Replacement of an obturator section of an existing two-piece implant-retained edentulous obturator

There is an increasing number of people in the community who have postablative surgery for tumors of the maxilla. Postsurgical defects these individuals have are usually restored by means of a complete or partial denture obturator with various materials, including resilient silicone extensions. These patients require long-term maintenance of their obturator prostheses, which must be considered in the context of their general health and ongoing medical care. When a resilient silicone bulb is used to obturate the defect, the silicone sometimes deteriorates, whereas the denture base remains functional. This article describes a simple procedure to construct a replacement, resilient silicone bulb obturator while retaining the original complete or partial denture base.

Morphologic changes in forearm flaps of the oral cavity

PURPOSE

This study was undertaken to investigate the morphologic changes in the forearm flap in the oral environment.

PATIENTS AND METHODS

Histologic evaluation of biopsy specimens from 20 forearm flaps was done 1 to 75 months after intraoral reconstruction after treatment of cancer. Hematoxylin and eosin and Azan were used to stain the deparaffinized sections.

RESULTS

The clinical features of the grafted flap seemed to depend on the time since the operation. The cornified layer of the epidermis of the flaps showed thinning histologically.

CONCLUSION

After 11 months of exposure to an intraoral environment, "mucosalization" of the forearm flap is evident.

The free revascularized lateral upper arm flap in maxillofacial reconstruction following ablative tumour surgery

The lateral arm flap is well established in microvascular reconstructive surgery for covering small and moderate-sized defects both of the extremities and in the head and neck region. In the last 3 years 25 patients underwent a lateral upper arm flap for primary repair of tumour related defects of the tongue (n = 10), floor of the mouth (n = 7), mandible (n = 4), inner cheek (n = 2), oropharynx (n = 1) and lower lip (n = 1). Defects extended from the anterior floor of the mouth to the oral tongue in three cases and in four cases the defect reached the pharyngeal tongue. Two flaps had neurovascular anastomoses between the posterior cutaneous nerve of the arm and the lingual nerve. In all patients the donor defect was closed primarily. Twenty four lateral upper arm flaps healed uneventfully although six patients developed severe alcoholic delirium. One flap was lost on the fourth postoperative day due to venous insufficiency. There were no significant complications at the donor site. At the time of this report 16 patients were taking a normal diet while nine patients were taking pureed food. Among the advantages of this flap are anatomically reliable vascular supply, its good aesthetic quality, and position of the donor site. Furthermore the posterior radial collateral artery is a nonessential vessel of the arm. The flap is also potentially sensate. Among the disadvantages are smaller vessels for microvascular anastomoses. In conclusion, we believe that for repair of moderate-sized defects of the maxillofacial area the lateral upper arm flap can be recommended as the first choice.

The lateral upper arm free flap for intraoral reconstruction

Twenty-three consecutive patients who were reconstructed with a lateral upper arm free flap (LUFF) were examined especially concerning functional and morphological results at the recipient and donor sites. There were 22 intraoral and one upper oesophageal reconstruction after radical laryngectomy. The LUFF rendered good functional and esthetic results except for one case of complete and one case of incomplete flap necrosis due to vascular insufficiency of the supplying vessel of the neck. There was some sensory deficit of the donor site (n=10), but no radial nerve injury or conspicuous scarring. Recipient site dehiscence occurred in two cases and a temporary orocervical fistula was seen in one case. Oral function was maintained due to the thin and pliable flap. Excellent flap adaptation to the adjacent tissue was obtained in eight cases of complete loss of lingual attached gingiva in the molar region and in four cases of loss of buccal attached gingiva. The success and functional results of LUFF were comparable to the results of 14 cases in which radial forearm free flaps (RFFF) were used. Although the length of the pedicle and the diameter of the vessels in LUFF are smaller than in RFFF, neither pedicle length nor vessel diameter proved to be a problem. Extent of scarring and risk of vascular compromise proved to be less as compared to RFFF. LUFF is, therefore, the flap of choice for intraoral soft tissue reconstruction and it is advised to reserve RFFF for cases in which LUFF fails.

[The correction of the immune status at the postoperative rehabilitative stage in lung cancer patients by using millimeter-wave resonance therapy]

Results are submitted of study into effects of microwave resonance therapy (MRT) on parameters characterizing cell immunity in those lung cancer patients having undergone a radical operation. This study comprised 58 patients as the main group, with 31 patients being controls. Indices for cell immunity were also studied in 20 donors. There was a rise in T-lymphocytes after MRT in the postoperative period. MRT contributed to prolongation of patients' lives, reduction of the incidence of chemotherapy-related dyspeptic complications and that of leukopenia cases by 8 and 9 percent respectively.

