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Prosthodontic management of postsurgical soft tissue deformities associated with marginal mandibulectomy. Part II: Surgical flaps
Prosthodontic management of postsurgical soft tissue d~fevmities associated with marginal mandibulectomy. Part II: Surgical flaps Arie Shifman, D.M.D.,* and James B. Lepley, D.D.S.** I. D. F. Center of Oral and Dental Medicine, Tel-Hashomer, Israel, and Memorial Sloan-Kettering Cancer Center.
New York, N.Y.
T
he prosthodontic treatment of marginal resections of the mandible in which there was inadequate soft tissue for surgical closure was described in Part I.’ This article deals with the prosthodontic management of marginal mandibulectomy patients with excessive soft tissue because of surgical Aap procedures.
TONGUE FLAP Tongue Raps can be easily approximated for surgical closure of marginal excisions of the mandible.
The views expressed herein are those of the authors and do not necessarily reHrct the views of the Medical Corps, Israel Defense Forces. Presented before the American Academy of Maxillofacial Prosthetics. San Antonio, Tex. *klajor. I. D. F. Center of Oral and Dental Medicine. **Chief, Dental Service, Memorial Sloan-Kettering Cancer Cerlter.
Fig. 1. Postoperative
condition
showing
tongue
closing marginal defect of right side of mandible.
0072.3913/AZ,‘O90303
+ 06$00.60/O ,R 1982 The C. V. Mosby Co
flap
However, derangement of basic oral functions may result from this type of surgery. Nevertheless, the tongue has good adaptation, and usually the patient will experience little difficulty in speech and swallowing (Fig. 1). The rationale for using a conservative prosthodontic approach that utilizes the denture space was discussed in Part I.’ Again, the same principle is applied and obviates the need for preprosthetic surgery. The prosthesis is supported on the flap tissue and stabilized and braced by the adjacent tongue tissue (Figs. 2 and 3). The tongue has a special&d papillary mucous membrane that is best adapted to mechanical friction and forces.
FOREHEAD FLAP ROTATED INTRAORALLY A forehead flap could be rotated intraorally either above or below the zygomatic arch for the reconstruction of intraoral surgical defects.2,3The donor site is
Fig. 2. Modified final prosthesis adapted to soft tissue deformity associated with tongue flap.
THE JOURNAL OF PROSTHETIC DENTISTRY
303
SHIFMAN
Fig. 3. Prosthesis opposing
natural
dentition.
covered with a split-thickness skin graft taken from elsewhere. This technique has recently become popular
because of its versatility: The graft can cover wide and different locations in the pharynx and the oral cavity and is most useful after radical neck dissection. Imme-
304
LEPLEY
Fig. 5. Excessive forehead flap tissue covering lar ridge, floor of mouth, teeth.
Fig. 4. Postoperative facial appearance after use of forehead flap. Note also dropping of lower lip as result of lower lip surgery.
AND
alveomandibular
and remaining
diate postoperative radiation therapy can also be more safely delivered because the flap contains the anterior branch of the superficial temporal artery. The main objection to the forehead rotated flap procedure is from an esthetic standpoint. Because of esthetic needs, the incision is made above the eyebrows, follows the hairline, and dissects the whole forehead tissue to the base of the flap. The postoperative appearance is thus less objectionable (Fig. 4). Intraorally, the floor of the mouth is filled with excessive tissue of the forehead flap, which has a cushionlike consistency (Fig. 5). Treatment of a patient. In this particular patient the maxillary dentition seemed sound, but the remaining mandibular molar teeth could barely be seen due to the excessive soft tissue (Fig. 6). A prosthesis was constructed with the loaded impression technique. Separate impressions of both sides were made by displacing the soft tissue near the teeth with modeling compound, and irreversible hydrocolloid was used to complete the impression (Fig. 7). The cast for removable partial denture fabrication was retrieved with an occlusal index (Figs. 8 and 9). Both sections of the metal framework were connected in the anterior region of the mouth with autopolymerizing acrylic resin, and the metal framework acted as a custom-made tray (Fig. 10). After border molding, the final impression was made with impression wax (Fig. 11). The finished prosthesis was well tolerated (Fig. 12). In another patient the flap tissue almost completely filled the denture space, both horizontally and vertically (Figs. 13 and 14). However, space for the denture was actually available since the excess tissue could be displaced and recorded in this position. This tissue acted as a shock absorber for the final prosthesis. For
SEPTEMBER
1982
VOLUME
48
NUMBER
3
SURGICAL
FLAPS
Fig. 6. Panoramic radiograph revealing molar teeth of patient in Fig. 5.
Fig. 7. Unilateral modeling compound impression of remaining molar teeth depresses soft tissues. Final impression is made with irreversible hydrocolloid. Fig. 8. Separate casts of both sides and occlusal index registered in mouth. this patient a complete mandibular denture was functioning against a complete maxillary natural dentition (Figs. 15 and 16).
