Prosthetic treatment after surgical removal of the maxilla and floor of the orbit

MAXZLLOFACZAL

PROSTHESIS

PROSTHETIC TREATMENT AFTER SURGICAL MAXILLA AND FLOOR OF THE ORBIT JOHN

REMOVAL

OF THE

E. ROBINSON, D.D.S."

Zoller Memorial

Dental Clinic,

University

of Chicago, Chicago, Ill.

URGICAL EXCISION OF TUMORS of the head and neck, necessitating

gross tissue removal, results in an anatomic and functional loss that must be restored as quickly and completely as possible. l-* Although restoration of the loss cannot always be entire, any measure of improvement over the existing situation is of benefit to the patient. When the surgical procedure is to be followed by radiation therapy, reconstructive surgery may not be feasible, and there must be some means to restore these patients to a socially acceptable condition. The need for prostheses, as a means of rehabilitation, has become more evident as advances in modern surgical techniques have permitted surgeons to perform these difficult and extensive procedures. To illustrate, the step-by-step procedure for rehabilitating by prosthetic devices a patient who has an anatomic and functional loss resulting from tumor invasion of the antrum and orbit will be described.

S

HISTORY

A 59-year-old white woman was first seen in the ear, nose, and throat clinic with a swelling in the left maxillary mucobuccal fold. This appeared as a firm projection extending from the area of the second bicuspid to the second molar. The patient was edentulous. One week previously, she noticed this swelling and was seen by an oral surgeon who took complete skull and sinus roentgenograms. He noted that the left sinus appeared clouded and he recommended that she have an ear, nose, and throat evaluation. There was no pain in connection with the swelling. Roentgenologic findings demonstrated a mass which completely obliterated the left maxillary sinus. There was evidence of extension into the floor of the orbit, and destruction of the lateral and medial antral walls. A biopsy was performed and a diagnosis of squamous cell carcinoma of the antrum was made. Presented before the American Academy of Maxillofaci.al Prosthetics and the Chicago Otolaryngology Society. *Assistant Professor of Dentistry. 178

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I
Fig. 1.

F

Fig. 3.

Fig. I.-The presurgical acrylic resin template with an 18 gauge gold wire loop for providing retention after surgery. Fig. P.-The intraoral defect approximately 3 weeks after surgery. Fig. 3.-The extraoral defect. The communication between the intraoral and extraoral defects is complete.

180

J. Pros. Den. Jan..Feb., 1963

ROBINSON

Fig. 4.

Fig. 5.

Fig. 6.

Fig. 4.-The Fig. Z-The Fig. 6 .-The

presurgical template is in position. spring wire attachment is in position on the original spring wire attachment with the suture attached.

presurgical

template.

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TREATMEKT

Fig. ‘I.-The fixation of the template proximity of the loop to the orbital rim.

PRESURGICAL

AFTER

TVMOR

by means of the spring

181

EXCISIOK

wire

attachment.

Sote the

PREPARATION

Primary and secondary impressions were made of the maxillae prior to surgery, and a clear acrylic resin template* was fabricated with an 18 gauge wire loop processed into the defective side (Fig. 1) . This loop was to serve as a means of fixation, either by direct suturing to the facial musculature and skin or, if the orbital contents were to be exenterated, by extension of the suture material up and through the orbital opening and attachment to the forehead with adhesive tape. SURGICAL PROCEDURE

Through a Weber-Fergusson incision, a radical maxillary resection was performed and removal of the left zygoma and 40 per cent of the hard palate was accomplished (Fig. 2). The tumor was found to extend into the orbit, which necessitated complete orbital exenteration (Fig. 3). 4 split thickness skin graft was taken from the left thigh and applied to the cheek, roof of the orbit, and ethmoid sinus area. The previously fabricated template was inserted immediately with fixation, as described, through the orbit (Fig. 4). The cavity was then packed with chlortetracycline gauze. 0n the third day postoperatively, the packing was removed and the cavity and graft site inspected. The presurgical template required adjustment in the left tuberosity region, but otherwise it was tolerated without difficulty. The patient wore the template during the entire postoperative hospital course, and on the twelfth day postoperatively, she was discharged. POSTSURGICA4L MANAGEMEIXT

To facilitate removal and fixation of the template after the patient was discharged from the hospital, a spring wire attachment was added to the posterior *The term template, devoid of teeth.