Utilization of the neutral zone technique for a maxillofacial patient

The use of a neutral zone technique to fabricate a more stable complete mandibular denture for a maxillofacial patient is presented. The technique incorporates an altered sequence from traditional denture fabrication, resulting in a shortened treatment period.

[Functional complementation of intra- and extra-oral implants. Apropos of a case of extensive loss of substance of the face]

The respective indications for oral or extra-oral implants lead to no confusion: stabilization of dental prostheses for the first, stabilization of maxilo-facial epitheses for the others. We demonstrate that the complementarity of the two types of implants can prove to be very useful in maintaining the maxillary dental prosthesis and the epithesis in a case of severe loss of facial substance affecting particularly the pre-maxilla. This complementary characteristic made it possible to recover fairly rapidly phonation and deglutition, and to remedy somewhat the esthetic damage. In other words to create the essential conditions for a return to everyday life.

Psychologic response of the edentulous patient after primary surgery for oral cancer: A cross-sectional study

STATEMENT OF PROBLEM

Edentulous patients can have difficulty in tolerating dentures and this may lead to psychologic disturbance. The problem is potentially more severe for edentulous patients after primary surgery for oral cancer, where treatment can include composite resection and reconstruction, followed by adjuvant radiotherapy.

PURPOSE

This study investigated the psychologic response and oral satisfaction of edentulous patients treated by surgery for oral squamous cell carcinoma, and to make a comparison to edentulous noncancer counterparts.

METHODS AND MATERIAL

The cross-sectional study included patients who were alive and disease-free 2 to 3 years after primary surgery. Seventy patients underwent surgery at the Regional Maxillofacial Unit, Liverpool, in 1993 and 1994. Twenty-eight patients were disease-free; 26 completed questionnaires that included a general health questionnaire (GHQ), a body satisfaction scale, a self-esteem scale, an oral symptom checklist, and a denture satisfaction questionnaire. Comparison was made with 98 noncancer edentulous patients from the same unit.

RESULTS

There were similarities in psychologic and oral satisfaction scores between the noncancer and cancer edentulous patients. Cancer patients reported lower self-esteem (P <.02). Cancer patients who were not rehabilitated with either conventional or implant-retained prostheses had significant psychologic morbidity as measured by the GHQ, self-esteem, and body satisfaction scales. Cancer patients with implant-retained overdentures reported greater satisfaction with their dentures compared with their counterparts who wore conventional dentures (P <.05).

CONCLUSION

Edentulous cancer patients who do not achieve oral rehabilitation after surgery for oral cancer exhibited significant psychologic morbidity. Patients with implant-retained overdentures exhibited a tendency to adopt the same psychologic response with improved denture satisfaction as edentulous patients with conventional dentures, despite the former having more extensive disease that would otherwise make the provision of dentures much more difficult if implants were not used.

Multidisciplinary treatment for an implant retained auricular prosthesis rehabilitation

Retention of a facial prosthesis is the most important factor in creating a useful prosthesis for the patient. This paper presents a detailed case study of an auricular defect that was rehabilitated using two types of prosthetic retention: adhesive and osseointegration. We present the patient selection criteria, the surgical considerations prior to implant placement, retention component selection, prosthetic fabrication techniques and patient management after prosthetic delivery. The osseointegrated prosthesis made a large improvement in the patient's quality of life.

[Modificated epiglottic laryngoplasty]

OBJECTIVE

To investigate the surgical method and effect of laryngeal rehabilitation of patients with glottic carcinoma (T3 category) after extended partial laryngectomy.

METHOD

36 cases were operated with modificated epiglottic laryngoplasty. The materials for laryngoplasty included the epiglottic and one lateral partial thyroid cartilage and muscle-cartilage membrane flap and one arytenoid cartilage. The modificated technique was designed.

RESULT

33 cases were postoperatively in pulling-out-tube. The voice of 30 cases was clear, loud and comprehensible, but low and hoarse voice in other 3 cases. The 3 and 5 year survival rates were 89.3% and 77.3% respectively. The 3 and 5 year stable rates of laryngeal function were 95.6% and 94.1% respectively.

CONCLUSION

The modificated epiglottic laryngoplasty was effective surgical method for the patients with glottic carcinoma (T3 category).