LOWER LIP DEFORMITIES Median surgical splitting of the lower lip and bilateral retraction through submental incisions will enable a better intraoral surgical approach for marginal resection of the mandible.4 In addition to the loss of sensory innervation, a dropping of the lower lip in tato will result (Fig. 4). The prosthesis is compromised either by diminishing the occlusal vertical dimension or by creating an anterior open-bite situation to compensate for the lowered lip line (Fig. 12). The hazards of surgery are sometimes seen when an intraoral incision for deepening the vestibule in the
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 9. Casts related with occlusal index for fabrication of single cast.
305
SHIFMAN
Fig. 10. Custom-made impression tray formed Borders were molded at later stage. Fig. 11. Final “pressure” wax impression.
by joining
two sections
AND
LEPLEY
in mouth.
Fig. 12. Intraoral prosthesis supported on forehead flap tissue. Note anterior open-bite condition. Fig. 13. Residual ridge reconstructed with forehead flap. Excessive soft tissue occludes against maxillary teeth in posterior segments.
Fig. 14. Radiographic maxillary
306
view showing
soft tissues overlying
residual bone in contact with
molars.
SEPTEMBER
1982
VOLUME
48
NUMBER
3
SURGICAL
FLAPS
Fig. 15. Complete mandibular denture constructed to conform with forehead flap. Thin sections of metal cover retromolar pad areas to enable occlusal contact with maxillary second molars.
Fig. 17. Furrow in anterior lower vestibule 30 years after vestibular deepening.
Fig. 16. Complete mandibular denture in occlusion against natural maxillary dentition.
lower lip region divides the insertion of the mentalis muscle and results in obliteration of the mentolabial groove (Figs. 17 and 18). The swollen appearance of the lower lip cannot be corrected prosthodontically. SUMMARY
AND
CONCLUSIONS
Marginal mandibulectomy patients exhibiting various soft tissue deformities resulting from the surgical technique used were prosthodontically treated without being subjected to preprosthetic surgery. Although preprosthetic surgery may be necessary, the degree of postoperative soft tissue deformity encountered in most patients can be managed by prosthodontic techniques alone.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 18. Loss of lower lip contour by obliteration mentolabial sulcus in patient seen in Fig. 17.
of
More clinical research is necessary to ascertain the preferred treatment approach that will result in the long-term preservation of form and function in this group of patients.
307
SHIFMAN
4.
REFERENCES 1. Shifman, A., and Lepley, J. B.: Prosthodontic management of postsurgical soft tissue deformities associated with marginal mandibulectomy. Part I: Loss of the vestibule. J PROSTHET DENT 48~178, 1982. 2. Conley, I.: Regional flaps of the head and neck. Philadelphia, 1976, W. B. Saunders Co., p 21. 3. Lore, J, M.: An Atlas of Head and Neck Surgery, ed 2. Philadelphia, 1973, W. B. Saunders Co., vol 1, p 282.
AND
LEPLEY
Naumann, H. H., editor: Head and Neck Surgery. Philadelphia, 1980, W. B. Saunders Co., vol 2, p 350.
Reprint requests to: DR. A. SHIFMAN P.O. Box 1031 PETACH-TIKVAH, 49110 ISRAEL
ARTICLES TO APPEAR IN FUTURE ISSUES Xylene: A potential danger to the maxillofacial
prosthodontist
Andrew H. Glassman, D.D.S.
Rotational path removable partial denture design Theodore E. Jacobson, D.D.S., and Arthur J. Krol, D.D.S.
A qualitative
comparison of various record base materials
John D. Jones, D.D.S.
Modification of a semiadjustable articulator intercondylar width
to accept the patient’s
Nikos M. Kafandaris, D.D.S., M.D., MS., and Petros T. Theodorou, D.D.S.
A replacement technique for a broken occlusal rest Altug Kazanoglu, D.M.D.,
M.S., and Edwin H. Smith, D.D.S., M.Sc.D.
Surface topography of silicone rubber prosthetic materials fabricated by conventional processing techniques Keith Kent, D.M.D.,
and Robert F. Ziegel, Ph.D.
Full crown restorations and gingival inflammation population
in a controlled
David L. Koth, D.D.S., M.S.
An evaluation of the retentive properties of various permanent crown posts H. G. Kurer, L.D.S., M.Sc.(Manc),
M.G.D.S., R.C.S.(Eng)
A parallel tube provisional
splint technique
Nathaniel H. Lenchner, D.D.S.
Photoelastic stress analysis of cast gold endodontic posts Gordon D. Mattison, D.M.D.,
M.S.