as employed

in this article,

refers

to an acrylic

resin

denture

base,

J. Pros. Den. Jan.-Feb., 1963

ROBINSON

182

border on the defective side (Fig. 5). The attachment consisted of a small section of orthodontic spring, attached to plastic sprue material shaped to form a loop at one end (Fig. 6). When introduced into the mouth, the spring would bend upon itself, assuming an upright position once it approximated the defect. The height of the attachment’brought the loop very close to the inferior orbital rim. A piece of suture material previously tied to the loop could then be pulled through the orbital opening and fastened to the forehead (Fig. 7)) allowing the patient to manipulate the prosthesis without difficulty. Approximately 2 months after operation, when considerable shrinkage of the defect had occurred and the skin graft had established itself, an obturator template of clear acrylic resin was constructed (Fig. 8). The purpose of this template was to accustom the patient to an appliance without the sutural support and to observe the extent to which extension into the defect with the obturating portion of the final denture could be accomplished. Shortly thereafter, a permanent set of dentures was constructed (Fig. 9), and the patient was also provided with a prosthesis to restore the missing eye (Fig. 10). DISCUSSION

A surgical prosthetic appliance can be useful to the surgeon in many instances and can contribute immeasurably to the success of both the operative procedure and the rehabilitation of the patient. When a decision is made to operate upon a patient, if the end result is bound to debilitate the patient in any way, every means to assist the patient to rapid recovery and rehabilitation should be explored. The patient who must be subjected to this kind of surgical procedure is in need of complete understanding and sympathy. This kind of consideration for the patient is as important as the operation itself. A thorough evaluation should be made of the anticipated procedure, by both the surgeon and prosthodontist, so that every possibility of success is assured. It is important that the entire procedure be outlined in advance, so that all concerned realize

Fig. S.-The

clear acrylic

resin obturator

template with minimal

extension

into the defect.

glul~ef

‘13

Fig. 9.-The

PROSTHETIC

permanent

TREATMENT

AFTER

TUMOR

EXCISION

183

dentures in place.

the limitations of the other. Many times an alteration in the method of resecting the maxilla will contribute considerably to the success of the appliance contemplated. Knowing the extent of the anticipated surgical procedure, the prosthodontist can consider the various means at his disposal to proceed with the best possible technique and material to construct the appliance. Advance knowledge of these things often allows preliminary appliances to be constructed m.hich afford the patient a period of adjustment, so that the final appliance is accepted and tolerated with less difficulty. SIJMMARY

This article describes a practical and logical method for the management of a. patient sustaining considerable tissue and functional loss resulting from tumor surgery of the head. These organized steps for advancing the patient to full rehabilitation are designed so that at no one time is the patient required to accept too much of a burden concerning prosthetic adjustment.

Fig. lO.-The

silicone rubber eye prosthesis

is in place without

and with eye glasses.

184

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J. Pros. Den. Jan..Feb., 1963

REFERENCES

1. Pollack, R. S.: Tumor Surgery of the Head and Neck, Philadelphia, 1957, Lea & Febiger, pp. 61-65. 2. Schuch8y4ktigHi F. : The Surgical Management of the Paranasal Sinuses, Laryngoscope 61: 3. Montana, J. A.,‘and Hedges, T. R., Jr.: Carcinoma of the Maxillary Sinus With Ocular Involvement? Am. J. Ophth. 49:1337-1340, 1960. 4. Tabb, H. G.: Maxdlectomy in Carcinoma of the Antrum. An Analysis of 81 Cases and a Description of Certain Modifications of the Basic Technique of Extirpation, Tr. Am. Laryng., Rhinol. & Otol. Sot. 69:119-130, 1959. 5. Miglani, D. C., and Drane, J. B.: Maxillofacial Prosthesis and Its Role as a Healing Art, T. PROS. DEN. 9:159-168. 1959. 6. Kruisbrmk, J. J.: Surgical and Prosthetic Repair of Maxillofacial Defects After Removal of Oral Tumors, D. Abs. 4:10-11, 1959. 7. Kazanjian, V. H., and Converse, J. M. : The Surgical Treatment of Facial Injuries, ed. 2, Baltimore, 1959, Williams and Wilkins Company, pp. 446-448. 8. Longacre, J. J., and Coauthors: The Immediate vs. the Late Reconstruction in Cancer Surgery, J. Plast. & Reconstruct. Surg. 28:549-561, 1961. 950 EAST CHICAGO

59-m

37, ILL.

ST.