Ten-year experience in oral implant rehabilitation of cancer patients: treatment concept and proposed criteria for success

Between 1988 and 1997, 18 irradiated patients (group 1, 83 implants) and 22 nonirradiated patients (group 2, 92 implants) received resection of the cancer-involved mandible and floor of the mouth and subsequently underwent mandibular rehabilitation with endosseous implants. Implant-supported prostheses were placed in 26 patients, while 13 patients received implant-tissue-supported prostheses. Between 1988 and 1991, patients were restored with implant-tissue-supported prostheses (based on 2 to 4 implants). This strategy was later changed because of the development of denture-related lesions. Since 1992, group 1 patients have been restored exclusively with implant-supported prostheses on 5 to 6 implants; group 2 patients have been rehabilitated alternatively with implant-tissue-supported prostheses on 4 implants. Special criteria for determining the success of implant-supported maxillofacial prostheses were developed. With a mean follow-up period of 37 months, 160 implants (91%) were clinically osseointegrated. Both types of restorations provided sufficient oral rehabilitation. However, only completely implant-supported prostheses avoided soft tissue ulcers. The cumulative success rate was approximately 75% after 7 years for group 1 patients and about 86% after 10 years for group 2 patients. The success rates for implants placed after the change in strategy were approximately 86% (group 1) and 94% (group 2) after 5 years. Based on these experiences, it is suggested that irradiated patients should be restored with exclusively implant-supported prostheses, without any mucosal contact.

Tracheo-oesophageal puncture by retrograde passage of a gastroscope via mini-laparotomy and gastrotomy

Secondary tracheo-oesophageal puncture is frequently used for voice restoration after laryngectomy. A method utilizing a flexible gastroscope passed via a mini-laparotomy and gastrotomy in a retrograde manner is described in a patient where extensive pharyngeal resection made it impossible to cannulate the upper aerodigestive tract. The patient suffered minimal morbidity and produced reasonable speech.

Osseointegrated implants in post-surgical prosthodontic rehabilitation

The advent of osseointegrated implants and their use in dentistry has been well documented and continues to become more and more a part of conventional dental treatment. Apart from their use in simple situations they can prove invaluable when there is little hope of success with the other options. Two cases are presented here that involve multiple tooth loss as a result of surgical intervention and treatment of pathological lesions.

Rehabilitation with dental implants of oral cancer patients

The aim of this study was to evaluate the risks and complications of rehabilitation with dental implants after tumour surgery and radiotherapy. After a disease-free survival of 18 months, 29 patients who had undergone oral cancer treatment were rehabilitated with dental implants. The complication rate of implants in irradiated, non-irradiated and grafted bone was analyzed at least 3 years after implant placement. In the healing period, 28.6% of the implants in irradiated bone and 8.4% in non-irradiated bone showed soft tissue complications. Of the implants, 26.7% in the irradiated and 14.7% in the non-irradiated mandibular bone were lost in the first 36 months after placement. Thirty-one point two percent of implants inserted in non-irradiated bone grafts were affected and did not osseointegrate. Of 109 inserted implants, 70 were suitable for prosthetic rehabilitation. There are high complication rates after implant placement in oral cancer patients. Irradiation adversely affects soft tissue healing. Osseointegration is frequently disturbed, especially when implants were placed in non-vascularized bone grafts.

Assessment of prosthetic restorations on bone-lock implants in patients after oral tumor resection

The feasibility of implant treatment in patients after oral ablative tumor surgery has not yet been investigated with consideration of the requisite high periodontal standards. A report on this topic has to deal not only with implant survival but also with implant health, bone response, soft tissue health, failure pattern, time of failure, and ease of restoration. For the assessment of an implant system, an overview must be accomplished that takes into account the different restorations used and their interaction with the implant system that was used. This study presents the Bone-Lock implant system (Howmedica Leibinger GmbH, Freiburg, Germany) in a retrospective investigation after 5 years of follow-up with special emphasis on the prosthetic restorations used following resection of oral malignancies. From early in 1990 through June 1996, we inserted 210 dental endosteal Bone-Lock implants (58 patients) after oral tumor resectioning. Included in the study were 45 patients with 162 implants and prosthetic restorations that had been loaded for 1 year (dentures retained by telescopic or bar-clip or ball attachments, implant-supported prostheses, tooth-to-implant connected bridges). Regular follow-up consisted of evaluation of the Plaque Index (Silness and Löe) and of the Sulcus Bleeding Index (Löe), measurements of pocket probing depth, implant mobility (by means of the Periotest method), bone resorption (according to X-ray findings), and a questionnaire that registered patient satisfaction. The results were evaluated for each restoration and were compared with baseline standards. The overall 5-year survival rate was 83.2%. For implants that had been in place for over 365 days, the survival rate was 93%. The investigation showed that after resection of oral malignancies, patients could be treated with dental implants and superstructures with long-term efficacy similar to that found in healthy subjects considering internationally accepted standards. Implant treatment in tumor patients appeared to offer the most positive periodontic results when use of bar-clip or telescope-retained overdentures was involved. The patient satisfaction level with the described prosthodontic treatment was satisfactory.