Burnished amalgam restorations: A two-year clinical evaluation Kenneth N. May, Jr., D.D.S., Aldridge D. Wilder, Jr., D.D.S., and Karl F. Leinfelder, D.D.S., M.S.
308
SEPTEMBER
1982
VOLUME
48
NUMBER
3
New York, N.Y.
T
he prosthodontic treatment of marginal resections of the mandible in which there was inadequate soft tissue for surgical closure was described in Part I.’ This article deals with the prosthodontic management of marginal mandibulectomy patients with excessive soft tissue because of surgical Aap procedures.
TONGUE FLAP Tongue Raps can be easily approximated for surgical closure of marginal excisions of the mandible.
The views expressed herein are those of the authors and do not necessarily reHrct the views of the Medical Corps, Israel Defense Forces. Presented before the American Academy of Maxillofacial Prosthetics. San Antonio, Tex. *klajor. I. D. F. Center of Oral and Dental Medicine. **Chief, Dental Service, Memorial Sloan-Kettering Cancer Cerlter.
Fig. 1. Postoperative
condition
showing
tongue
closing marginal defect of right side of mandible.
0072.3913/AZ,‘O90303
+ 06$00.60/O ,R 1982 The C. V. Mosby Co
flap
However, derangement of basic oral functions may result from this type of surgery. Nevertheless, the tongue has good adaptation, and usually the patient will experience little difficulty in speech and swallowing (Fig. 1). The rationale for using a conservative prosthodontic approach that utilizes the denture space was discussed in Part I.’ Again, the same principle is applied and obviates the need for preprosthetic surgery. The prosthesis is supported on the flap tissue and stabilized and braced by the adjacent tongue tissue (Figs. 2 and 3). The tongue has a special&d papillary mucous membrane that is best adapted to mechanical friction and forces.
FOREHEAD FLAP ROTATED INTRAORALLY A forehead flap could be rotated intraorally either above or below the zygomatic arch for the reconstruction of intraoral surgical defects.2,3The donor site is
Fig. 2. Modified final prosthesis adapted to soft tissue deformity associated with tongue flap.
THE JOURNAL OF PROSTHETIC DENTISTRY
303
SHIFMAN
Fig. 3. Prosthesis opposing
natural
dentition.
covered with a split-thickness skin graft taken from elsewhere. This technique has recently become popular
because of its versatility: The graft can cover wide and different locations in the pharynx and the oral cavity and is most useful after radical neck dissection. Imme-
304
LEPLEY
Fig. 5. Excessive forehead flap tissue covering lar ridge, floor of mouth, teeth.
Fig. 4. Postoperative facial appearance after use of forehead flap. Note also dropping of lower lip as result of lower lip surgery.
AND
alveomandibular
and remaining
diate postoperative radiation therapy can also be more safely delivered because the flap contains the anterior branch of the superficial temporal artery. The main objection to the forehead rotated flap procedure is from an esthetic standpoint. Because of esthetic needs, the incision is made above the eyebrows, follows the hairline, and dissects the whole forehead tissue to the base of the flap. The postoperative appearance is thus less objectionable (Fig. 4). Intraorally, the floor of the mouth is filled with excessive tissue of the forehead flap, which has a cushionlike consistency (Fig. 5). Treatment of a patient. In this particular patient the maxillary dentition seemed sound, but the remaining mandibular molar teeth could barely be seen due to the excessive soft tissue (Fig. 6). A prosthesis was constructed with the loaded impression technique. Separate impressions of both sides were made by displacing the soft tissue near the teeth with modeling compound, and irreversible hydrocolloid was used to complete the impression (Fig. 7). The cast for removable partial denture fabrication was retrieved with an occlusal index (Figs. 8 and 9). Both sections of the metal framework were connected in the anterior region of the mouth with autopolymerizing acrylic resin, and the metal framework acted as a custom-made tray (Fig. 10). After border molding, the final impression was made with impression wax (Fig. 11). The finished prosthesis was well tolerated (Fig. 12). In another patient the flap tissue almost completely filled the denture space, both horizontally and vertically (Figs. 13 and 14). However, space for the denture was actually available since the excess tissue could be displaced and recorded in this position. This tissue acted as a shock absorber for the final prosthesis. For
SEPTEMBER
1982
VOLUME
48
NUMBER
3
SURGICAL
FLAPS
Fig. 6. Panoramic radiograph revealing molar teeth of patient in Fig. 5.
Fig. 7. Unilateral modeling compound impression of remaining molar teeth depresses soft tissues. Final impression is made with irreversible hydrocolloid. Fig. 8. Separate casts of both sides and occlusal index registered in mouth. this patient a complete mandibular denture was functioning against a complete maxillary natural dentition (Figs. 15 and 16).
