Prosthetic Rehabilitation

Patients with head and neck defects may undergo reconstruction surgically, prosthetically, or with a combined approach. In some situations, prosthetic rehabilitation may be the preferred treatment option. Presurgical treatment planning and evaluation of the patient is paramount to successful reconstruction and rehabilitation. Patient education and assessment of the patient’s expectations are essential in the acceptance of a proposed treatment plan. Communication and joint treatment planning early in the process between the surgeon and maxillofacial prosthodontist will optimize results.

Most patients requiring prosthetic facial rehabilitation have undergone ablative surgery for head and neck cancers. These patients are often best treated by a multidisciplinary approach involving the surgeons performing ablative and reconstructive surgery and the maxillofacial prosthodontist. Presurgical and postsurgical planning should be coordinated by the responsible specialist before proceeding with the surgery. This coordination facilitates a more concerted effort between the various disciplines so that eradication of the disease and postsurgical outcome emerge favorably. Prosthodontics is one of the 9 dental specialties recognized by the American Dental Association. Maxillofacial prosthetics is a subspecialty of prosthodontics dedicated to prosthetic correction and management of maxillofacial defects acquired from tumor ablative surgery, trauma, congenital defects, or alterations of growth and development. The number of practitioners who actively practice this subspecialty is very low; therefore, accessibility may be an issue. Resources available through the American Academy of Maxillofacial Prosthetics and the International Society for Maxillofacial Rehabilitation may be helpful in locating a maxillofacial prosthodontist. Ideally, patients should be referred to the maxillofacial prosthodontist early in the treatment process. This early referral allows time for proper evaluation and consultation in which treatment options and the prosthetic rehabilitation process can be discussed with the patient and family. Other valuable information, such as preoperative photographs and models, may be gathered early in the treatment process.

Surgical and prosthetic reconstruction options

Head and neck defects caused by ablative cancer surgery, trauma, and congenital malformation result in many functional and psychological difficulties for patients and those around them. Surgical reconstruction techniques, prosthetic rehabilitation, or a combination of both to correct facial disfigurement may improve function, self-confidence, and psychological well-being of the patient. The site, size, and cause of the defect, in conjunction with the patient’s age, health, and desires, are used to determine the method of surgical reconstruction and prosthetic rehabilitation. In some cases, prosthetic rehabilitation may be preferred because of the complexity of the reconstructive surgery, anticipated complications from radiation therapy, and the value placed on aesthetics. Surgical reconstruction with flaps taken from sun-exposed skin may result in a mismatch of shape, color, and texture. In these situations, a prosthesis may be the best choice to create symmetry and to blend with the tone and texture of the skin adjacent to the defect. One of the greatest advantages of a prosthesis over surgical reconstruction is the ability to perform periodic surveillance of the surgical site. By using a prosthesis, it is possible to directly visualize recurrent areas that may be apparent from the perioperative period to the third year of follow-up. With surgical reconstruction, the ability to perform surveillance is markedly reduced.

Fabrication of facial prostheses

Facial prostheses are used to replace, cover, and change the appearance of disfigured or missing anatomic structures. In addition, these prostheses may function to support devices such as eyeglasses, warm the incoming air, close an opening, and protect the underlying fragile tissues. Prostheses also play an important role in restoring body image and assisting the reintegration of the patient with the society. However, prostheses have limitations and realistically cannot perfectly restore aesthetics and function. A well-made prosthesis is intended to pass “the grocery store or shopping mall test,” that is, it will allow a person to walk through a public place without attracting attention. It is important for patients and those around them to have realistic expectations. Pictures available on the Internet may have been touched-up or may represent an unusually exceptional outcome. Dramatic results can be achieved in a Hollywood movie in which prostheses and hours of applying makeup are used to create special effects. However, this is not practical for patients in whom the prosthesis requires daily removal, cleaning, and skin care.

Facial prostheses are custom fabricated and most often made of silicone elastomers because of the material’s clinical inertness, strength, durability, and ease of manipulation. Creating a prosthesis is a labor-intensive process requiring many hours of work. The number of appointments vary with the complexity of the defect and the patient’s expectations. The process involves the following steps: (1) making an impression of the affected area, (2) creating a cast or model of the affected area, (3) sculpting a prosthesis out of wax or clay ( Fig. 1 ), (4) creating a mold of the sculpted form, (5) casting the mold in a base material intrinsically colored to match the patient’s overall skin tone ( Fig. 2 ), and (6) extrinsic coloring and characterization to enhance details and create a prosthesis that matches the adjacent skin ( Figs. 3 and 4 ).

Many patients find the impression appointment the most stressful because the impression is made during the early phase of the doctor-patient relationship. In addition, the tissues may still be sensitive from surgery or radiation therapy. Often, the impression covers the eyes or nose and may lead to a claustrophobic feeling for the patient. This problem is best managed by the maxillofacial prosthodontist building a positive and trusted relationship with the patient, explaining the procedure in advance, reassuring the patient that the impression materials are safe, talking to the patient through the process, and allowing adequate time for healing and tissue remodeling before impression making. Adequate healing is important not only for patient comfort but also for ensuring that the impression made in the first step is accurate. An accurate cast of the defect is required to produce a well-fitting prosthesis. In general, prosthesis fabrication begins 6 to 8 weeks after surgery or the completion of radiation therapy. This period is a guideline, and the actual determination of adequate healing is made clinically.

Matching the tone and characteristics of the skin adjacent to the defect can be demanding and complicated by the patient’s exposure to sunlight or a dermatologic condition. Therefore, the patient’s usual complexion should be considered. If the patient has a recent tan, sunburn, or rash, the mix of the base shade and extrinsic coloring should be delayed until these conditions are resolved. Patients should also be encouraged to use a sunblock to avoid these problems and to reduce the risk of premature aging and skin cancer. For patients who have an unusually wide variation in skin tone, such as a summer complexion and a winter complexion, multiple prostheses in differing colors may be fabricated for seasonal use.

Fabrication of facial prostheses

Facial prostheses are used to replace, cover, and change the appearance of disfigured or missing anatomic structures. In addition, these prostheses may function to support devices such as eyeglasses, warm the incoming air, close an opening, and protect the underlying fragile tissues. Prostheses also play an important role in restoring body image and assisting the reintegration of the patient with the society. However, prostheses have limitations and realistically cannot perfectly restore aesthetics and function. A well-made prosthesis is intended to pass “the grocery store or shopping mall test,” that is, it will allow a person to walk through a public place without attracting attention. It is important for patients and those around them to have realistic expectations. Pictures available on the Internet may have been touched-up or may represent an unusually exceptional outcome. Dramatic results can be achieved in a Hollywood movie in which prostheses and hours of applying makeup are used to create special effects. However, this is not practical for patients in whom the prosthesis requires daily removal, cleaning, and skin care.

Facial prostheses are custom fabricated and most often made of silicone elastomers because of the material’s clinical inertness, strength, durability, and ease of manipulation. Creating a prosthesis is a labor-intensive process requiring many hours of work. The number of appointments vary with the complexity of the defect and the patient’s expectations. The process involves the following steps: (1) making an impression of the affected area, (2) creating a cast or model of the affected area, (3) sculpting a prosthesis out of wax or clay ( Fig. 1 ), (4) creating a mold of the sculpted form, (5) casting the mold in a base material intrinsically colored to match the patient’s overall skin tone ( Fig. 2 ), and (6) extrinsic coloring and characterization to enhance details and create a prosthesis that matches the adjacent skin ( Figs. 3 and 4 ).