Clinical team approach to treatment of
post-oncologic surgery patient
P.J. Boyne, J. Nethery, M. Kattadiyil, and W. Campagni
INTRODUCTION
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| Fig. 1 Appearance of facial defect after oncologic surgery. |
Patients having
received total rhinectomy and maxillectomy with a resultant post surgical
defect presenting no superior bony support for a facial and maxillofacial
prosthesis and without a hard palate for palato pharyngeal obturation
are difficult to restore functionally and esthetically. The skin-to-prosthesis
interface is extremely difficult to reproduce esthetically especially
in patients having lesions involving extensive basal cell carcinoma with
previous recurrence and a history of having previously received irradiation
to the face. Additionally in patients with latent or active osteoporosis,
the remaining bony marginal area is difficult to intercept with titanium
implants to support such prosthetic reconstruction. This case will illustrate
the difficult prosthodontic obturation and nasal skin prosthesis reconstruction
in a very fragile patient with a large defect resulting from surgical
excision for recurrent basal cell carcinoma.
CASE REPORT
The patient was referred from her general surgeon in Tucson,
Arizona to Dr. Robert Jamesand Dr. Philip Boyne for the placement of implants
and for surgical and prosthodontic facial reconstruction in April of 1992.
The patient had a large post-surgical defect of the nose and maxilla and
inability to speak intelligibly, to swallow well, and to manage a soft
diet due to the lack of a posterior pharyngeal and palatal obturation.
The 82 year-old female patient was extremely alert, responsive,
attentive, and coherent, despite the fact that she was wearing a loose
temporary obturator which made her speech articulation difficult.
The patient could not speak at all without the temporary
obturator, even though the prosthesis was quite loose and unstable. The
obturator was based on the remaining posterior aspect of the left tuberosity
of the maxilla and lateral posterior nasal wall and was being held anteriorly
by a narrow isthmus of the skin of the vermillion border of the lip.
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| Figure 2: This photo shows the presence of some of the implants. |
The skin margins of the surgical defect appeared to be normal,
with no residual neoplastic disease remaining clinically. The mucosa of
the defect from the lateral aspects of the nasal surgical wall posteriorly
and the velopharyngeal area appeared normal.
The patient had a history of being treated at the age of
13 for acne by radiation of the face. At the age of 20, she noticed some
dermal lesions which were selectively removed surgically at that time.
There were no biopsy reports available from these initial excisions. In
1990, she had a larger lesion removed from the side of the nose which
was diagnosed as basal cell carcinoma. One year later, she had recurrence
of the malignant lesion and had a total rhinectomy and a partial maxillectomy
which included removal of the nasal septum, right maxillary antrum, and
nasal ethmoids bilaterally.
The initial surgical-prosthodontic plan involved placement
of two custom made titanium implants by Dr. James in an antero-lateral
position into the tuberosity of the remaining maxilla and the placement
of an implant in the remaining portion of the nasal bone. Bone grafting
would also be done around the custom made implants which were to be placed
posteriorly in the remaining maxilla. On the portion of the zygomatic
buttress remaining on the right at the junction of the skin and the soft
tissue, root form transcutaneous implants would be placed to support the
prosthesis.
The operation as planned was carried out on August 25, 1992
by Drs. Boyne and James, after which the custom constructed implants were
immediately attached together with an acrylic reinforced bar. This bar
was then attached to an obturator and the patient was placed on a soft
diet to avoid undue stress on the provisionally loaded implants.
Approximately six months post operatively, the patient had
been tolerating the obturator well. Two additional implants, one in the
midline of the existing posterior palatal bone and one in the nasal bone
were placed. Both these areas had been previously grafted in the August,
1992 surgery with demineralized freeze-dried bone. During the surgery,
a nasal strut appliance was placed on the posteriorly based implants and
the implant in the zygomatic buttress of the right side.