LOWER LIP DEFORMITIES Median surgical splitting of the lower lip and bilateral retraction through submental incisions will enable a better intraoral surgical approach for marginal resection of the mandible.4 In addition to the loss of sensory innervation, a dropping of the lower lip in tato will result (Fig. 4). The prosthesis is compromised either by diminishing the occlusal vertical dimension or by creating an anterior open-bite situation to compensate for the lowered lip line (Fig. 12). The hazards of surgery are sometimes seen when an intraoral incision for deepening the vestibule in the
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 9. Casts related with occlusal index for fabrication of single cast.
305
SHIFMAN
Fig. 10. Custom-made impression tray formed Borders were molded at later stage. Fig. 11. Final “pressure” wax impression.
by joining
two sections
AND
LEPLEY
in mouth.
Fig. 12. Intraoral prosthesis supported on forehead flap tissue. Note anterior open-bite condition. Fig. 13. Residual ridge reconstructed with forehead flap. Excessive soft tissue occludes against maxillary teeth in posterior segments.
Fig. 14. Radiographic maxillary
306
view showing
soft tissues overlying
residual bone in contact with
molars.
SEPTEMBER
1982
VOLUME
48
NUMBER
3
SURGICAL
FLAPS
Fig. 15. Complete mandibular denture constructed to conform with forehead flap. Thin sections of metal cover retromolar pad areas to enable occlusal contact with maxillary second molars.
Fig. 17. Furrow in anterior lower vestibule 30 years after vestibular deepening.
Fig. 16. Complete mandibular denture in occlusion against natural maxillary dentition.
lower lip region divides the insertion of the mentalis muscle and results in obliteration of the mentolabial groove (Figs. 17 and 18). The swollen appearance of the lower lip cannot be corrected prosthodontically. SUMMARY
AND
CONCLUSIONS
Marginal mandibulectomy patients exhibiting various soft tissue deformities resulting from the surgical technique used were prosthodontically treated without being subjected to preprosthetic surgery. Although preprosthetic surgery may be necessary, the degree of postoperative soft tissue deformity encountered in most patients can be managed by prosthodontic techniques alone.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 18. Loss of lower lip contour by obliteration mentolabial sulcus in patient seen in Fig. 17.
of
More clinical research is necessary to ascertain the preferred treatment approach that will result in the long-term preservation of form and function in this group of patients.
307
SHIFMAN
4.
REFERENCES 1. Shifman, A., and Lepley, J. B.: Prosthodontic management of postsurgical soft tissue deformities associated with marginal mandibulectomy. Part I: Loss of the vestibule. J PROSTHET DENT 48~178, 1982. 2. Conley, I.: Regional flaps of the head and neck. Philadelphia, 1976, W. B. Saunders Co., p 21. 3. Lore, J, M.: An Atlas of Head and Neck Surgery, ed 2. Philadelphia, 1973, W. B. Saunders Co., vol 1, p 282.
AND
LEPLEY
Naumann, H. H., editor: Head and Neck Surgery. Philadelphia, 1980, W. B. Saunders Co., vol 2, p 350.
Reprint requests to: DR. A. SHIFMAN P.O. Box 1031 PETACH-TIKVAH, 49110 ISRAEL
ARTICLES TO APPEAR IN FUTURE ISSUES Xylene: A potential danger to the maxillofacial
prosthodontist
Andrew H. Glassman, D.D.S.
Rotational path removable partial denture design Theodore E. Jacobson, D.D.S., and Arthur J. Krol, D.D.S.
A qualitative
comparison of various record base materials
John D. Jones, D.D.S.
Modification of a semiadjustable articulator intercondylar width
to accept the patient’s
Nikos M. Kafandaris, D.D.S., M.D., MS., and Petros T. Theodorou, D.D.S.
A replacement technique for a broken occlusal rest Altug Kazanoglu, D.M.D.,
M.S., and Edwin H. Smith, D.D.S., M.Sc.D.
Surface topography of silicone rubber prosthetic materials fabricated by conventional processing techniques Keith Kent, D.M.D.,
and Robert F. Ziegel, Ph.D.
Full crown restorations and gingival inflammation population
in a controlled
David L. Koth, D.D.S., M.S.
An evaluation of the retentive properties of various permanent crown posts H. G. Kurer, L.D.S., M.Sc.(Manc),
M.G.D.S., R.C.S.(Eng)
A parallel tube provisional
splint technique
Nathaniel H. Lenchner, D.D.S.
Photoelastic stress analysis of cast gold endodontic posts Gordon D. Mattison, D.M.D.,
M.S.
Burnished amalgam restorations: A two-year clinical evaluation Kenneth N. May, Jr., D.D.S., Aldridge D. Wilder, Jr., D.D.S., and Karl F. Leinfelder, D.D.S., M.S.
308
SEPTEMBER
1982
VOLUME
48
NUMBER
3