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Immediate surgical sectional stent prosthesis for maxillary resection
Immediate surgical sectional stent prosthesis for maxillary resection Seymour Birnbach, D.D.S.* New York University Dental Center, New York, N. Y.
The surgical removal of a maxillary malignant tumor may save the patient's life. In the total rehabilitation of the maxillectomy patient the maxillofacial prosthodontist has two primary objectives: (1) to restore the functions of mastication, deglutition, and speech and (2) to achieve normal orofacial appearance. Postoperative prosthodontic treatment is an established modality in the rehabilitation of the maxillectomy patient. An immediate.surgical prosthesis can cohtribute to the postoperative recovery and comfort of tile patient. Conventional surgical procedures involve adapting a skin graft to the defect and supporting it with XeroformJ" or petrolatum gauze.' The immediate surgical prosthesis, accurately fitted to t h e defect, may be substituted for the Xeroform or petrolatum gauze packing 9routinely used to support the skin graft.
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Fig. 1. Processed acrylic resin denture base filled with dental tissue-conditioning material.
TECHNICAL PROCEDURES Tile prosthesis is filled with a tissue-conditioning material consisting of a polymer powder (usually ethyl methacrylate) and an aromatic ester/alcohol mixture (Fig. 1).-0When fully polymerized the tissue conditioner remains soft and flexible and maintains a physiologic adaption to the skin graft. When correctly seated on the residual palate, tile prosthesis will fill the entire surgical defect9with an excess of the tissue-conditioning material (Fig. 2). The flexible tissue-conditioning material is then molded with finger pressure on top of the readapted external *Associate Clinical Professor, Department of Removable Prosthodontics, Division of Maxillofacial Prosthetics; Attending Prosthodontist and ChiefofService, Peninsula Hospital Center, Far Rockaway, N. Y., arid North Shore Hospital, Manhasset, N.Y. J'Chesebrough Pond's Inc., ltospital Products Division, New York, N. Y.
0022-391317810.t39-0t47500A010 ~ 1978 Thc
C. V. Mosby Co.
Fig. 2. The surgical defect is filled with an excess of tissueconditioning material.
THE JOURNAL OF PROSTIIETIC DENTISTRY
447
BIRNBACH
Fig. 3. A, The surgical flap is retracted; the skin graft is in place, B, The tissue-conditioning material is in intimate contact with cheek surfaces and bony recesses.
Fig. 4. The skin graft is wrapped about the prosthesis. surgical skin flap to sculpt anatomic facial contours. After polymerization, (3 to 4 minutes) tile external skin flap is reflected laterally and tile excess tissue conditioner is removed. The tissue-conditioning material, supported by tile denture base, is now in intimate contact with the skin graft on both of the cheek surfaces and in the bony recess areas of the curetted sphenoid and ethmoid sinuses (Fig. 3). The entire surgical defect is obturated by tile soft tissueconditioning material. 448
Should the surgeon experience difficulty with the positioning of the skin graft and the preliminary suturing of it to the borders of the surgical defect the skin graft may be wrapped about the prosthesis and adapted to the defect without any preliminary suturing of the graft (Fig. 4). 3 The in toto removal of this expansive prosthesis is most difficult, if not impossible, after the final closure of the external surgical skin flap. Depending upon the extent of the defect the prosthesis may extend superiorly to the infraorbital region and may become engaged laterally in the undercut tissues. T o avoid the entrapment of the stent the polymerized conditioningmaterial is cut into three sections, each separated by a wafer of Teflon gauze (Fig. 5). The entire prosthesis is then reseated into the defect, section by section (Fig. 6), and the surgeon t h e n proceeds with the reapproximation of the facial surfaces of the skin flap (Fig. 7). The sectionally placed prosthesis is readily removed b y t h e prosthodontist without disturbing the skin graft. ADVANTAGES OF A SURGICAL PROSTHESIS An immediate surgical prosthesis with a sectional stent will support the skin graft and eliminate the need for a nasopharyngeal feeding tube? The prosthesis permits nutritional intake without fear of APRIL 1978
VOLUME 39
NUMBER 4
IMMEDIATE SURGICAL STENT PROSTHESIS FOR MAXILLARYRESECTION
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Fig. 5A. T h e tissue-conditioning material is cut into three sections for easy removal. Fig. 5B. T h r e e separate sections of stent with Teflon gauze s e p a r a t i o n s prior to reinsertion in the m o u t h , section b y section.
Fig. 6. A, T h e entire prosthesis consisting of the acrylic resin base a n d the three separate sections of tissue-conditioner stent a d a p t e d against the skin graft 9 B, A d r a w i n g shows the acrylic resin base a n d three sections of the tissue-conditioner stent a d a p t e d to the deep b o n y recesses a n d skin graft. TIlE JOURNAL OF I'ROSTIIETIC DENTISTRY
449
BIRNBACH
Anatomic facial contours are maintained by the stent support of the external surgical skin flap. The patient usually is not aware of the extent of the surgical procedure and is psychologically better prepared to cope with his postoperative condition. CONCLUSION The maxillofacial prosthodontist, as a member of the surgical team, is able to aid in the recover)' and rehabilitation of the maxillectomy patient by fabricating and placing an immediate surgical prosthesis. The prosthesis supports the skin graft and maintains normal anatomic facial contours. The immediate postoperative restoration of mastication, deglutition, and speech shortens the patient's recovery time in the hospital and expedites the patient's return to the community as a functioning member, s REFERENCES 1.
