a disposable plastic syringe. A tray is
sprayed with adhesive* and used to place additional impression
material over the extended neck and the angle of the chin (Fig­
ure 12-17).
A sectional stone mold is developed from this impression.
A copper tube is incorporated within the mold to maintain the
lumen of the esophageal prosthesis during fabrication. Judicious
scraping of the stone mold in the area of the pharyngostoma a b
prior to processing may be necessary to ensure an adequate seal. Fig. 12-18. a: Completed transitional esophageal prosthe­
During the early phases of healing, when tissue contours are. sis with balloon cuff attached, b: Transitional
changing rapidly, a ballooning cuff may be useful (Figure 12- prosthesis in place, showing flange designed to
18a). The cuff is attached in the area of the pharyngostoma and support lumen at proper angle in relation to the
inflated at mealtime, thereby minimizing the leakage of fluids 2 openings of the stoma.
(Figure 12-18b). As healing progresses, the balloon may be
eliminated, since tissue contraction will adapt to improve the „
seal of the silicone rubber prosthesis. The prosthesis should be
removed after each meal and cleaned with soap and water. Ap­
propriate tinting and sculpting will ensure an esthetic result (Fig- ‘
ure 12-19 a,b).

Special Rehabilitation Aids

Following removal of the larynx, the most efficient method

of achieving vocal rehabilitation is generally considered to be
esophageal, or alaiyngeal, speech. The technique requires the
implosion and entrapment of a column of air in the upper part
of the esophagus. Controlled release of the air causes the walls
of die esophagus to vibrate and produce phonation similar to a b
that produced by the vocal folds. These esophageal sounds are Fig. 12-19. a: Hollow, custom-fitted esophageal prosthesis.
then articulated by the lips, teeth, tongue, and cheeks. The voice b: Anterior flannp mntnmwi anri fir,**** ul— *
520 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
patient from achieving adequate volume and control for extended
speech. The surgical procedures required for total laryngectomy
and radical neck dissection may result in reduced activity of the
pharyngeal segment of the esophagus. Reduced innervation, or
lack of adequate sphincter activity, can also complicate the
patient’s ability to achieve alaryngeal speech18.
The application of digital pressure to various levels of the
esophagus may aid in the production of audible alaryngeal
speech, but this technique makes it difficult for the patient to
perform tasks requiring the use of both hands while speaking
(Figure 12-20). A prosthetic aid can be made to simulate digital
pressure8. Elastic tape, 25 mm in diameter, is adapted to the
patient’s neck as a collar. The ends are overlapped and held in
place by hook and loop tape. Softened modeling plastic is added
to the collar at the critical pressure point in the neck to make an
impression of anatomical contours and to develop adequate pres­
sure to minimize the effort of maintaining prolonged a laryn­
geal speech. The modeling plastic is then replaced with room-
temperature-vulcanizing silicone rubber (Figure 12-21 a,b). For
esthetics, the collar may eventually be eliminated by incorpo­
rating both the bulb and the elastic tape into an ascot.
Fig. 12-20.
Application of digital pressure
to pharyngeal section of
esophagus enables patient
to assume normal posture
and perform alaryngeal
speech aid with minimal ef­
fort. (Source: Grisius R, et al.
Prosthetic treatment of the
laryngectomized patient. J
Prosthet Dent. 32:300;1974.)
Fig. 12-21. a: Impression developed for making a speech
aid duplicated in silicone rubber and adapted to
the hook and loop tape, b: Completed speech
aid in position. (Source: Grisius R, et al. Pros­
thetic treatment of the laryngectomized patient.
J Prosthet Dent 32:300;1974.)
Section on vaginal radiation carriers contributed by John Beumer III.
Vaginal Radiation Carriers*
The use of individually constructed carriers for delivery of
intracavitary radiation therapy for the treatment of carcinomas
has been discussed in Chapter 4. The custom-made radiation
carrier enhances the therapeutic effect by positioning and main­
taining the radioactive source adjacent to the tumor site while
minimizing tissue distortion and increasing patient comfort. A
similar approach may be used to treat vaginal carcinomas.
An impression of the vagina is made using irreversible
hydrocolloid supported by an acrylic resin rod (Figure 12-22a).
Adhesive is placed on the rod to enhance the retention of the
irreversible hydrocolloid impression material. To prepare the
sectional mold, the impression is poured in 2 stages (Figure 12-
22b), coating the first half with petrolatum prior to pouring the
second half. Frequently, the tumor site can be visualized in the
mold. Consultation with the radiation physicist determines the
exact position of the radioactive sources within the prosthesis.
Indelible pencil lines are made on the mold to indicate the loca­
tion of the polyethylene tubing that will house the radioactive
material (Figure 12-22c).
A wax pattern is made within the sectional stone mold,
recovered, and uniformly reduced approximately 2 mm around
the periphery. After the mold has been soaked in water and coated
with separating medium, the wax pattern is suspended within
the mold from wax cylinders. A thin mix of autopolymerizing
resin is then poured into the mold around the suspended wax
pattern. When polymerization is completed, the mold is sepa­
rated and the resin vaginal carrier is retrieved (Figure 12-22d).
The center core of wax is removed, and the carrier is
smoothed and polished. Grooves are then prepared in the car­
rier for the polyethylene tubing, using the previously determined
indelible pencil lines as a guideline. After the tubing is secured
in position with autopolymerizing acrylic resin, the carrier is
perforated to allow for drainage and repolished (Figure 12-22e).
When the earner has been properly positioned within the va­
gina, the radioactive material is placed into the polyethylene
tubing by the radiation therapist and maintained in position for
the prescribed time period (Figure 12-22f).
A similar prosthesis can be utilized as a stent for the sup­
port of the newly formed vagina during the healing stages fol­
lowing a sex-change operation.
Burn Stents
The treatment of an individual who has sustained exten­
sive bums, especially of the face and extremities, will severely
test the skills of the health care team. Management of the pa­
tient depends not only on the area involved, but also on the
extent and the severity of the bums. Consequently, each patient
requires a thorough evaluation by all disciplines concerned with
providing care. Often, rehabilitation will extend over a prolonged
 Miscellaneous Prostheses 521

Fig. 12-22. a: Impression of vagina, b: Cast, c: Indelible pencil lines indicate where the radioactive sources are to be placed.
d: Acrylic resin stent is retrieved, e: Polyethylene tubing is attached, f: Radioactive appliance is loaded after stent
has been inserted.

period; therefore, the patient will require extensive medical and ten scars already present. Fujimori described a method of sponge
psychological support from all concerned. fixation for continuous pressure21.
During the suigical and physical therapy phases, the max­ Diagnostic impressions of the recently burned patient are
illofacial prosthodontist can make valuable contributions to best made with irreversible hydrocolloid impression materials.
patient care. Services that can be provided include the fabrica­ Even after initial healing, the tissues are sensitive to both pres­
tion of diagnostic casts of various areas of the body, to be uti­ sure and elevated temperatures. Premedication is also recom­
lized during surgical reconstruction, as well as prosthetic re­ mended, especially when full-face impressions are to be made.
placements for missing facial structures. Bums to the nares may necessitate the use of an oral airway
Extensive scar contracture usually occurs during primary ** while making facial impressions.
healing following bums of the skin. Surgical reconstructive pro­ Impressions of hands that have been contracted by scar
cedures include releasing scar bands with the placement of split­ tissue can be made in sections with thin mixes of irreversible
thickness skin grafts. These grafts must be closely adapted and hydrocolloid, each supported by baseplate wax. This technique
supported against the host tissue bed if they are to survive. Ap­ allows the hand to be removed from the impression with the
propriate adaptation and support will also minimize graft shrink­ fingers in flexion22. The impressions are poured in artificial stone
age. Such support can be.provided by a prosthesis. Support for to create casts from which various splints and exercise devices
free split-thickness skin grafts is required for approximately 6 can be fabricated (Figure 12-23).
months. The impression procedure is usually accomplished at the
Replacement of the skin involving the anterior region of first dressing change, which usually occurs approximately 10
the neck presents an especially difficult problem for the plastic days following surgery22. For bums confined to the neck, the
surgeon19. Some of the devices that have been utilized to pre­ head must be hyperextended during the impression procedures
vent contracture of the anterior part of the neck following a to ensure maintenance of the proper chin-neck angle (Figure
split-thickness skin grafting are elastic bandages; Sayre-type, 12-24a). It is advisable to place a layer of petrolatum gauze
cervical-wrap collar dressings20; and custom-made, leather- directly over the split-thickness skin graft site to protect the fri­
molded splints. Custom splints may also be used to apply pres­ able tissue. The impression should extend well beyond all the
sure to minimize the formation of hypertrophic scars, or to flat­ margins of the graft. A double layer of baseplate wax is adapted
524 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

Nasal Stents
Nasal stents may be utilized in a variety of ways in con­
junction with reconstructive surgery. Stents provide support for
cartilage transplants during postsurgical healing for the correc­
tion of nasal deformities in cleft lip patients. Nasal stents can
also maintain contour and minimize scar contracture following
skin grafting procedures to the nostrils. Stents may also be fab­
ricated to counteract previously formed scar tissue and to widen
the nostrils of trauma or bum patients prior to grafting proce­
dures. Young described the use of modeling plastic to gradually
develop the desired contours of the nares that had collapsed
following reconstructive plastic surgery29 (Figure 12-27 a,b).
These impressions were flasked, processed in clear acrylic resin
to render them less conspicuous, and hollowed-out to maintain
a patent airway (Figure 12-27 c,d). Stents can also be fabricated
from silicone rubber or vinyl, but additional reinforcement is
usually required within the lumen to prevent collapse of the
nares during inhalation (Figure 12-28). If necessary, these ma­
terials may be intrinsically tinted to approximate skin tones.
The contraction of scar tissue following facial bums can
also lead to obliteration or severe narrowing of the nares3. Na­
sal stents should be made as soon as possible to minimize this
constriction of the nostrils (Figure 12-29). If narrowing has al­
ready occurred, one method of treatment is to fabricate a series
of nasal stents in increasing sizes to gradually enlarge the nasal
passageways. Doran suggested the use of an expandable nasal
stent that eliminates the need for repeated remakes or modifica­
tions30. An orthodontic jackscrew expander was incorporated
into the lumen of the sectioned stent and gradually activated
until the desired opening of the nares was obtained. After ex­
pansion was completed, the sides of the stent were sealed with
autopolymerizing resin, and the stent was worn to maintain the
nostril opening. If further corrective surgical procedures are
contemplated, the acrylic resin stent can be used to place and
support a split-thickness skin graft.
The replacement of the entire nose with an island pedicle
graft, usually from the forehead, has met with limited success.
It is extremely difficult to maintain a viable graft that possesses
the proper tissue texture and esthetic contours. If a pedicle graft
is utilized, then nasal stents may be beneficial during healing to
support the newly fonned openings of the nares and columella
(Figure 12-30).