Primary temporary AO plate reconstruction of the mandible

OBJECTIVE

This study assessed the incidence of complications and revisions after primary temporary AO plate reconstructions of the mandible performed from 1971 through 1996.

STUDY DESIGN

In a retrospective record review, the data of 51 patients undergoing primary temporary AO plate reconstructions after composite mandibular resection were analyzed according to age, gender, date of reconstruction, anatomic location of reconstruction, use of additional radiotherapy and/or flap surgery, and incidence of associated complications and revisions.

RESULTS

Associated complications and revisions accompanying primary temporary AO plate reconstructions were evaluated through use of the incidence rates of associated complications (IACs) and revisions (IARs), which are reported as the numbers of associated complications and revisions, respectively, per 100 patients. Of the entire sample, the highest incidence rate of associated complications was associated with infection (33.5); this was followed by the rates for plate exposure (27.9) and plate fracture (10.7). With an overall incidence rate of 38.3 revisions per 100 patients, the corresponding site-related incidence rates of associated revisions were found to be 55.0 for reconstructions of the anterior mandible crossing the midline, 37.1 for those of the body segment of the mandible, and 31.1 for reconstructions involving the ramus and/or condyle area of the mandible. Revision rates were observed to be significantly higher in irradiated (53.6 vs 31.5) and non-flap-added reconstructions (43.2 vs 24.8). Analysis of treatment group-related incidences revealed irradiated non-flap-added reconstructions to be associated with the highest failure rates, whereas additional flap surgery resulted in a significant reduction in complications (50.0 vs 108.0) and revisions (20.0 vs 65.7).

CONCLUSIONS

This study showed primary temporary AO plate reconstructions after composite mandibular resection to be associated with a high rate of complications and revisions. The results emphasize the need to relate outcome measures to site-related and treatment-related parameters.

Radiation shielding in oral implantology: a case example

Patients who are to receive implant therapy and are about to undergo radiation treatment require a means to eliminate, or reduce, the amount of radiation received by the implants and their osseous housing. This requirement is even more important if the implants were recently inserted and osseointegration (Sigma) has not yet been achieved. Lead shielding of the implant sites protects the fixtures and the surrounding bone so that osseointegration can be achieved and maintained.

Evaluation of voice and speech following subtotal reconstructive laryngectomy

Subtotal reconstructive laryngectomy (SRL) can be used to preserve voice in the treatment of selected laryngeal carcinomas. This study was designed to analyze both voice and speech results achieved after SRL in 14 male patients, aged from 48 to 73 years. Surgery was performed between 1983 and 1993. Fundamental frequencies, ranges of frequency, intensities, and intensity ranges were established using an S.I. 80 Philips AAC 600 Audio Active Comparative Language System. Five prolonged vowels and six phonetically balanced sentences were recorded on a tape positioned at a distance of 30 cm from the mouth of each patient during a 3-min recording time. The recorded material was then evaluated by a panel of ten trained listeners who were asked to consider the qualitative parameters and perceptual characteristics of voice and speech according to a scorecard modified from one devised by Voiers and Formigoni. Although a decrease was determined in Fundamental Frequency and intensity of the voice when compared to normal values, the quality and perception of speech were found to be satisfactory. The verbal message could be understood almost exactly by means of constant sonority, correct articulation and improved pneumophonic coordination. These values demonstrate that the new voice achieved after SRL is less sonorous and allows for understandable and socially acceptable speech.

Indications for the vastus lateralis flap in oral and maxillofacial surgery

OBJECTIVE

To find out the applications, usefulness and advantages of the microsurgically anastomosed vastus lateralis flap. We evaluated the results of 60 consecutive oral and maxillofacial reconstructions and established typical indications for use of this flap.

DESIGN

The transplant was applied as a pure muscle flap in 17 cases, four of those being a split-skin flap for coverage of defects on the scalp. Further reconstructions were done with myocutaneous flaps for the tongue (n = 13), floor of the mouth (n = 16) and external skin defects (n = 6) as well as to close perforating defects (n = 8).