Fig. 7. Readaption of the skin flap prior to suturing. aspiration into the nasopharynx and regurgitation through the nostrils. The postoperative discomfort from nasal tube feeding experienced by t h e patient will be eliminated. Upon recovery from surgery and return to a conscious state the patient will be able to intelligibly communicate with family and friends. Optimal speech is restored, morale is high, and the patient is more optimistic about future rehabilitation.
450
Rankow, R. N.: An Atlas of Surgery of the Face, Mouth and Neck. Philadelphia, 1968, XV. B. Saunders Company, pp 126-128. 2. Braden, M.: Tissue conditioners. 1. Composition and structure. J Dent Res 49:145, 1970. 3. Kazanjian, V. H., and Converse, J. M.: Surgical Treatment of Facial Injuries, ed 3, vol 2. Baltimore, 1974, The Williams & ~Vilkins Company, pp 1408-1445. -t. Adisman, 1. K.: Maxillofacial prosthetics. In Goldman, Iq. M., Forrest, S. P., Byrd, D. L., and McDonald, R. E.: Current Therapy in DentistD', vol 3. St. Louis, 1968, The C. V. Mosby Company, p 217. 5. Adlsman, I. K.: Prostheses in the Treatment of Malignant Tumors of the Paranasal Sinuses. International Workshop on Cancer of the tlead and Neck. New York, 1965, Butterworfl~ & Co., Ltd., p 252. Reprint requests to: I'~..SEYMOUR BIRNBACll
206-07 HIt.LSIDE AVE. QuEESs VXH_ACE,N. Y. 11427
APRIL 1978
VOLUME 39
NUMBER 4
The surgical removal of a maxillary malignant tumor may save the patient's life. In the total rehabilitation of the maxillectomy patient the maxillofacial prosthodontist has two primary objectives: (1) to restore the functions of mastication, deglutition, and speech and (2) to achieve normal orofacial appearance. Postoperative prosthodontic treatment is an established modality in the rehabilitation of the maxillectomy patient. An immediate.surgical prosthesis can cohtribute to the postoperative recovery and comfort of tile patient. Conventional surgical procedures involve adapting a skin graft to the defect and supporting it with XeroformJ" or petrolatum gauze.' The immediate surgical prosthesis, accurately fitted to t h e defect, may be substituted for the Xeroform or petrolatum gauze packing 9routinely used to support the skin graft.
...
N
,
.
.
''K .
.
.
.
\ .
Fig. 1. Processed acrylic resin denture base filled with dental tissue-conditioning material.
TECHNICAL PROCEDURES Tile prosthesis is filled with a tissue-conditioning material consisting of a polymer powder (usually ethyl methacrylate) and an aromatic ester/alcohol mixture (Fig. 1).-0When fully polymerized the tissue conditioner remains soft and flexible and maintains a physiologic adaption to the skin graft. When correctly seated on the residual palate, tile prosthesis will fill the entire surgical defect9with an excess of the tissue-conditioning material (Fig. 2). The flexible tissue-conditioning material is then molded with finger pressure on top of the readapted external *Associate Clinical Professor, Department of Removable Prosthodontics, Division of Maxillofacial Prosthetics; Attending Prosthodontist and ChiefofService, Peninsula Hospital Center, Far Rockaway, N. Y., arid North Shore Hospital, Manhasset, N.Y. J'Chesebrough Pond's Inc., ltospital Products Division, New York, N. Y.
0022-391317810.t39-0t47500A010 ~ 1978 Thc
C. V. Mosby Co.
Fig. 2. The surgical defect is filled with an excess of tissueconditioning material.
THE JOURNAL OF PROSTIIETIC DENTISTRY
447
BIRNBACH
Fig. 3. A, The surgical flap is retracted; the skin graft is in place, B, The tissue-conditioning material is in intimate contact with cheek surfaces and bony recesses.