Fig. 12-27. a: Skin grafting procedures to nostrils, b: Modeling plastic impression used to develop desired contours, c: Im­
pressions flasked and processed in clear acrylic resin to render them less conspicuous, d: Stents hallowed out to
maintain a patent airway.

Fig. 12-28. Fig. 12-29. Fig. 12-30.

Silicone rubber nasal stent reinforced Silicone rubber nasal stent was main­ Processed clear acrylic resin nasal
with resin, supporting a graft taken tained by using orthodontic head gear stents to support pedicle graft from
from an ear for reconstruction on a to support a pedicle graft for replacement the forehead and used to maintain
cleft lip. of the entire nose of a burn patient. patent airway of reconstructed nose.

An implant of autogenous bone or silicone rubber is also
frequently required to support the grafted tissues and to prevent
collapse of the bridge of the nose. Boucher described the use of
a removable partial denture with a hinged extension to provide
support for the bridge of the nose after several unsuccessful
cartilage implantations31.
Auditory Inserts
Custom auditory inserts can be useful in a number of func­
tions. An auditory insert, or custom ear plug, of acrylic resin,
polyvinylchloride, or silicone rubber may be required as a stent
during surgical reconstruction of an external auditory meatus
(Figure 12-31). Also, this appliance may serve as a custom ear
plug following mastoid surgery. Swimmers plagued with chronic
ear infections can also benefit from custom-made auditory in­
serts (Figure 12-32).
sio logy, is usually fabricated from acrylic resin. An opening is
e frequently when surgery and/or the fields of radiation involve
F ig . 12-31. a: Surgical reconstruction of an external audi­
tory meatus, b and-c: Impression of recon­
s tru c te d a re a , d: S to n e m old fille d w ith
autopolymerizing clear acrylic resin, e: Hollowed
auditory meatus insert polished and placed as
stent to support reconstructed auditory meatus.
Ear Mold Nubbin, Pacific Coast Earmold Laboratory, San Francisco, CA.
Miscellaneous Prostheses 525
F ig. 12-32. Enlarged auditory meatus, following mastoid
surgery, protected by custom silicone ear plug.
In addition, the custom auditory insert aids the anesthesi­
ologist. The remote monitoring pickups are taped to the arm
and chest of the patient and attached to the physician’s custom
acrylic resin insert. This insert provides auditory acuity as well
as comfort to the anesthesiologist during prolonged surgical
procedures requiring constant monitoring.
The impression material is loaded in a disposable plastic
syringe and injected into the auditory meatus as well as into the
convolutions of the pinna of the ear, if present. The opening of
the disposable syringe is enlarged to facilitate injection. A mold
is formed by suspending the impression in a cup that is then
filled with rapid-setting artificial stone. After the stone has
reached its initial set, the mold is scored lengthwise and split in
half. It is lubricated with petrolatum, reassembled with rubber
bands, and filled with either tinted room-temperature-polymer­
izing silicone rubber, or clear acrylic resin. The choice of mate­
rial depends on the purpose of the custom ear plug. Retaining a
substantial amount of detail of the pinna of the ear peripheral to
the auditory insert facilitates alignment, retention, and seal.
The auditory insert, used as a patient monitor for anesthe­
bored completely through the polymerizing resin, and a recep­
tacle is embedded for the monitoring pickup. The hub of the
spinal needle can serve this purpose, although a snap-on audi­
tory tube may be preferable*.
Trismus Appliances
Trismus can be severe following surgical procedures or
radiation therapy to the head and neck. Trismus occurs most
the muscles of mastication or the temporomandibular joint.
Several methods have been utilized to counteract trismus
and increase interarch space. Exercising the mandible during
the immediate postsurgical period will tend to minimize the
formation of constricting scar tissue. Rouse suggested that the
patient place downward pressure on the mandible with the fin­
526 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
gers, stretching the musculature to the maximum, and then
maintain this opening for a slow count to 1032. The patient re­
peats this exercise throughout the day. Several other methods
have proven useful to counteract trismus for dentulous patients.
An ever-increasing number of tongue blades can be forced be­
tween the anterior teeth, acting both as a wedge and as a visual
gauge to the degree of opening. Whereas tongue blades may
also be used for edentulous patients, more pressure can be ap­
plied if the dentition is present. Another method is to utilize 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 (Figure 12-33 a,b). The threads guide the
teeth along the increasing taper while the patient controls the
timing and degree of pressure required to gradually increase
the jaw separation. This device can be fabricated quickly by
shaping baseplate wax to the desired taper, forming the threads,
and making a mold with rapid-setting stone. The appliance is
processed in acrylic resin. The threads are refined and the de­
vice is polished.
Fabrication of a dynamic opening device has been described
by several authors33,34,35. The purpose of this device is to apply a
firm and constant opening force between the maxilla and the
a in the area of the bicuspids. If fewer posterior teeth are present,
Fig. 12-33. a: Threaded, tapered screw of acrylic resin, b:
Resin screw between posterior teeth that pa­
tient turns to wedge teeth apart. Patient con­
trols timing and degree of pressure required to
gradually increase jaw separation. Note use of
“closed eye” facial prosthesis as early cover­
age of facial defect following surgery. Also, na­
sal stent used to maintain contours of nostril and
prevent collapse on inhalation.
Getz Hold, Teledyne Dental, E lk Grove, IL.
mandible with extraoral elastics (Figure 12-34). The prognosis
for this type of prosthesis is enhanced when teeth are present.
Irreversible hydrocolloid impressions should be made of the
occlusal surfaces of both arches. If trismus is severe, these im­
pressions can be made with shallow impression trays or flat,
thin plates of metal that have been perforated and coated with
adhesive*. A large spoon may also be flattened and perforated
to function as an impression tray for patients with minimal
interocclusal clearance. Stents of clear acrylic resin are then
fabricated on the resultant casts of both arches. Two stainless
steel perforated metal plates are cut into horseshoe shapes. Ten-
gauge steel rods about 40 cm long are then welded to the buccal
edges of these metal plates. The perforated metal plates are then
attached to the acrylic resin stents with autopolymerizing resin.
An alternate method is to add a shallow, doughy layer of
autopolymerizing resin to the perforated metal trays and to de­
velop the occlusal stents directly on the natural dentition. This
latter method presents the potential hazards of excess resin lock­
ing into the undercuts of the teeth, making removal of the stent
difficult with a compromised patient.
The extraoral rods are contoured so that stability is main­
tained as the forces are applied. The rods should be shaped to
converge at the lips to avoid irritating the oral commissures.
The mandibular rod is positioned parallel to the occlusal plane,
while the maxillary rod is placed 10 to 15 mm to the buccal of
the mandibular rod. A U-shaped crimp is placed in the man­
dibular rod at the fulcrum axis of the mandibular arch. In a pa­
tient with a full complement of teeth, this axis would be located
the fulcrum is located more anteriorly. The maxillary rod is ex­
tended posteriorly toward the temporal region and then bent at
an acute angle downward and forward. This modification should
now place the maxillary rod 7 or 8 cm below the mandibular
rod. A crimp is also placed in the maxillary rod in the opposite
direction. Elastics are stretched between the two U-shaped
crimps on the opposing rods to provide active separating force.
Fig. 12-34.
Dynamic opening de­
vice activated with
extraoral elastics.

