Prosthodontic rehabilitation in cancer patients

International Journal of Contemporary Dental and Medical Reviews (2015), Article ID 080215, 5 Pages
REVIEW ARTICLE
Prosthodontic rehabilitation in cancer patients: Various
treatment modalities available
C. Gyan Kumar1, K. Sounder Raj1, D. Kalpana2, D. P. Shruthi3, D. R. Prithviraj1, Srinivas Kumar4
1
Department of Prosthodontics and Implantology, Govt. Dental College and Research Institute, Victoria Hospital Campus, Bengaluru, Karnataka, India,
Department of Prosthodontics, Dayanand Sagar College of Dental Sciences, Bengaluru, Karnataka, India, 3Private Practitioner, No.260, 4th Main, N R Colony,
Basavangudi, Bengaluru, Karnataka, India, 4Department of Prosthodontics, Gitam Dental College, Vishakapatanam, Andhra Pradesh, India
2
Correspondence
Dr. Gyan Kumar C, Department of
Prosthodontics and Implantology, Govt.
Dental College and Research Institute,
Fort, Bengaluru - 560 002, Karnataka,
India. Phone: +91-9901653315.
Email: gyan_kumarc@yahoo.co.in
Received 27 February 2015;
Accepted 28 April 2015
Abstract
Patients with head and neck cancer suffer highest morbidity. Patients suffer physically
and psychologically. Cancer and its various treatments disable the patients, thorough
evaluation, presurgical planning, and post-treatment rehabilitation play an important
role. The patients overall well-being, optimal restoration of health, and function should
be the goal.
Keywords: Mandibulectomy, maxillectomy, obturator
doi: 10.15713/ins.ijcdmr.72
How to cite the article:
C. Gyan Kumar, K. Sounder Raj, D. Kalpana,
D. P. Shruthi, D. R. Prithviraj, Srinivas Kumar,
“Prosthodontic rehabilitation in cancer
patients: Various treatment modalities
available,” Int J Contemp Dent Med Rev,
vol.2015, Article ID: 080215, 2015.
doi: 10.15713/ins.ijcdmr.72
fistula, cosmetic disfigurement, and radiation caries.[1,2] Patients
often require rehabilitation for swallowing, mastication, speech,
cosmetics to lead happy social life. Prosthodontic rehabilitation
requires coordinated integration with a multidisciplinary team.
Members of this team include a surgical oncologist, radiation
oncologist, prosthodontist, oral maxillofacial surgeon, speech
therapist, otolaryngologist, and social worker to treat and make
patients comfortable.[3] An important and critical member of
this team is prosthodontist who coordinates with team members
in every stage of patients treatment. Prosthodontist is involved
in the diagnosis, examination, treatment, maintenance of oral
function, speech, cosmetics, and health of patients undergoing
cancer treatment.[4]
The scope of services provided by a maxillofacial
prosthodontist presents a wide array of rehabilitative challenges.
Maxillofacial prosthetic treatment does not substitute for plastic
or reconstructive surgery and in certain circumstances it is an
alternative.[5] With recent developments in three-dimensional
printing and rapid prototyping technologies, accurate and
precise impression of the tissues can be recorded without causing
Introduction
Quality of life of patients suffering with cancer is highly
compromised due the disease itself, postsurgical disability
or limitation, ill effects of radiation, and side effects of
chemotherapeutic drugs. The primary goal of treating disabled
cancer patients depends on the quality of life which has a
physical function, social interaction, psychological function, and
treatment of disease as parameters. The cosmetic, functional,
psychological results of cancer treatment produce devastating
effects on the patient’s quality of life. The goal of cancer treatment
should not only be on survival, but rehabilitation, which aims to
improve multiple impairments’ and quality of life. The goal is to
relieve suffering and minimize morbidity by doing, so the quality
of life is assured and upholds self-image during psychological
adjustments.
Patients with head, neck cancer suffer from jaw deviations due
to mandibulectomy and maxillectomy in various forms like from
total to segmental which ultimately impairs masticatory function,
speech, xerostomia due to radiation, nasal reflux due to oronasal
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Prosthodontic rehabilitation in cancer patients
Kumar, et al.
annoyance and discomfort to the patients. Implants, pterygoid
implants, and zygoma implants offer various possibilities
when intraoral structures are detrimental for supporting the
prosthesis.[6] To reduce potential untoward effects of cancer
treatment, the primary concern of the treatment is to assure
that the oral cavity is prepared, train the patients in oral hygiene
methods and therapeutics for oral health preservation and
educate the patient for possible short-term and long-term
complications.
Maxillofacial prosthodontic rehabilitation as an integral
facet of cancer care is required by patients undergoing therapy.