RESULTS

The long and high-calibre vascular pedicle, the unvarying anatomy, and the time-saving possibility of simultaneously resecting the tumour and raising the flap in the head and neck region proved to be particularly advantageous during flap transfer. The best results were obtained in extensive, deep, or perforating defects and in tongue reconstruction; neuromuscular connection of the transplant is possible. Pure muscle transplants have only a few indications for application in the oral cavity because of their tendency to shrink. Donor site morbidity was generally low; the flap was lost in 5 cases.

CONCLUSION

This hitherto rarely used transplant is well-suited for maxillofacial reconstructions if the correct indications apply.

Central island tongue flap

Pedicled tongue flaps have proved to be an effective method of repairing defects due to tissue loss in the oral cavity. Their central position, mobility, and excellent blood supply make their use feasible in a variety of sites. This paper describes the use and applications of central island tongue flaps to reconstruct defects of anterior floor of the mouth. This procedure was conducted at the Department of Oral and Maxillofacial Surgery, Medical University Hanover, introducing an improved surgical method and presenting the actual operation performed in our department. This method is considered superior for resurfacing the anterior floor of mouth defects because it is easy to perform and results in recovery of function and cosmetics.

The effect of different transplanted soft tissues on bone resorption around loaded endosseous implants in patients after oral tumor surgery

One hundred eighty-five dental implants loaded for at least 1 year in 49 patients treated with ablative tumor and reconstructive surgery in the oral cavity were examined to ascertain peri-implant bone resorption. While 96 implants penetrated local mucosa and served as the control group, 27 implants were associated with split-thickness skin grafts, 9 in mucosal grafts, 18 in myocutaneous flaps, 30 in jejunal grafts, and 5 in a vastus lateralis and a temporalis muscle flap. Restoration type was similar in all groups (overdentures) except for implants placed in the jejunal grafts (fixed implant-supported prostheses). Regular follow-up was done over an observation period of 3 to 5 years after implant placement. Overall survival rate of the 89 implants surrounded by transplanted soft tissues was 94.1%. Bone loss under the various transplanted soft tissues was similar to or less than that under local mucosa. Over time, only horizontal bone resorption under jejunal grafts and vertical bone resorption under mucosal grafts showed higher values. Mean values of all measurements for split-thickness skin grafts were higher than for local mucosa for the horizontal as well as for the vertical resorption pattern. It can be concluded that transplanted tissues foreign to the oral cavity have no detrimental effect on bone resorption around loaded dental implants and do not endanger their long-term stability. Of all the transplants used, split-thickness skin grafts are least recommended as peri-implant soft tissue.

Implant retained overdentures in mandibular reconstruction: a case report

This case report describes the clinical and laboratory procedures used in the rehabilitation of a patient treated for oral cancer with surgery and radiation therapy. During surgery, a large portion of the mandible was removed and reconstructed with a bone graft. Following therapy, the patient was left with poor esthetics and difficulties with mastication and speech. The goal of prosthodontic treatment was to improve esthetics and restore function. This was successfully achieved through the placement of dental implants and the construction of an implant retained overdenture. A bar was employed to split the implants together and an O-ring system was chosen for retention. The decision to use this type of prosthesis and attachment selection was based on the patient's dental history, esthetic demands, and the need for stress distribution.

Speech, deglutition and life quality after intraoral tumour resection. A prospective study

The aim of the present prospective study was to evaluate the functional sequelae and postoperative development of quality of life after intraoral tumour surgery in 40 consecutive patients with a squamous cell carcinoma of the floor of the mouth. Immediate reconstruction of intraoral soft tissues after tumour resection was accomplished by local flaps (cheek and tongue) (n=27) and by revascularized transfer of small bowel grafts (n=5) and myocutaneous/fasciocutaneous flaps (n=8). Mobility of the tongue was assessed by ultrasound. Quality of speech was analysed using the Freiburg speech intelligibility test. Life quality was assessed by the functional living index-cancer preoperatively and six months postoperatively. A significant decrease in both mobility of the tongue and quality of speech was registered. The most substantial effect on quality of speech resulted from decreased movement of the base and the dorsum of the tongue. A significant increase in life quality at the end of the study period occurred only in the group of patients without substantial reduction of intelligibility of speech, while no significant improvement of postoperative life quality of patients with more severe deterioration of speech quality was found.