If additional tension is desired in a downward and forward di­
rection, a second crimp is placed in the posterior area of the
mandibular rod. Additional elastics are stretched from this sec­
ond crimp in the mandibular rod to the anterior notch in the
maxillary rod.
Dynamic bite openers are used with difficulty in edentu­
lous patients. The rods can be attached either to record bases
fabricated from intraoral impressions, or to existing dentures. If
the dentures are utilized, it may be necessary to remove the
posterior teeth to gain adequate space. Determination of the
fulcrum point is essential to minimize the tipping action of the
denture bases during activation of the appliance.
Elastic tension is progressively increased over an extended
period of time. Gradual increases in tension, combined with
frequent rest periods, will minimize patient discomfort. The
patient should be monitored frequently and his or her progress
evaluated by measuring the distance between the maxillary and
mandibular central incisors with a millimeter gauge.
A commercial device, the Therabite® Jaw Motion Reha­
bilitation System*is available for mechanically assisted therapy.
M outh-Controlled Devices for Assisting the
Handicapped
A mouth-controlled prosthesis can significantly benefit in­
dividuals paralyzed by spinal cord injury as well as victims of
poliomyelitis, cerebral palsy, and other degenerative diseases
that affect the control of the arms and hands. Mouth-controlled
devices offer these patients some independence. A Lucite rod
or an aluminum tube attached to an occlusal stent can be
equipped with a rubber tip for typing, dialing a telephone, play­
ing games, turning pages, or operating electrical switches (Fig­
ure 12-35). Modifying the end of the wand with a retentive tube
to accommodate a pencil or paint brush also increases the
patient’s ability for self-expression. Lutwak added a friction-
grip snap connector that accepts various attachments that the
patient can change unaided36. A 7 mm polyethylene tube can
Fig. 12-35. Use of head and neck musculature to turn pages
of book with a mouth-controlled device equipped
with a rubber tip.
Therabite Corp., Newton Square, PA.
“ Ticonium, Ticonium Co., Albany, NY.
Miscellaneous Prostheses 527
also be attached to die mouthpiece to function as a straw, aiding
the patient in taking nourishment35.
Preservation of the remaining dentition is critical, espe­
cially with a compromised patient who already requires assis­
tance to maintain plaque control. It is important, therefore, that
leverage forces be distributed over a maximum number of teeth.
Blaine and Nelson listed several other factors to be considered
during the fabrication of the interocclusal portion of the de­
vice37. Covering all the teeth distributes the stresses, increases
lateral stability, and prevents supereruption of teeth. Stabilizing
the prosthesis with the opposing dentition in centric relation at
a vertical dimension that is less than the physiologic rest posi­
tion minimizes fatigue to the neuromusculature and the tem­
poromandibular joint. Various modifications can be incorpo­
rated in the design to accommodate a denture wearer. However,
the efficiency of the device may be compromised, depending
on the quality of the residual ridge and the stability that can be
developed. To fabricate the device, impressions of both arches
are made in irreversible hydrocolloid, and the resultant casts
are mounted on an articulator with a centric relation record. A
face-bow transfer should be made to allow for an increase in
the vertical dimension of occlusion along the proper arc of clo­
sure on an articulator. The intraoral structure of the device may
then be made of acrylic resin, silicone rubber, or cast metal.
Although silicone rubber and soft liners may increase patient
comfort, the durability and maintenance of the prosthesis must
be considered, especially since cleansing must be accomplished
by someone other than the patient.
Zalkind discussed the fabrication of a device with an acrylic
resin mouthpiece38. The resin is designed to contact the hard
palate, as well as the occlusal and incisal surfaces of all the
maxillary teeth, while extending approximately 2 mm onto the
labial surfaces. The mandibular teeth are imprinted into the
mouthpiece in centric relation to a depth of 1 to 2 mm. The
^entire intraoral prosthesis is not allowed to exceed 2 to 3 mm of
thickness to minimize encroachment on the interocclusal dis­
tance. An arch-shaped metal framework is embedded into the
resin of the intraoral segment to hold the extraoral aluminum
wand. The intraoral segment can also be fabricated from cast
nickel-chrome alloy” to reduce bulk, while increasing stability
and comfort. A Lucite rod is attached to the intraoral frame­
work at an angle so that the rod will be out of the normal line of
vision.
The sophistication of these mouth-controlled devices can
be increased by incorporating mechanical or electronic assis­
tance. Mechanically operated oral movers, which can be con­
structed to function as a grasping device, have been de­
scribed34-39'40. The jaws of the appliance open when the patient’s
mandible protrudes, and then they close as the mandible retrades.
The tips of the device are covered with rubber tubing to prevent
objects from slipping. In function, this type of device requires
mandibular movement at an increased vertical dimension of
528 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

occlusion. Therefore, the occlusal stents must be fabricated to

be compatible with the condylar guidance of the patient, and
not to exceed his or her physiologic rest position in the retruded
position. Casts of the patient’s dentition should be mounted on
a semi-adjustable articulator, utilizing a face-bow transfer and
centric relation record. The condylar elements of the instrument
are set with the aid of protrusive records. After processing, the
acrylic resin stents are perfected intraorally to eliminate any
interferences during protrusive movements.
Cloran discussed the use of electronics to increase the ver­
satility of mouth instruments; specifically, incorporating a tele­
scoping mechanism41. A power pack and microswitches can be
included within the instrument, or they can be positioned else­
where for the convenience of the patient, such as on the arm of
a wheelchair. A simple stand may also be constructed to hold all
these devices at an angle that the patient can easily approach
with his or her mouth.

Custom Prosthesis for Lagophthalmos of the Eye

Inability to close the eyelids (lagophthalmos) is a major
problem for patients with facial paralysis (Figure 12-36a). The
most common cause of facial paralysis is Bell’s palsy; how­
ever, the seventh cranial nerve can also be damaged during pa­
rotid tumor removal or face-lift procedures42,43. The primary
objective in treating lagophthalmos is to protect the cornea and
preserve vision. Ideally, function, esthetics, and comfort are
improved. Lateral tarsorrhaphy, facial nerve graft, hypoglossal
nerve crossover, and regional muscle transfer are surgical tech­
niques being explored with varying success. These procedures
require hospitalization, general anesthesia, and extensive reha­
bilitation44. The use of lid magnets, springs, and silicone bands
have the potential for extrusion and foreign body reaction.
Lid loading consists of implanting a weight in the upper
lid to allow gravity-assisted lid closure when the levator palpe­
bral muscle relaxes. Smellie determined that 0.75 to 1 gram is
the average weight required for effective closure42. Gold is pre­
ferred because of its non-reactivity, high specific gravity, and
color match to the skin45. In the technique described by Grisius
and Hoff, the eyelid is taped shut and an impression is made in
irreversible hydrocolloid to develop a stone mold46. Test weights
are taped to the upper lid to determine the appropriate weight to F ig. 12-36. a: Permanent unilateral facial paralysis prevents
close the lid. A custom prosthesis is waxed on the stone mold lid closure, b: Gold custom prosthesis on mas­
and cast in type III gold (Figure 12-36b). Three holes are drilled ter cast, c: Postoperatively, the eyelid is com­
in the prosthesis to facilitate suturing. The polished prosthesis pletely closed to prevent corneal exposure, d:
is taped to the upper lid and tested for ideal closure. The steril­ Esthetics improved after placement of custom
ized gold prosthesis is placed by the surgeon as an outpatient prosthesis (Source: Grisius MM, Hof RL. Treat­
procedure under local anesthesia (Figure 12-36 c,d). Custom ment of lagophthalmos of the eye with custom
fabrication of the cast gold prosthesis enhances the esthetic re­ prosthesis. J Prosthet Dent. 70:333-5;1993.)
sults by following the natural eye contour.

References
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growth and development, proceedings of the conference (p.
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an interprofessional conference. U.S. Government; 1966.
3 Converse JM: Reconstructive plastic surgery. Philadelphia,
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4 Lazzarri, JB: Intraoral splint for support of the lip in Bell’s
palsy. J Prosthet Dent. 5:579; 1955.
5 Larsen SJ, Carter JF, Abrahamian HA: Prosthetic support for
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6 International Association of Laryngectomees: First aid for
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7 Swerdlow H, Ketcham AS, de Kernion J: Tracheostomy
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8 Grisius R, Moore D, Simpkins W: Prosthetic treatment of the
laryngectomized patient. J Prosthet Dent. 32:300; 1974.
9 Harley WT, Rothwell KS: Fabrication of tracheotomy
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10 Rudd K, Morrow R, Rosenthal D: Prosthesis for the temporary
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11 George PG: A modified functional appliance for treatment of
obstructive sleep apnea. J Clin Orthod. 21:171;1987.
12 Waldhorn RE: Sleep apnea syndrome. A m er Fam Phys.
32:149;1985.
13 Meyer JB, Knudson RC: The sleep apnea syndrome. Part I:
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14 Meyer JB, Knudson RC: The sleep apnea syndrome. Part II:
Treatment. J Prosthet Dent. 63:320; 1990.
15 Yoshida K: Prosthetic therapy for sleep apnea syndrome. /
Prosthet Dent. 72:296; 1994.
16 Moore DJ: Glossectomy rehabilitation by mandibular tongue
prosthesis. J Prosthet Dent. 28:429; 1972.
17 Moore D: Cervical esophagus prosthesis. J Prosth Dent. 30:
442; 1973.
18 Diedrich WM, Youngstrum KA: Alaryngeal speech (p. 137).
Springfield, IL, 1966; Charles C. Thomas, Publisher.
19 Cronin TD: The use of a molded splint to prevent contracture
after split skin graft on the neck. P last R econstr Surg.
27:7;1961.
20 Frackelton WH: Neck bums—early and late treatment. In:
Transactions of the international society of plastic surgeons.
Skoog T, Ivy RH, eds. First Congress-1955. Baltimore, 1957;
The Williams & Wilkins Co. pp. 130-135.
M iscellaneous Prostheses 529
21 Fujim ori R , H iram oto M , Ofuji S: Sponge fixation m ethod of
early scars. Plast Reconstr Surg. 42:322; 1968.
22 M oore D J: The role o f the m axillofacial prosthetist in support
o f the burn patient. / Prosthet Dent. 24:68; 1970.
23 Leake JE, Curtin JW: Electrical bum s o f the m outh in children.
Clin Plast Surg. 11:669-683;1984.
24 L inebaugh M L , K oka S: O ral e le c trical burns: etiology,
histology, pathology and prosthodontic treatm ent. J Prosthod.
2:136; 1993.
25 Thom pson HG, Juckes WW, Farm er AW: Electrical burns to
the m outh in children. Plast Reconstr Surg. 35:466; 1965.
26 A ckerm an A B , G oldfaden GL: Electrical bum s o f the m outh
in children. Arch Dermatol. 104:308; 1971.
27 R eisberg DJ, Fine L, Fattore L, et al.: Electrical bum s o f the
oral comm issure. J Prosthet Dent. 49:71-76;1983:
28 Ryan JE: Prosthetic treatm ent fo r electrical burns o f the oral
cavity. J. Prosthet. Dent. 42:434-436; 1979.
29 Y oung JM : In te rn a l n a re s p ro sth e sis. J P rosthet D ent.
24:320; 1970.
30 Doran PC: D ynam ic orofacial resin adjustable nasal stents. J
Prosthet Dent. 33:315;1975.
31 Boucher LJ, W ilde L, Frackelton W: Internal nasal prosthesis.
J Prosthet Dent. 6:120; 1956.
32 R o u se PB: T he role o f p h y sical th erap ists in su p p o rt o f
m axillofacial patients . J Prosthet Dent. 24:193; 1970.
33 B row n KE: Dynamic opening device fo r m andibular trism us.
J Prosthet Dent. 20:438; 1968.
34 R ahn A 0, B oucher LJ: M axillofacial Prosthetics, Principles
and Concepts. Philadelphia, 1970; W.B. Saunders Co.
35 Chalian VA, Drane JB, Standish SM: Maxillofacial prosthetics:
m ultidisciplinary practice. Baltim ore, 1971; T he W illiams &
W ilkins Co.
36 Lutw ak E: A new m outh stick prosthesis fo r handicapped
patients. J Prosthet Dent. 37:61;1977.
37 Blaine HL, Nelson EP: A m outhstick fo r quadriplegic patients.
J Prosthet Dent. 29:317; 1973.
38 Z a fo n d M , M itrani Z, Stem N: M outh-operated devices for
handicapped persons. J Prosthet Dent. 34:652; 1975.
39 Beder 0: M anipulative appliances for quadriplegics. J Prosthet
Dent. 14:785; 1964.
40 D onnelly M, Beder 0: A m anipulative appliance. J Prosthet
Dent. 28:309; 1972.
41 C lo ra n A J: T ele sc o p ic m o u th in stru m e n ts fo r se v erely
handicapped patients. / Prosthet Dent. 32:435; 1974.
42 Sm ellie GD: Restoration o f the blinking reflex in facial palsy
b y a sim p le lid -lo a d in g o p e ra tio n . B rit J P la st Surg.
19:279;1966.
43 R uben LR, L ee GW, Sim pson RL: R eanim ation o f the long­
sta n d in g p a rtia l fa c ia l p a ra ly sis . P la st R econstr Surg.
77:41; 1986.
530 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