Restoration of speech, deglutition, mastication and restoration
of facial defects, and control of saliva are the primary goal of
maxillofacial rehabilitation. The strategy and techniques of
rehabilitation are directly related to the cancer characteristics,
type of surgical intervention, and treatment modalities used.[7]
The process of rehabilitation begins at the time of initial diagnosis
and treatment planning. Devan stated preservation of remaining
sound structures is more important than the meticulous
restoration of missing structure. Hence, the preservation of
remaining sound teeth is an important asset in prosthodontic
treatment. Planning should adopt the philosophy of prevention
and conservation to achieve best functional, psychological,
physical, and cosmetic outcome.[8] Factors influencing the
treatment plan include prognosis and systemic status of the
patient, site and size of the defect, nature of functional and
cosmetic defect, adjunct therapy that may compromise the
surgical result anticipated changes to function and cosmetics.[9]
Surgical resection will create defects of the maxilla, palate or
adjacent soft palate ranging from small perforations to extensive
resections leading to variety of sequelae [Figures 1-6]. This leads
to incomprehensible speech, impaired masticatory function,
difficult deglutition, uncontrolled oral secretions, and facial
disfigurement. Mandibulectomy leads to jaw deviation, esthetic
impairment, impaired speech, drooling of salvia. Glossectomy,
either total or partial leads to impaired speech, lack of cleansing
ability, etc. Prosthodontic intervention is utmost important
from initial diagnosis and treatment planning to prevent or
minimize the sequelae. Aramany and cantor cutis classification
of maxillofacial and mandibular resection will help us in future
planning of prosthesis in a planned manner, rather doing
Figure 2: Immediate surgical obturator
Figure 3: Hemimaxillectomy on patient’s left side
Figure 1: Maxillary defect with oronasal communication
Figure 4: Definitive prosthesis consisting of the cast partial denture
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Kumar, et al.
Prosthodontic rehabilitation in cancer patients
resection in an unplanned manner.[10] Prosthodontic intervention
with maxillary obturator is required to restore the contours of
the resected palate and restore the functional separation of the
oral and nasal cavities. Immediate surgical obturator placed at
the completion of surgery provides support for remaining soft
tissues of the cheek and lip and minimizes wound contamination
and enables patients to speak and swallow. This is possible
through thorough planning presurgically such that stability for
immediate and final prostheses in enhanced and simultaneously
remaining tissues are protected throughout the treatment. The
definitive obturator prosthesis is more permanent prosthesis
designed and fabricated when the surgical site is stable. Soft
palate speech bulb prosthesis can be used for patients who have
soft palate insufficiency to allow speech swallowing. The palatal
lift prosthesis can be provided for patients with speech disorders
due to palatopharyngeal incompetence after oncological therapy
[Figure 1].[11]
Mandibular and tongue defects
Disabilities resulting from resections of the tongue, floor of
mouth or mandible would include impaired speech articulation,
swallowing, and deviation of the mandible during functional
movements, poor control of salivary secretions, and often
cosmetic disfigurement [Figures 7 and 8]. Bony mandibular
resections if continuity is not restored surgically through free
fibro-osseous fibular flap, a mandibular guidance appliance like
guiding flange or palatal ramp to direct mandible to an intercuspal
position can be made. The severity of morbidity associated with
composite resection of the tongue, floor of the mouth, and
mandible is greatly reduced by the introduction of microvascular
free flap transfer and use of osseointegrated implants.[12] A free
tissue transfer with fibula allows the placement of dental implants
to support the prosthesis.
Extra oral defects
Rehabilitation of facial defects in patients who have lost an
eye, ear, nose or sustained damage to intraoral structures by
an artificial prosthesis can immensely change the quality of life.
Figure 5: Hemimaxillectomy with oronasal communication
Figure 7: Hemimandibulectomy
Figure 6: Maxillary obturator to restore the contours of the resected
palate and recreate the functional separation of the oral cavity,
sinus, and nasal cavity
Figure 8: Prosthesis to restore speech and esthetics
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Prosthodontic rehabilitation in cancer patients
Kumar, et al.
advances in imaging modalities, use of implants has collectively
enhanced rehabilitation outcomes.[22-24] With rapid prototyping
a life like prosthesis of defect can be fabricated. The software
allows virtual designing of the prostheses enhancing outcomes
and thus improving the quality of life.
There has been a shift in the use of retention mechanisms as the
conventional retention system had its own limitations due to
availability of the materials, movable tissue beds, and patients
coping ability to accept the results. Retention mechanisms of
prosthesis depend on spectacles, hair bands, adhesive retained
or implant retained. Improved retention enhances patient
comfort, changed daily maintenance, and increased life span of
the prosthesis.[13] Silicone elastomers have achieved wide clinical
acceptance. Currently many facial and craniofacial defects are
reconstructed with a combination of the free microvascular free
flap, tissue expanders, and use of a maxillofacial prosthesis.[13-16]
Conclusion
Prosthodontic rehabilitation broadens the range for recovery
after head and neck oncology therapy,[25] brings about image
restoration and confidence to patients who have suffered
the consequences of head and neck cancer.[26,27] The scope
of prosthodontic services can be improved by education
public awareness professional practice and availability of
services.
Dental Care Prior to Radiation and Chemotherapy
Complete oral and dental evaluation, including radiographs, hard
and soft tissue, periodontal caries examination is mandatory.
Hopeless teeth with questionable prognosis, including root
fragments in the area of radiation should be removed, caries teeth
should be restored. Pre-prosthetic surgery may be needed to
remove a potential source of infection or anatomic interferences
for future prosthetic placement.[17] Oral prophylaxis and home
care instruction like fluoride mouth washes and toothpastes
should be provided, topical fluorides, and radiation stents made up
of lead may be used to protect other tissues from radiation hazards.
Uses of Prosthodontic
Radiotherapy
Splints
and
Stents
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