Fig. 4. The skin graft is wrapped about the prosthesis. surgical skin flap to sculpt anatomic facial contours. After polymerization, (3 to 4 minutes) tile external skin flap is reflected laterally and tile excess tissue conditioner is removed. The tissue-conditioning material, supported by tile denture base, is now in intimate contact with the skin graft on both of the cheek surfaces and in the bony recess areas of the curetted sphenoid and ethmoid sinuses (Fig. 3). The entire surgical defect is obturated by tile soft tissueconditioning material. 448
Should the surgeon experience difficulty with the positioning of the skin graft and the preliminary suturing of it to the borders of the surgical defect the skin graft may be wrapped about the prosthesis and adapted to the defect without any preliminary suturing of the graft (Fig. 4). 3 The in toto removal of this expansive prosthesis is most difficult, if not impossible, after the final closure of the external surgical skin flap. Depending upon the extent of the defect the prosthesis may extend superiorly to the infraorbital region and may become engaged laterally in the undercut tissues. T o avoid the entrapment of the stent the polymerized conditioningmaterial is cut into three sections, each separated by a wafer of Teflon gauze (Fig. 5). The entire prosthesis is then reseated into the defect, section by section (Fig. 6), and the surgeon t h e n proceeds with the reapproximation of the facial surfaces of the skin flap (Fig. 7). The sectionally placed prosthesis is readily removed b y t h e prosthodontist without disturbing the skin graft. ADVANTAGES OF A SURGICAL PROSTHESIS An immediate surgical prosthesis with a sectional stent will support the skin graft and eliminate the need for a nasopharyngeal feeding tube? The prosthesis permits nutritional intake without fear of APRIL 1978
VOLUME 39
NUMBER 4
IMMEDIATE SURGICAL STENT PROSTHESIS FOR MAXILLARYRESECTION
•I•,•.•1,'•1'.'•.':
9
~
I'=" .
.
:l. "l,'~a-~a,.'.; ~C,:,'~' ,':-~ .,,'-~'.-1.:.~. ~ :-~...,.:,.:v~,l ~
. t . ~
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).. :.
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.
.. ,! ~;, ,-'1~il'.,,.~k '" ~
it; ~i
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,.,
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,'~'~,.,.~,
.
".,
."
..!
~
. :I ,.,,.x ." l:",,.> ,". .'~_ . . . . . . ~ , .,.>..:::.~,~_
;.-',~.!v-'-"..-~,, ; ;." ,,':.' Y.::.; :.
:~. -,
.
..~.g.:',,
.,~...J,
,,'~
x!
.~
"~1~'3.~',~ ~"
,.
~~),.
~...}
~'~~',,~,.i~.t..
Fig. 5A. T h e tissue-conditioning material is cut into three sections for easy removal. Fig. 5B. T h r e e separate sections of stent with Teflon gauze s e p a r a t i o n s prior to reinsertion in the m o u t h , section b y section.
Fig. 6. A, T h e entire prosthesis consisting of the acrylic resin base a n d the three separate sections of tissue-conditioner stent a d a p t e d against the skin graft 9 B, A d r a w i n g shows the acrylic resin base a n d three sections of the tissue-conditioner stent a d a p t e d to the deep b o n y recesses a n d skin graft. TIlE JOURNAL OF I'ROSTIIETIC DENTISTRY
449
BIRNBACH
Anatomic facial contours are maintained by the stent support of the external surgical skin flap. The patient usually is not aware of the extent of the surgical procedure and is psychologically better prepared to cope with his postoperative condition. CONCLUSION The maxillofacial prosthodontist, as a member of the surgical team, is able to aid in the recover)' and rehabilitation of the maxillectomy patient by fabricating and placing an immediate surgical prosthesis. The prosthesis supports the skin graft and maintains normal anatomic facial contours. The immediate postoperative restoration of mastication, deglutition, and speech shortens the patient's recovery time in the hospital and expedites the patient's return to the community as a functioning member, s REFERENCES 1.
Fig. 7. Readaption of the skin flap prior to suturing. aspiration into the nasopharynx and regurgitation through the nostrils. The postoperative discomfort from nasal tube feeding experienced by t h e patient will be eliminated. Upon recovery from surgery and return to a conscious state the patient will be able to intelligibly communicate with family and friends. Optimal speech is restored, morale is high, and the patient is more optimistic about future rehabilitation.
450
Rankow, R. N.: An Atlas of Surgery of the Face, Mouth and Neck. Philadelphia, 1968, XV. B. Saunders Company, pp 126-128. 2. Braden, M.: Tissue conditioners. 1. Composition and structure. J Dent Res 49:145, 1970. 3. Kazanjian, V. H., and Converse, J. M.: Surgical Treatment of Facial Injuries, ed 3, vol 2. Baltimore, 1974, The Williams & ~Vilkins Company, pp 1408-1445. -t. Adisman, 1. K.: Maxillofacial prosthetics. In Goldman, Iq. M., Forrest, S. P., Byrd, D. L., and McDonald, R. E.: Current Therapy in DentistD', vol 3. St. Louis, 1968, The C. V. Mosby Company, p 217. 5. Adlsman, I. K.: Prostheses in the Treatment of Malignant Tumors of the Paranasal Sinuses. International Workshop on Cancer of the tlead and Neck. New York, 1965, Butterworfl~ & Co., Ltd., p 252. Reprint requests to: I'~..SEYMOUR BIRNBACll
206-07 HIt.LSIDE AVE. QuEESs VXH_ACE,N. Y. 11427
APRIL 1978
VOLUME 39
NUMBER 4