44 Leatherbarrow B, Collin JR: Eyelid surgery in facial palsy.

Eye. 5:585-90;1991.
45 Jelks GW, Smith B, Bosniak S: The evaluation and
management of the eye in facial prosthesis. Clin Plast Surg.
6:397;1979.
46 Grisius MM, Hof RL: Treatment of lagophthalmos of the eye
with a custom prosthesis. J Prosthet Dent. 70:333; 1993.
Index

A* bleomycin, 28t, 3 0 ,30f

cyclophosphamide, 28t, 231
Abandonment, fear of, 16 5-fluorouracil, 28t, 29
Actinomyces, in radiation caries, 71 hormones, 28t, 30
Adenoid cystic carcinoma, 230 6-mercaptopurine, 28-29, 28t,
Adhesive for facial prosthesis, 396 methotrexate, 2 8 -2 9 ,28t, 231
Adrenocortical hormones; see Antineoplastic drugs plant alkyloids, 28t, 30 .
Airflow during speech, 254, 280 oral effects of, 31-41
Airway tube, 514 candidiasis, 3 5 -3 6 ,36f, 41
Alcohol, diagnostic procedures in, 3 8 ,38t
and incidence of oral carcinoma, 4 ,1 2 0 -1 2 1 ,120f hemorrhage, 3 2 -3 3 ,33f, 39
and rehabilitation, 4 infection, 33-36
and psychosocial ramifications, 4 bacterial, 3 4 -3 5 ,34f, 40
Alkylating agents; see Antineoplastic drugs fungal, 35-36, 36f, 41
Alveolar mucosa, 154 viral, 3 5 -3 6 ,35f, 40
carcinoma of, 15 4 ,154f management of, 37-41
disability secondary to surgery, 155 mucositis, 30f, 31-32, 31 f, 39
treatment of, 154 mucormycosis, 35-36, 36f
Alveolectomy, preventative measures for, 37-38
in irradiated patients, 69, 69f, 79 xereostomia, 32,39
in preparation for dentures, 6 9 ,69f, 79 Anxiety in cancer patients, 9-10,17
Ameloblastoma, Aspergillosis, 231
Amphotericin B, 41, 63 Auditory inserts, 525, 525f
Angular cheilitis in irradiated patients, 71,71 f Auricular defects, restoration of, 399-402,438-443
Antibiotics, implants and, 438-440,439f, 441-443,441f, 442f,
in bone necrosis, 94 443f
in chemotherapy, 28t, 30 impressions for, 401,442
use of, in irradiated patients, 63, 79, 81, 94 processing of, 402, 402f, 403f, 443
Antimetabolites; see Antineoplastic drugs retention of, 402, 442, 443f
Antineoplastic drugs, 27-30, 28t sculpting of, 401
alkylating agents, 27-28, 28t surgical alterations for, 400,400f
antibiotics, 28t, 30 temporary prostheses, 401
antimetabolites, 28-29, 28t

*
Note that f after the page num ber indicates pages on which figures are found; t indicates pages on which tables are found.
534 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
B in irradiated patients, 103
Backscatter, secondary to radiation therapy
with dental restorations, 62f
with osseointegrated implants, 1 0 5 ,1 06f
Bacterial infections,
in irradiated patients, 82
secondary to antineoplastic drugs, 34-35, 34f, 40
Basal cell carcinoma, 379-381
clinical features, 380, 380f
histopathology of, 380-381
treatment of, 381
Bleomycin; see Antineoplastic drugs
Bolus manipulation
in jaw-tongue defects, 172-173
in maxillectomy defects
Body image, 6 -7 ,1 7 -1 8
Bone grafting, free autogenous,
in cranial defects, 457-458
in mandibular reconstruction, 1 5 5 -1 6 1 ,157f, 158f,
159f, 160f
and placement of osseointegrated implants, 156,
159f, 163-164, 166-167, 194-196, 200-201, 202f,
260t, 259-261, 261 f
with sinus lift, 259-261, 260t, 261 f
Brachytherapy, 49-50, 49f, 95f
Burns, 482, 520-523
electrical, 482, 523
exercise prosthesis for, 521-522, 522f
scarring in, 522-523
stents for, 520-523, 522f, 523f
c orthodontic treatment of, 346-347, 347f
Candida albicans; see Candidiasis
Candidiasis,
after tongue and mandible surgery, 144,145f
in immunosuppressed patients, 35, 36f, 41
in irradiated patients, 63, 68f, 71, 71 f
and leukoplakia, 125-126
with palatal papillary hyperplasia, 129
and silicone liners, 71, 98
treatment of, 41, 63, 71
Caries,
and diet, 84
and fluoride 83-84,
following partial mandibulectomy, 145
and radiation, 65, 66f, 71, 84-86, 86f
Centric registrations,
in mandibulectomy patients, 1 8 6 -1 8 9 ,1 9 1 ,1 92f,
207-208, 209f
in maxillectomy patients, 256-257, 256f, 274, 275f
Cephalometry, 291, 291f.
Cervical injuries, 484
Cheek, support prosthesis for, 512, 512f
Chemotherapy; see Antineoplastic drugs
Cisplatin; see Antineoplastic drugs
Cleft lip; see Cleft palate
Cleft palate,
abnormal growth patterns in, 345-346
bilateral, 334f, 335, 335f, 336f
bone grafting of, 341 f, 350, 351 f
classification of, 334— 335, 336f
development of, 335-337
definitive prosthodontic
treatment of 353-363
complete dentures
for, 357-360, 357f
fixed partial dentures for, 354— 355
implant assisted prosthesis for, 362, 362f,
overdentures dentures for, 360-362, 360f,
361 f
removable partial dentures for, 355-357,
357f
single maxillary dentures for, 357f, 3 5 9 -
360
etiology of, 336, 338t
genetic evaluation and counseling of, 340
growth and development of, 345-346
historical background of, 331, 332f, 333f
incidence of, 335-337, 338t
lip closure in, 340-343, 343f
obturator prosthesis for, 347-349, 348f, 349f
palate closure in, 344-345, 348f
pharyngeal flap and, 347-348, 348f, 349f
revision surgery of,
nasal revision surgery of, 343-344
✓ pharyngeal flap, 347-348
speech in, 286-287, 3^12-314
surgical lip repair o f , 240-343, 343f
surgical palatal repair of, 344— 345, 348f
treatment principles for,
in adolescence, 346-347, 347f
in adulthood, 353-362, 354f, 355f, 356f,
357f, 360f, 361 f, 362f
in infancy, 337-345, 339f
with mixed dentition, 346, 347-353, 348f,
353f
with primary dentition, 345
unilateral, 334, 335f, 336f
velopharyngeal function in, 301, 301 f
Cleveland, Grover, 225
 Index 535