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| Figure 3: The implants completed, and the obturator in place. |
In June of 1994 the patient came for a consultation with
Dr. Jaime Lozada, the new director of implant dentistry, and Dr. Boyne,
at which time the nasal portion of the prosthesis was addressed. It was
decided that the bar previously placed required elongation to accommodate
the nasal prosthesis and that the nasal prosthesis could be held with
Hader clips to the bar without the necessity of using the superiorly based
implant in the nasal bone itself. During the previous months the patient
had experienced some loosening of the custom based implants in the posterior
portion of the maxilla.
In November of 1995, an iliac crest bone graft was performed
to obtain additional bone posteriorly in the remaining portion of the
maxillary tuberosity bilaterally as well as in the left maxillary antrum.
The two unstable custom made implants were removed and the area grafted.
There was adequate bone in the right maxillary area at the
junction of the zygomatic buttress with the margins of the defect and
a 3.5mm x 10mm implant was placed in a horizontal orientation in that
area. A 2.8mm x 4mm percutaneous-type custom-made implant was placed in
the lateral nasal wall to obtain stability in that area and a mid-palatal
implant 3.8mm x 10mm was also placed.
The left maxillary vestibule was incised at the attached
mucosal margin, an osteotomy into the maxillary sinus was made, the antral
membrane was elevated and a bone graft was placed in the antral floor
to accommodate implants placed on the left side of the nasal facial maxillary
defect. The antral bone graft was composed of the patient’s autogenous
bone taken from the iliac crest in a 50/50 mix with porous bone mineral.*
The patient’s post-operative course from this surgical
procedure was uneventful and inJanuary of 1996, the patient was seen by
Dr. Nethery and Dr. Lozada for reconstruction of a permanent obturator
and for the placement of additional implants as well as uncovering those
that had been placed in the November 1995 surgery of iliac crest bone
graft.
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| Figure 4: The patient is pleased with the result. |
At this time two implants on the right side and one on the
left posterior extending into the antral floor were placed into the previously
grafted areas. In 1997 the prosthesis was completed with a new obturator
and a nasal prosthesis. The nasal prosthesis was attached to a vertical
T-bar which was attached to the obturator with a functional full maxillary
denture construction. This type of nasal prosthesis eliminated the need
for an implant in the nasal bone superiorly. However the additional bone
graft placed there was maturing and remodeling well so that in the future
an implant could be placed there if necessary in any possible reconstruction
of the prosthesis.
Presently the prosthesis is functioning very well and the
nasal portion of the reconstruction is esthetically satisfying to the
patient.
The obturator and the facial prosthesis received a final adjustment by Dr. Nethery of May 1998. The patient has moved to Florida. She continues to remain in contact with her prosthodontist here at Loma Linda and is doing very well both from the standpoint of a facial prosthesis and the functional maxillary obturator, and denture.
CONCLUSION
This case demonstrates the difficulty in obturation of large
facial reconstructions where the skin itself is involved in the neoplastic
process leaving poor margins for interfacing with the nasal prosthesis
and where underlying bony margins are insufficient for the reception of
osseous implants without extensive bone grafting. The initial placement
of implants using bone graft substitutes resulted in failure of integration
of some of the implants requiring replacement and delaying the total rehabilitation
of the patient. Once adequate bone had been established through autogenous
grafting and the implants placed in a good osseous base, the prosthetic
reconstruction proceeded successfully.
The case illustrates the necessity for a clinical team evaluation
and treatment planning and a multi-disciplinary approach to the total
reconstruction and rehabilitation of these types of post-oncologic surgical
patients.
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*BioOss - Geistlich and Sons, Wolhusen, Switzerland
Philip J. Boyne, DMD, is professor of oral and maxillofacial surgery.
James Nethery, SD’65, assistant professor of educational services,
is clinical director of the Dental Oncology Service.
Mathew Kattadiyil, BDS, MS’99, is assistant professor of restorative
dentistry.
Wayne Campagni, DMD, is professor of restorative dentistry, and director
of the advanced education program in prosthodontics.
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