CHAPTER 22 MANAGEMENT OF PATIENTS WITH FACIAL DISFIGUREMENT
Many publications have described the various techniques for treating patients with facial disfigurement. This chapter focuses on the need to understand patients with facial disfigurement in order to provide proper rehabilitation. Understanding their fears and needs will help in the proper treatment planning for each particular case.
Patients with tumors in the head and neck region seek treatment because they hope to be free from the disease and go back to their ordinary lives. New medical approaches and treatment modalities can prolong the lives of patients with tumors of the head and neck region and, in some cases, control or even cure the disease. Unfortunately, the surgical removal of tumors in this area can cause severe facial disfigurement that, in a very short time, abducts the bearer of a facial deformity from social life. The people shown in Figure 22-1 had been enjoying life, but suddenly became incapable of doing so due to their disease and tumor resection.
Many patients report that they had no knowledge of and received no information from their doctors regarding the next step after surgical removal of their tumors. The lack of interaction between head and neck surgeons, maxillofacial prosthodontists, and anaplastologists indicates that proper training and communication should be optimized to prevent these patients from having to suffer their disfigurement for many years—in extreme cases, for decades—as has been witnessed at the P-I Brånemark Institute.
Figure 22-2. A, Severe facial disfigurement after surgical tumor resection compromising the prosthetic rehabilitation. B, Compromised socket due to a very thick free flap. There is no depth to host the orbital prosthesis naturally. C, Compromised aesthetics and function due to failure in surgical nasal reconstruction.
In cases of trauma, patients experience almost the same problems and fears as tumor patients as they all came initially from an ordinary social life, but patients with congenital deformities seem to accept the deformity more passively because they were born with it and have had to struggle from the very early stages of their lives. Nevertheless, congenitally disfigured patients should be handled with the same approach used in tumor or trauma cases, respecting the individuality of each patient. It is of utmost importance that health care providers understand and respect patients appropriately, regardless of their socioeconomic and cultural background.
With the invention of osseointegrated implants by Brånemark in the 1970s, many complex intraoral cases that could not be solved adequately by conventional techniques had, for the first time, a very predictable and safe solution. The literature offers many publications that explore the biomechanics of intraoral implants. Not much has been reported in relation to the use of implants in the craniofacial area, though some multicenter studies revealed that extraoral osseointegrated implants can provide predictable and safe long-term treatment success.
For the nonirradiated patient success rates of 94.4%, 96.3%, and 97% have been reported with the flange implant system (Nobel Pharma [Nobel Biocare, Yorba Linda, CA]).1–3 For the irradiated patient the success rate is somewhat lower and has been described between 57.9% and 64%; a later study confirmed these outcomes, reporting a success rate of 62%.4,5
Surgical intervention into irradiated bone may initiate osteoradionecrosis and, to minimize this risk, the possibility of hyperbaric oxygen (HBO) therapy is introduced. The standard protocol (modified Marx protocol)6 for this approach is described as 20 dives in a hyperbaric oxygen chamber (one dive per day, 2.4 ATA for 90 minutes) prior to the surgery, surgery at the 21st day, followed by another 10 dives (one per day) after the surgery.
From the macroscopic biomechanical point of view, a fixture is osseointegrated if there is no progressive relative motion between the fixture and the surrounding living bone and marrow under functional levels and types of loading for the entire life of the patient.7
Until 1977, when the osseointegration concept was applied to extraoral applications by Brånemark and colleagues,8,9 the most common means of retention for facial prosthesis were:
Unfortunately, these techniques have not proved to be retentive because the adhesive properties of the glue may be compromised by perspiration, sometimes causing embarrassing situations due to prosthesis displacement in public. Another disadvantage of adhesive retention is that daily application and removal of adhesives tends to deteriorate the margins of the prosthesis very quickly, reducing its durability and compromising the aesthetics (Figure 22-3). In addition, the skin bed that hosts the prosthesis might be compromised by radiotherapy, making tissue damage more probable.10–13