Closure, primary, in irradiated patients, 79 osteoplastic, 457

Composite resection, polyethylene, 460-461
of alveolar ridge, 154 silicone, 461
complications of, 136,148,152 Cyclophosphamide; see Antineoplastic drugs
of floor of mouth, 147, 147f, 148f
of tongue, 133-134, 136f, 137f D
of tonsil, 1 5 1 -1 5 2 ,151f, 152f
Compton effect, 44 Death, fear of, 16
Congenital cranial defects, 473-474 Deglutition,
Coronoid process, related to zygomatic arch, 491, 491 f normal, 1 7 5 -1 7 7 ,175f
Cranial defects, abnormal, 1 7 9 -1 8 0 ,179f
etiology of, 455 evaluation of, 177-179
indications for restoring, 455-456 palatal aids for, 1 8 1 -1 8 3 ,181f, 183f
Cranial fractures, 485 and psychosocial adjustments, 5
Craniofacial implants, Dehiscence of bone graft, in mandibular reconstruction, 159
prosthetic procedures, Delirium, in oral cancer patients, 10-11
auricular defects, 441-443, 441 f, 442f Dementia, in oral cancer patients, 10
midfacial defects ,410, 41 Of, 414f, 415 Dental radiation, and incidence of oral cancer, 130
nasal defects, 4 4 3 -4 4 4 ,444f, 445f Dentures, complete
orbital defects, 444— 445, 445f, 446f, 447f, in cleft palate patients, 357-360
448f impressions, 358-359
success rates, 445-449, 448t vertical dimension of occlusion, 359
surgical placement, 4 3 8 -4 4 1 ,439f, 440f, 441 f treatment concepts, 357-358
Cranioplasty and incidence of oral cancer, 128-129
autogenous bone grafts, 457-458 in irradiated patients, 98-103
autopolymerizing acrylic resin, 459-460 bone necrosis, risk of, 9 8 ,98t, 10Ot
with metal mesh, 460 centric registrations for, 103
cartilage, 458 delivery and followup of, 103
complications, 459-460 impressions for, 102
CT-Stereolithography, 467-474 occlusal forms for, 103
dermis, 458 placement and timing of, 99
f a t , 458 with preexisting bone necrosis, 101
heat polymerizing acrylic resin, 464— 4 6 5 ,465f soft liners, use of, 98-99
indications for, 456-457 soft tissue necrosis, risk of, 101
metals, 458-459 in mandibulectomy defects, 201-213
prosthetic methods of, 461 centric registrations for, 207-208, 209f
conventional, 461-467 delivery and follow up of, 212-213, 213f
cast preparation, 462-463, 463f, impressions for, 206-207, 207f
464f lip plumper, 213, 213f
impressions, 4 6 2 ,462f, 463f occlusal scherrfes for, 209-212, 209f,
placement, 466-467, 467f 21 Of, 211 f
processing, 464— 465 processing, 21 2 ,2 1 2f
use of radiographs, 462, 463f prognostic factors in, 202-206, 203f,
wax pattern, 464 204f, 205f
CT-stereolithography, 467-474 tooth placement in 210-211, 209f, 21 Of,
creating custom models, 4 7 0 - 211f
474 in maxillectomy defects, 251-258
fabrication of implant, 474-472, centric registrations for, 256-257, 256f,
471 f 257f
imaging, 468 delivery and follow-up of, 257-258, 258f
3-D reconstruction, 469-470 impressions for, 2 5 3 -2 5 7 ,255f
placement, 4 7 2 -4 7 3 ,472f, 473f occlusal schemes for, 257
536 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

processing of, 2 5 7 -2 5 8 ,259f resection of, 2 3 2 -2 3 3 ,232f, 243f

prognostic factors in, 251-253,251 f, 252f tumor behavior of, 231-232
relines for, 281-282,281f of skin, 381-383
vertical dimension of occlusion in, 256-257 clinical features, 3 8 2 ,382f
in partial maxillectomy defects, 258, 259f histopathology of, 382-383
psychological aspects of, 226 prognosis of, 383
tolerance of, 279-281 treatment of, 383
partial; see Partial dentures of tongue, 131-145
Depression, and oral-facial cancer, 8 ,1 9 classification of, 132
Diet, in irradiated patients, 65 clinical appearance of, 131,131 f
Dynamic bite openers, 5 2 6 -5 2 7 ,526f clinical considerations in, 131
complications secondary to resection of,
E 136
composite resection of, 133-134
Ear, disability secondary to resection of, 138f,
auditory inserts for, 525, 525f 139f, 140-145, 140f, 141f, 142f, 143f,
prosthesis, fabrication of; see Auricular defects 144f, 145f
surgical reconstruction of, 385-386, 386f pathologic considerations in, 131
Ectodermal dysplasia, 370-374 prognostic factors, 132-133
dental malformations of, 370-371, 372t radiation therapy for, 133
description of, 370-371, 372t radical neck dissection in, 1 3 4 ,136f
prosthetic treatment of, 3 7 1 -3 7 2 ,373f, 374f reconstruction of, 1 4 0 ,140f, 142f, 165f,
Edema, 166, 166f, 169, 170, 170f, 183-184, 183f,
from bilateral neck dissection, 148 201f,202f, 203-204
from irradiation, 65 staging of, 132
Emotional adjustment to cancer, 17-22 surgical modifications of, 136-139
Endodontic therapy, treatment of, 133-136
after radiation therapy, 8 7 -9 0 ,87t, 88t, 88f, 89t of tonsillar region, 1 5 0 -1 5 3 ,1 50f
before radiation therapy, 7 8 ,78f classification of, 132,151
Envelope of motion of mandible, normal vs mandibulectomy, clinical considerations in, 150
141-146 complications of, 132,151
Epidermoid carcinoma, composite resection of, 151-152
of alveolar ridge, 1 5 4 ,154f disability in, 153
disability in, 155 pathologic considerations in, 150
occurrence of, 154 prognosis of, 151
prognosis of, 154 reconstruction of, 1 5 2 ,151f, 152f
reconstruction of, 1 5 4 -1 5 5 ,155f staging of, 132,151
treatment of, 154 treatment of, 151
of floor of mouth, 1 4 5 -1 5 0 ,1 46f Equilibration, occlusal, in mandibular defects, 188-189,
classification of, 132,146 188f
clinical considerations in, 145-146 Esophagus,
composite resection of, 1 4 7 -1 4 8 ,147f prosthesis for, 51 9 ,5 1 9f
disability in, 1 4 8 -1 5 0 ,147f speech aid for, 519-520, 520f
pathologic considerations in, 145-146 External radiation therapy,
prognosis of, 146 and osteoradionecrosis, 93-95, 94f
radical neck dissection of, 148 and preradiation extractions, 73-74
reconstruction of, 1 4 8 ,148f principles of, 50-52, 52f
staging of, 132 and salivary output, 65-68, 67f
surgical variations of, 1 4 7 -1 4 8 ,148f, Extractions, dental,
149f, 150f postradiation, 79-83
treatment of, 146-148 criteria for, 8 1 -8 2 ,9 0
of paranasal sinuses, 230 with hyperbaric oxygen, 81

risk of bone necrosis, 7 9 -8 1 ,80t, 811
surgical procedures, 79, 82
preradiation, 74— 79
antibiotics, use of, 79
criteria for, 72-74
healing time for, 75, 78-79
radical alveolectomy and, 69, 69f, 79
risk of bone necrosis in, 74-78, 76t
surgical procedures, 79
of third molars, 78
Eye; see Facial defects
F thoraco-acromial, 139
Facial defects,
prosthetic restoration of
adhesives for, 396
auricular prostheses; see Auricular
defects
materials for, 387-401
acrylic copolymers, 390-391
acrylic resins, 3 9 0 ,390f
chlorinated polyethylene, 391
coloration of, 397
color research, 398
common problems, 398-399
historical background of, 3 8 9 -
390
polyphosphazenes, 395
polyurethane elastomers, 3 9 1 -
3 9 2 ,392f
polyvinyl chloride and copoly­
mers, 391
research literature for, 396-397,
397t, 399t, 400t,
silicone block copolymers, 395
silicone elastomers, 392-395,
394f
siphenylenes, 395
midfacial prostheses; see Midfacial
defects
nasal prostheses; see Nasal defects
ocular prostheses; see Ocular prostheses
ocular implants, 41 7 -4 2 1 ,4 1 8f, 420f,
421 f
orbital prostheses; see Orbital defects
psychosocial djustm entto, 18
surgical reconstruction of,
auricular defects, 3 8 5 -3 8 6 ,386f
nasal defects, 386-387, 387f
lateral facial defects, 41 6 ,4 1 8f
vs prosthetic restoration, 385
Index 537
Fibula flaps; see Free vascularized flaps
Fistulae
chylous, 136
following composite resection, 136
Five-fluorouracil (5FU); see Antineoplastic drugs
Flaps
deltopectoral, 139
forehead, 1 3 9 ,139f
free vascularized; see Free vascularized flaps
myocutaneous, 9 7 ,1 3 3 -1 3 4 ,134f, 1 4 0 ,140f, 142,
142f, 1 5 1 ,151f, 1 5 2 ,152f, 1 6 0 ,160f
pharyngeal, 347-349, 348f
tongue, 1 3 7 ,137f, 1 3 9 ,139f, 142f, 151,151 f, 152,
172
Floor of mouth, carcinoma of; see Epidermoid carcinoma
Fluoride,
carrier, topical application of, 83, 83f
experimental studies of, 83-84, 85t
use of, in irradiated patients, 72, 83-84
Fluoridated water, and incidence of oral cancer, 130
Fractionated radiation therapy, 45-46
Fractures, facial,
anatomic considerations in, 4 8 7 ,487f
classification of, 487-488
general principles in, 4 8 8 ,488f
of mandible, 488-490, 489f
angle, 489
body, 489
clinical features of, 4 8 8 -4 8 9 ,488f
condyle, 4 9 0 ,490f
coronoid, 489
management of, 492-493
ramus, 489
symphysis, 489
temporomandibular joint injury, 493-494
midface,
Le Fort 1,491
Le Fort II, 491
Le Fort III, 491
management of, 492-493
zygomaticomaxillary complex of, 490-493
of nose, 486
of orbit, 485
prosthodontic management of
anterior localized avulsive defects, 502,
503f, 504f
early management, 496,497
edentulous patienmts, 5 0 6 -5 0 7 ,507f
fixed vs removable, 5 0 0 -5 0 1 ,500f
general concepts, 499-502
implants, 501-502,501 f
538 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

intermediate management, 499 H

large avulsive defects, 505-506, 506f
stents and splints, 497-498, 498f Healing, effect of radiation on, 54, 69, 79-83, 80t, 82t, 0 3 -
radiographic considerations in, 492 1 0 7 ,104f, 105f
surgical management of, Hemifacial microstomia, 368-370
Barton bandage, 493 description of, 368-369, 368f, 369t
early management, 492-493 incidence of, 368, 369t
edentulous, 506-507, 507f prosthetic treatment of, 369t, 370, 370f
impressions, 497 surgical treatment of, 369, 369t
lingual splint, 4 9 7 -4 9 8 ,498f Hemorrhage secondary to antineoplastic drugs, 3 2 -3 3 ,33f
Free vascularized flaps Hormones; see Antineoplastic drugs
complications, 168 Hyperbaric oxygen,
fibula, 148f, 1 6 3 ,163f, 164f, 165t, 165f, 166f, 196f, and postradiation extractions, 81
197f, 1298f and osteoradionecrosis, 94f, 96-97
iliac crest, 162 and soft tissue necrosis, 97
radial forearm, 140f, 142f, 1 6 3 -1 6 4 ,164f, 165f, treatment protocol, 96-97
238-239, Hyperkeratosis; see Leukoplakia
rectus abdominus, 239f
scapula, 1 6 6 ,167f, 170f
Frontal bone, defects of, 473
Fungal infections, Illness, psychological effects of, 15-16
secondary to antineoplastic drugs, 35, 36f, 41 Implants,
secondary to composite resections, 1 4 4 ,145f cranial; see Cranioplasty
secondary to irradiation, 63, 63f, 71, 71 f frontal bone, 473
materials for
G acrylic resin
in cranial defects, 459-460,
Gingiva, carcinoma of, 154,154f 464-465, 465f, 466f, 467f, 4 7 1 -
Glossectomy, 472, 471 f, 472f, 473f
partial, disability in, 139f, 1 4 0 -1 4 1 ,142f, 147f, 149 in frontal bone defects, 474
surgical reconstruction after, 1 4 0 ,140f, 142f, 166, in ocular implants, 4 2 0 ,420f
167f, 170f, 183-184 polyethylene, 460-461
total silicone, in cranial defects, 461
disability in, 169 stainless steel, 459
tongue prosthesis for, 169-170,182, tantalum, 458
183f, 516-518, 516f, 517f, 518f titanium, 459
Glossoptosis, 366 vitalium, 459
Grafts, ocular, 417-421
bone; see Bone grafting osseointegrated,
epithelial, in anterior mandible defect patients, 194-
buccal, 168 1 9 9 ,196f, 197f, 198f
palatal, 168 in auricular defects, 438-441, 439f. 441 f,
split thickness skin, 150f, 155f, 169 441-443, 442f, 443f, 448t
pedicle; see Flaps in cleft lip and palate patients, 341 f, 3 6 0 -
Granuloma, midline, 231 361, 361f, 362, 362f
Guidance, mandibular, 184-189 craniofacial; see Craniofacial implants
intermaxillary fixation for, 184-185 in ectodermal dysplasia patients, 3 7 1 -
prognosis of, 184 374, 373f, 374f
occlusal equilibration, 1 8 8 -1 8 9 ,188f in irradiated sites, 1 0 3 -1 0 7 ,104f, 105f,
resection guidance restorations for, 185-188, 106f
186f, 187f in lateral mandible discontinuity defects,
Guilt in cancer patients, 17 213-215, 214f, 215f
 Index 539

in lateral mandible discontinuity defects 253f, 254, 255f

reconstructed, 159f, 165f, 2 0 0 -2 0 1 ,200f,
201 f L
in maxillary defects, 2 3 7 ,238f, 258-266,
260t, 261 f, 262f, 263f, 264f, 265f, 266f, Lactobacillus, in radiation caries, 71
267f, 276-277, 278f Lagophthalmos, 528, 528f
in midfacial defects, 412,412f, 414f, 4 1 5 - Laryngectomy aids, 512-513, 512f, 513f
416 Leukoplakia, 121-128
in nasal defects, 4 0 3 ,403f, 438-441, and candidiasis, 125-126
440f, 443-444, 444f, 445f, 448t epidemiology of, 121
in orbital defects, 4 3 8 -4 4 1 ,440f, 444— definition of, 121
445, 445f, 446f, 447f, 448t differential diagnosis of, 124
in soft palate defects 319 -3 2 0 ,3 1 9f, 320f and erythroplasia, 1 2 4 ,125f, 126
Impressions, hairy, 126
altered cast, 191, 273-274, 274f, 275f histology of, 124f
of d e ft palate defects, 358-359 malignant potential of, 1 2 1 ,122t, 123t, 127t
of cranial defects, 4 6 2 -4 6 3 ,462f, 463f precancerous classification, 1 2 1 ,122t
of craniofacial implants, 441-442, 442f proliferative verrucous type, 1 2 5 ,125f
for delayed surgical obturators, 245 secondary to antineoplastic drugs, 2 7 ,27f
of dental implants, 197, 262-263 and tobacco use, 1 2 1 ,123t
of facial defects, 401, 404-405, 406f, 41 2 ,4 1 2f, treatment of, 126-127
415 Lichen planus, 1 2 8 ,128f
in facial fractures, 497 Lip defects, 1 4 1 ,141f, 213, 511-512, 511f
of irradiated patients, 102 Lip support
In mandibulectomy patients, 2 0 6 -2 0 7 ,206f, 207f, in clefts, 3 3 1 ,332f, 357f, 3 5 8 ,360f
215 in mandibular defects, 213,213f
of maxillary defects, 2 5 3 -2 5 5 ,255f, 273-274, Lip prosthesis, 5 1 1 -5 1 2 ,511f
274f, 275f, 276, 276f Lymphatics, neck, 1 3 5 ,135f
for palatal lifts, 322
of pharyngeal flap defects, low based, 349, 349f, M
357f
of soft palate defects, 3 0 8 -3 1 1 ,308f, 31 Of, 312f, Mandible, acquired defects of,
313f, 317,319 vs maxillary defects, 113,225, 226
for surgical obturators, 241 deviation of following partial mandibulectomy, 141-
for trismus appliances, 526 1 4 4 ,143f
for vaginal carriers, 520,521 f frontal plane rotation of, 1 4 3 -1 4 4 ,144f
for vestibuloplasty stent, 169 prosthodontic restoration of, 189-216
Infection, in anterior continuity defects,
bacterial, 34-35, 34f, 40 partial dentures, 1 9 2 -1 9 4 ,194f,
fungal, 3 5 -3 6 ,36f, 41, 6 3 ,63f, 71, 71 f, 1 4 4 ,145f 195f
viral, 3 5 -3 6 ,36f, 40,116-117 implant retained prostheses,
Iridium 192,49f, 50, 95f 1 9 4 -1 9 9 ,196f, 197f, 198f
Isodose curves, 4 7 -4 9 ,47f, 48f, 49f, 95f, in lateral continuity defects,
partial dentures, 1 9 9 ,199f, 200f
J implant retained prostheses,
2 0 0 -2 0 1 ,202f
Jaw fractures; see Fractures, facial in lateral discontinuity defects,
Jaw separation; see Trismus, appliances for complete dentures, 201-213,
Junction, 203f, 204f, 205f, 206f, 207f,
lines of, in facial prostheses, 400f, 4 0 2 ,402f, 406, 208f, 209f, 21 Of, 211f, 212f
406f, 408, 409f implant retained overlay den­
skin graft-mucosal, in maxillectomy defects, 234, tures, 213-216, 214f, 215f
540 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS
partial dentures, 189-191,192f,
193f
surgical reconstruction of, 155-168
complications of, 159,168
and with dental implants, 148,148f, 155,
156,158, 159f, 163-166, 164f, 165f
with free bone grafts, 155-161,157f, 158f
biology of, 156
complications, 159
goals of, 155
immediate versus delayed, 158-
159
with cast lingual splint, 160,
161 f, 498, 498f
mandibular body, 159-160
and reconstruction plates, 1137,
138, 138f, 158, 166f
ramus, 161
source of bone, 157
symphysis, 160-161,160f
techniques, 157-161
with vascularized free flaps, 161-168
complications, 168
fibula, 148, 148f, 154, 163-165,
163f, 164f, 165f, 195-196,196f,
198f
radial forearm, 142f, 163-166,
165f, 166f
rectus abdominus, 168
scapula, 166,167f, 201 f
Mandibular movement; see Envelope of motion
Mastication,
following tongue jaw neck dissection, 170-173,
173t
following maxillectomy, 273, 279
psychosocial ramifications of, 4
Maxilla
anatomy of, 228-229, 228f
prosthodontic restoration of, 240-282
air leakage after, 279-280
delayed surgical obturation in, 245-246
in dentulous patients, 267-279
impressions in, 273-277, 274f,
275f
partial denture design in, 269-
273, 270f, 272f
treatment concepts, 267-269
in edentulous patients, 251-258
delivery and followup in, 257-
258, 258f
impressions in, 253-257, 255f
occlusal schemes in, 251,257f
treatment concepts in, 251-253
vertical dimension of occlusion
in, 256-257, 256f
fluid leakage after, 279-280
with implants, 237, 238f, 259-266, 260t,
262f, 263f, 264f, 265f, 266f, 268f, 277,
278f
interim obturation in, 247,246f, 248f
in maxillary vs mandibular defects, 225-
226
processing, 257-258
speech after, 280-281
surgery vs prosthodontic
surgical obturator in, 240-244
surgical reconstruction of, 238-240, 237f
tumors of
epidermoid, 230, 230f, 232f
mesenchymal, 231,231 f
salivary gland, 230, 230f
Maxillary defects, restoration of
prosthodontic,
air leakage after, 279-280
delayed surgical obturators, 245-247,
246f
edentulous patients, 251-258
delivery and followup, 257-258,
258f
impressions, 253-255, 255f
occlusal schemes, 257
processing, 257
prognostic factors, 251-253,
251 f, 252f, 253f
vertical dimension of occlusion,
256-257, 256f, 257f
evaluation of, 279-280
implant retained obturator prostheses,
clinical data, 258-259, 260t
clinical procedures, 262-263,
263f
implant sites, 259-262, 261 f,
262f
retention bar design and
fabrication, 263-267, 263f, 264f,
265f, 266f, 267f
interim obturators, 246f, 247, 248f
partially edentulous patients, 267-275
clinical procedures, 273-274,
274f, 275f
partial denture design, 269-273,
269f, 270f, 272f, 272f
treatment concepts, 267-269,
268f
 Index 541

relines, 281 - 282 ,281 f of palate, 231

speech after, 250, 280-281 of maxillary sinus, 231
surgical modifications for,
access to defect, 2 3 7 ,237f N
hard palate resection, 234, 234f
implants, 2 3 7 ,238f Nasal conformer see Nasal stent
palatal mucosa, 235f, 236, Nasal defects, prosthetic restoration of,
retention of key teeth, 2 3 5 ,235f delivery, 408
skin grafting, 234-235, 236f implants in, 438-439, 440f, 4 4 3 -4 4 4 ,444f, 445f
soft palate resection, 2 3 6 ,236f impressions, 404
surgical obturators, 240-244 partial nasal prosthesis, 408
advantages, 240 processing, 407-408, 407f
design principles, 241 sculpting, 405-406, 405f, 406f
clinical procedures, 241-244, surgical alterations for, 4 0 2 -4 0 3 ,403f
242f, 243f, 244f surgical reconstruction for, 386-387, 387f
surgical reconstruction vs prosthodontic temporary nasal defects, 404
restoration, 237-238, 237f Nasal endoscopy, 2 9 2 -2 9 3 ,293f, 293t
surgical reconstruction, 2 3 8 -2 4 0 ,237f, Nasal stent, 524-525, 524f
240f Necrosis,
treatment concepts, general, 248-250 bone, 9 0 -97
treatment concepts, partially edentulous with brachytherapy, 94-95
patients, 267-269, 267f, 268f definition of, 90
Maxillary sinus with dentures, 911, 98
anatomy of, 2 2 8 -2 2 9 ,228f in edentulous patients, 98
bone grafting to receive implants, 259,261 f with external beam, 93-94
carcinoma of, 230, 230f hyperbaric oxygen, 81, 90, 9 4 ,94f, 9 6 -
myxoma of, 231 9 7 ,97f
salivary gland tumors of, 230, 230f incidence of, 91-93
Maxillectomy mandible vs maxilla, 91-92
bony cuts in, 232,233f following postradiation extraction, 79-83,
criteria for, 232 80t, 811,82t
skin incisions for, 232, 233f following preradiation extraction, 74-78,
surgical modifications for, 233-238, 234f, 235f, 76t, 77t
236f, 237f predisposing factors, 9 1 -9 3 ,90f, 91t
Meatal obturator, treatment of, 93-97, 93f, 94f, 95f
disadvantages of, 323-324 soft tissue, 97, 97f, 101
fabrication of, 324 with dentures, 101
position of, 323, 324f healing of, 97,101
use of, 323 Nominal single dose (NSD), 45
Melanoma, malignant, Nutrition, and oral cancer, 65,130
clinical features, 3 8 3 -3 8 4 ,384f Nystatin, 41, 63, 71
histopathology, 384
treatment of, 385 0
Mental disorders, in oral cancer patients, 8 -1 0 ,1 7 ,1 9
Methotrexate; see Antineoplastic drugs Obturator,
Microtia, 385, 386f air leakage in, 279-280
Mouth control devices, 5 2 7 -5 2 8 ,527f in cleft lip and palate, 331, 332f, 347-349, 348f,
Mucormycosis, 35-36, 36f, 231, 231f 349f, 355f
Mucositis, delayed surgical, 2 4 4 ,245f
radiation, 62-63, 62f evaluation of,
secondary to chemotherapy, 30f, 31-32, 31 f, 39 in soft palate defects, 314,319
Myxoma, in hard palate defects, 279-281
 542 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

fluid leakage in, 279-280 O ral flora, effects of irradiation on, 66t, 71—72,711
immediate surgical, 240-244, 242f, 243f, 244 O ral hygiene, in irradiated patients, 83
interim, 246f, 247, 248f O ra l function, after tongue-m andible resection, 1 6 9 -1 8 1
for maxillary defects; see Maxillary defects dysfunctional swallowing, 1 7 9 -1 8 0
meatal, 323-3 2 4 , 324f evaluation ot swallowing, 177— 179
reline of, 2 8 1 -2 8 2 , 281 f jaw m echanics after, 1 7 3 -1 7 4
fo r soft palate defects; see Soft palate defects, mastication, 1 7 0 -1 7 2
obturation of speech, 1 8 0 -1 8 3
Occlusion, O ra l mucositis,
fo r com plete dentures in irradiated patients, 103 in chem otherapy patients, 3 0 1 ,3 1 -3 2 ,3 1 1 , 3 9
in m andibulectom y patients, 1 4 3 -1 4 4 ,144f, 152f, in irradiated patients, 6 2 -6 3 ,6 2 1
1 8 8 -1 8 9 , 191, 2 0 9 -2 1 2 , 209f, 21 Of, 211f, 212f O rbital defects, restoration of,
in m axillectom y patients, 257 im plants in , 4 3 5 ,4 3 6 1 , 4 3 8 , 4401, 4 4 1 , 4 4 4 -4 4 5 ,
O ccult subm ucous cleft palate; see S ubm ucous cleft palate 4451, 44 6 f, 4471, 4481
O cu la r im plant, im p re ssion s lo r, 4 3 1 -4 3 2 , 4331
m aterials for, 4 1 9 -4 2 0 , 42 0 f, 421 f p ro ce ssin g , 434— 4 3 5,4351
surgical co nsideration for, 4 1 8 -4 1 9 re te n tio n , 4 3 5 -4 3 6 ,4 3 6 1
typ e s of, 4 1 8f, 4 1 9 -4 2 0 s c u lp tin g , 4 3 2 -4 3 4 , 4331. 4341
O cu la r prosthesis, O ss e o in te g ra te d im p la n ts; s e e Im p la n ts , o s s e o in te g ra te d
cast, fo rm a tio n , 4 2 6 , 4 2 6 f O s te o ra d io n e c ro s is ; s e e N e c ro s is , b o n e
co m p lica tio n s d u rin g fittin g , 4 2 2 -4 2 4 O s te o s a rc o m a , 1 5 4 -1 5 5
c o n tra c te d s o c k e t, 4 2 4 O s te o to m y , o f fib u la fre e fla p , 1 6 3
e c tro p ia n , 4 2 3 -4 2 4 , 4 2 4 f
e xte n d e d s h e lf, 4 2 3 P
p to s is , 4 2 2 - 4 2 3 , 4 2 2 f, 4 2 3 f
s a g g in g lo w e r lid, 4 2 4 P a la ta l g ra fts ; s e e G ra fts , e p ith e lia l, p a la ta l,
im p re s s io n s for, 4 2 5 , 4 2 5 f Palatal lift, 315, 320-322,321 f, 322t, 3231
iris o f, 4 2 7 -4 2 9 advantages ot, 321
painting of, 428-429, 428f, 429f contraindications for, 321
location of, 427 fabrication of, 322,3231
modification of stock eye, 431 in neurologic deficits, 321
processing, 430, 430f Palatal papillary hyperplasia, 129
patient instructions, 431 Palatal speech and swallowing aids, 181-184,1811,1831
pupil, fabrication of, 428 Palate, hard,
sclera, fabrication of, 427,429,427f anatomy of, 228-229,2281
wax pattern, 426-427,426f resection ot, 232-233
Operating room protocol, 242-243,496-497,497t maxiUectomy, 232,2331
Oral Cancer, paiatectomy, 232-233
epidemiology of, 113-115,115t restoration of; see Maxillary defects
etiology of, 116-130 tumors of, 229-232,230f, 231f, 2321
alcohol, 120-121,120f behavior ot, 231-232
dental radiation, 130 recurrence of, 233
dentures, 128-129,129t Paiatectomy, 232
erythroplakia, 121-128 Patient resources, pychosocial, 22-23
fluoridated water 130 Paranasal sinuses,
leukoplakia, 121-128,121f, 122t, 123t, anatomy ot, 228-229,228f
124f, 125f, 127t tumors of, 229-232
lichen planus, 128,128f behavior ot, 231-232
nutrition, 130 epidermoid, 230,2301,232*
palatal papillary hyperplasia, 129 mesenchymal, 231,231t
tobacco, 117-120,118t, 119t, 119f recurrence ot, 233
viruses, 116-117 salivary gland, 230,230t
 Index 543

surgical resection of, 232-233, 233f self-esteem, 17-18

Partial dentures, sex, effects of, 19
fixed, social support system in, 19-20, 22-23
in cleft palate, 354-355 stigma, fear of, 16
in mandibular defects, 1 9 7 ,197f, 198f, Ptosis, correction of, 422-423, 422f, 423f
202f
in trauma patients, 500-501 R
removable, designs of,
in cleft palate patients, 355-<356 Radial forearm flaps; see Free vascularized flaps
mandibular defects, 1 8 9 -1 9 5 ,190f, 194, Radiation effects,
195f, 199, 199f basic biologic, 44-45
mandibular guidance restoration and, on dentulous patients, management of,
1 8 5 -1 8 6 ,186f fluoride, use of, 83-84, 83f, 85t
maxillary defects and, 269-273, 269f, radiation caries, 65, 66, 66f, 85-86, 86f
270, 271 f, 272f restorative care, 84-86
with midfaciai prosthesis, 415 on diet, 65
Passavant’s pad, 299-301, 299f on general tissue, 5 4 ,54f
Pedicle flaps; see Flaps on olfaction, 64
Periodontal problems in irradiated patients, 72, 72f, 92 on oral cavity,
Photons, 43, 4 4 ,4 7 -4 8 , 50 bone, 68-69, 69f
Pierre Robin syndrome, 365-368, 365t, 366t, 367t, 368f candidiasis, 63,71
Pilocarpine, use of in irradiated patients, 68 edema, 6 5 ,65f
Plant alkaloids; see Antineoplastic drugs oral flora, 63, 63f, 71-72, 71 f
Pleomorphic adenoma, 230, 230f oral mucous membranes, 62-63,
Premaxilla, problems in clefts,331, 356f 62f, 64f
Preradiation extraction periodontium, 70, 70f, 72, 72f
criteria for, 72-78 saliva, 66-68
risk of bone necrosis in, 74-78, 76t, 77t salivary glands, 65-66, 66f
surgical procedures, 79 teeth, 65, 66f, 70, 70f, 71 f
of third molars, 78, 78f taste buds, 64
Postradiation extractions trismus, 65
criteria for, 79-83, 90 on skin, 62, 62f, 64f
risk of bone necrosis in, 7 9 -8 1 ,80t, 811, 82t Radiation stents, use of, 55-61
with hyperbaric oxygen, 81 displacing tissues, 55-56
Psychodynamic interactions, peroral cones, 57, 57f
abandonment, fear of, 16-17 positioning radioactive sources, 59-60
age, effect of, 19 oral, 59-60, 59f
anxiety, 9 -1 0 ,1 7 vaginal, 520
body image, 6 -7 ,1 7 -1 8 positioning tissues, 55-57, 55f, 56f
crises sets, 16-19 recontouring tissues, 58
death, fear of, 16, 21, 20t shielding, 58, 58f
depression, 8 ,1 9 templates for direct implantation, 60
disfigurement, effect of, 18 tissue bolus devices, 60-61, 61 f
extent of defect, effects of, 4 -6 ,1 8 -1 9 Radiation therapy,
functional disabilities, effects of, 4 -6 ,1 8 absorption in, 43
illness, 16-17 beam mixing and weighting, 48
inferiority, 17 biologic effects, 44— 45
location of defect, effects of, 4— 6 ,1 8 -1 9 brachytherapy, 49-50
ostracism, fear of, 16 complete dentures, use of, following, 98-103
patient resources, 22-23 bone necrosis, risk of, 98
punishment, fear of, 17 placement and timing of, 9 9 -1 0 1 ,100t
response of clinician to, 17,20 with pre-existing bone necrosis, 101
544 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

prosthodontic procedures in, 101-103 Relines, 281-282,281 f

soft liners, use of, 9 8 ,9 9 Resection Dentures; see Dentures, complete, in
soft tissue necrosis, risk of, 101 mandibulectomy defects
Compton effect in, 44 Removable partial denture design,
dental maintenance after, 83-86, 83f in mandibular defects, 1 8 9 -1 9 5 ,190f, 194f, 199-
dosimetry in, 46-47 2 0 0 ,199f
endodontic therapy after, 87-89, 87t, 88t, 89t, 90 in maxillary defects, 269-273, 269f, 270f, 271 f,
extraction of teeth after, 79-83 272f
criteria for, 79-83, 90 Robin sequence, (Pierre Robin Syndrome) 365-368
risk of bone necrosis in, 79-80, 80t, 811, airway maintenance of, 366
82t growth and development of, 367
with hyperbaric oxygen, 81 incidence of, 367-368
external radiation therapy, 5 0 ,52f, 67, 67f, 72-74 related nonsyndrome anomalies of, 3 6 6 ,366t
extraction of teeth prior to, 72-79 surgical treatment of, 3 6 6 ,367t
criteria for, 72-78 triad anomalies of, 3 6 5 -3 6 6 ,365f, 366t
risk of bone necrosis in, 74-78, 76t, 77t
surgical procedures, 79 s
of third molars, 78, 78f
fluoride use after, 8 3 -8 4 ,85t Saliva
fractionation, 45-46 changes in, secondary to radiation, 67-68
general tissue effects, 5 4 ,54f control of, after tongue resection, 144,149
indications for, 52-54 stimulation of, 68
isodose curves in, 47-48 substitutes for, 68
isoeffect models, 45 Salivary glands
modalities of, 50 effects of radiation therapy on, 6 5 -6 8 ,66f
nominal single dose (NSD) in, 45 tumors of, 230, 230f
pair production in, 44 Scapula flaps; see Free vascularized flaps
photoelectric effect in, 44 Sex hormones; see Antineoplastic drugs,
physical principles in, 43-44 Silicone,
restorative care after, 84-86 adhesives, 396
revascularization after, 82-83 fo r facial defects, 392
treatment planning in, 51-52 foams, 394-395
Radical neck dissection, HTV, 393
bilateral, 148 for implantation, 461
classical, 1 3 4 -1 3 6 ,136f primers, 396
complications of, 136 RTV, 393-394, 394f
functional, 136 Skin grafts, 142f, 150f, 1 5 4 ,155f, 169, 234-235
indications for, 133-148 Sleep apnea, 515-516, 516f
in mandibular defects, 134-136 Smell, radiation effects on, 64
modified radical, 135,136 Smoking; see Tobacco
morbidity from, 135 Social support system, 1 5 ,1 9 ,2 2 -2 3
selective, 136 Social worker’s role, 20
Reconstructive surgery, Soft palate defects, obturation of,
for facial defects, 385-387 definitive, 307-324
auricular, 3 8 5 -3 8 6 ,386f delayed surgical, 3 0 6 ,307f
lateral facial, 239, 239f, 416, 416f evaluation of, 314,315t
nasal, 386-387, 387f immediate surgical, 305-306, 306f
for mandibular defects; see Mandible, surgical implant retained, 319-320, 319f, 320f
reconstruction of impressions for, 309-311, 31 Of, 312f
for maxillary defects, 237-240, 237f, 239f junction hard-soft palate defects, 245,276-277,
vs prosthodontic restoration in maxillary defects, 276f
237-238 in lateral border defects, 318-319,318f
 Index 545

meatal, 323-324, 324f Swallowing,

in median posterior border defects, 314 -3 1 7 ,3 1 6f, dysfunctional, 170-172
317f normal, 174-177
palatal lift prostheses in, 3 2 0 -3 2 2 ,322t, 321 f, 323f
speech following placement of, 314-315, 315f, 319 T
size and position of, 313
in total soft palate defects, 308-314, 308f, 309f, Tantalum, use of in cranial defects, 458-459
.31 Of Taste following irradiation, 64
Soft tissue trauma, 486-487 Tissue bolus devices, 60-61, 61 f
Speech, Titanium, use of,
after tonsillar surgery, 153 in cranial defects, 459
in cleft palate, 286-287, 312-314 implants; see Implants, osseointegrated
closest speaking distance, 288-289, 288f in mandibular bone grafts, 1 5 9 -1 6 1 ,160f
components of, 285-286 TMJ injuries, 493
articulation, 286 Tobacco,
audition, 286 cessation of, 2 -3
neural integration, 286 and incidence of oral cancer, 117-119,119t, 123t
phonation, 285-286 quit rates for, 2 -3
resonation, 286 and second primary tumor, 2,115
respiration, 285 Tongue,
esophageal, 519-520 disability of, following resection, 1 4 0 -1 4 1 ,142f,
evaluation of, 181, 314, 315t, 319 149,153, 174-181, 203-204, 205f, 516
following mandibulectomy, 141,180-181 prosthesis for, 1 8 2 -1 8 3 ,183f, 516-518, 517f, 518f
following partial glossectomy, 141,180-181 surgical reconstruction of, 165f, 167f, 170f, 1 8 3 -
following total glossectomy, 182-184 184
following maxillectomy, 250, 280-281 tumors of; see Epidermoid carcinoma, of tongue
palatal aids for, 1 8 1 -1 8 2 ,181f, 183f Tonsillar carcinoma; see Epidermoid carcinoma, tonsillar
phonemes, 287-289, 287t region
prosthodontics, relationship to, 286-287 Tracheostomy,
psychosocial ramifications, 5 -6 obturator, 512-514, 513f, 514f
residual deficits and, 319 tubes, 514, 514f
sex differences, palatopharyngeal function and, Trauma
297, 298f causes, 479-483
in tongue prosthesis, 181-183 athletic, 482-483
Speech therapy, burns, 482
in glossectomy, 182, falls, 482
in soft palate defects, 314 firearms, 481-482, 481 f, 482f
Splints, motor vehicle, 480-481, 480f, 480t
Barton bandage, 493 sites,
for free flaps, 162 -1 6 3 ,1 62f cranium, 485
lingual, 1 6 0 ,161f, 497-498, 498f mandible, 487-490
Stickler syndrome, 366t midface, 490-492
Stigma of cancer, 16 nasal, 496
Streptococcus mutans in radiation caries, 71 orbital, 485-486
Stereolithography, 467-473,471 f, 472f, 473f soft tissue, 486-487
Stents, Trismus,
burn stents, 519-522, 522f appliances for, 5 1 5 -5 2 7 .526f
ear canal, 525, 525f following composite resection. 145
nasal, 5 2 4 ,524f following maxfledorny, 271
radiation; see Radiation stents, use of in irradaled patients, 65
vestibuloplasty, 169 treatment of, 65 ,525-527, 526f
Submucous cleft palate, 3 6 3 -3 6 5 ,363f, 364f Turbinates and prosthodontic restorations, 2 3 7 ,237f
546 MAXILLOFACIAL REHABILITATION: PROSTHODONTIC & SURGICAL CONSIDERATIONS

V Z

Vaginal radiation carrier, 520,521 f Zygomaticomaxillary complex, fracture of, 490-492,491 f

Velopharyngeal function
anatomy and physiology, 297-304, 297f, 298f,
299f, 301 f, 303f, 303t
classification, 289-290
etiology, 289-290
evaluation, 291 -2 9 3
endoscopy, 292-293, 293f
fluoroscopy, 291-292
general considerations, 290
nasal resistance, 295
oral vs nasal breathing, 296
orofice size, 295
patterns of closure, 293-295, 294f, 295t
prosthesis evaluation, 296-297
timing of closure, 296
Vertical dimension of occlusion
in cleft palate patients, 359
in mandibular defects, 208
in maxillary defects, 256-257
in radiation patients, 103
Vestibuloplasty, 168-169
buccal grafts, 168
criteria for, 168
lowering floor of mouth, 169
in mandible, 168— 169
palatal grafts, 168
after partial glossectomy, 168
skin grafts, 169
Videofluorscopy. 291-292, 292f
Vitallium, use of in cranial defects, 459
Viruses, and incidence of oral cancer, 116-117
Viral infection, secondary to antineoplastic drugs, 3 5 ,35f

W
Weber-Ferguson incision, 232-233, 233f
Wegener’s granulomatosis of hard palate, 231

X-rays
absorption of, 43-44
low energy, 47-50
Xerostomia
in chemotherapy, patients, 32
in irradiated patients, 65-68