The lecture discusses the current methods used to fabricate midfacial prostheses for large oral-facial defects. Topics include surgical alterations during resection of tumors in the region that enhance the prosthetic prognosis, methods used when making facial and intraoral impressions, and a discussion of the factors taken into consideration when designing the facial portion and the oral component. The lecture concludes with a detailed discussion of the use of osseointegrated implants used for retention and stability of the oral and facial components including the design of implant connecting bars.

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Maxillofacial Prosthetics – Restoration of Midfacial Defects – Course Transcript

  • 1. Restoration of Midfacial Defects John Beumer III DDS, MS Division of Advanced Prosthodontics UCLA School of Dentistry*The material in this program of instruction is protected by copyright ©. Nopart of this program of instruction may be reproduced, recorded, ortransmitted by any means, electronic,digital, photographic, mechanical, etc.or by any information storage or retrieval system, without prior permission.
  • 2. Tumors leading to large midfacial defects v  Carcinomas arising from the nasal septum v  Sarcomas v  Large basal cell carcinomas
  • 3. Large Midfacial DefectsReconstruction of large midfacialdefects is virtually impossible
  • 4. Large Midfacial DefectsSurgical alterations to enhance the prosthetic prognosis Skin grafts should be used to line v  All raw tissue surfaces v  All potential support surfaces v  All useful undercuts
  • 5. Large Midfacial Defects Skin lined vs non-skin lined defectsa b v Skin lined (a) v  Undercuts can be engaged v  More support v  Better stability v Mucosa lined (b)
  • 6. Large Midfacial DefectsIf the more than half of the upper lip is resected do not attempt to reconstruct itProblemsv Scarring of the reconstructed lip may limit oral accessv The reconstructed upper lip retracts superiorly and is unable to interact effectively with the lower lip to achieve lip seal. Speech and saliva control are thereby rendered ineffectivev The cosmetic result is usually unacceptable
  • 7. Large Midfacial Defects a bIn the previous two patients the non functional reconstructedlip was overlaid with the facial prosthesis. Both speech andthe esthetic result were enhanced. In patient (b) amoustache has been used to camouflage the lip margin.
  • 8. Large Midfacial DefectsPlacement of implants at the time of tumor resectionImplants were placed at the time of tumor ablation. Whenthe surgical site is healed the implants are fullyosseointegrated and can be used to retain, stabilized andsupport the proposed oral – facial prostheses
  • 9. Temporary Midfacial Prosthesesv  Large midfacial defect (a).v  Treatment partial dentures inserted. Note magnetic attachments (b).v  Temporary midfacial prosthesis inserted before patient was discharged from hospital (c).
  • 10. Temporary Midfacial Prosthesesv  Large oral-facial defect.v  Treatment partial denture and complete denture with obturator inserted.v  Temporary midfacial prostheses inserted before patient was discharged from hospital.
  • 11. Temporary Midfacial Prostheses Value v  Speech v  Swallowing v  Esthetics
  • 12. Temporary Midfacial ProsthesisRetention achievedwith by;o  Eyeglasseso  Engaging skin lined areas of the defect
  • 13. Combined nasal – orbital – cheek defectsChallengesv  Size and weight of the prosthesisv  Retention and stability v  Implant necessary in most instancesv  Movable tissues
  • 14. Combined nasal – cheek – orbital Defectsv  Large defect secondary to removal of a recurrent basal cell carcinomav  Implants were placed into all available implant sites
  • 15. Combined nasal – cheek – orbital Defectsv  Large midfacial tumorv  The entire defect was lined with a split thickness skin graftv  For such large defects implants are necessary for retention and several months later implants were placed.
  • 16. Combined nasal – cheek – orbital Defectsa b c de f g h Impression making. a: Patient positioned and draped. Note implant tissue bars (previously fabricated) have been secured. b and c: Thin layer of polysulfide impression material applied. d: Gauze with layer of adhesive for retention of plaster backing. e: First layer of plaster is thin. f: Succeeding layers will support impression material. g: Completed impression. h: Master cast. It is poured in layers to minimize distortion of master cast.
  • 17. Combined nasal – cheek – orbital Defectsa bc a: Tissue bars in position. b: Wax sculpture on patient. c: Acrylic resin substructure housing retentive elements designed to fit within contours of facial prosthesis. Silicone being injected into mold.
  • 18. Combined nasal – cheek – orbital Defects
  • 19. Combined Nasal – Cheek – Orbital Defects Completed implant retained prosthesis. Only implants can retain a prosthesis of this size.
  • 20. Combined oral – facial defects Prognosis v Support, retention and stability for the oral portion v Dentition v Amount of hard palate remaining v Implant sites v Retention and stability for the facial portion v Implant sites
  • 21. Prosthodontic procedures v  Impressions v  Oral portion v  Facial portion v  Records v  Sculpting
  • 22. Records, setting teeth and finishing the sculptingv  Mounted casts of patient with large midfacial defect.v  Wax sculpture of facial prosthesis. Note maxillary anterior teeth exposed to permit articulation with lower lip.
  • 23. a b c a: Large midfacial defect.d Posterior teeth remain bilaterally. b: Two piece RPD. c: One segment engages dentition and residual palatal structures. d: Another portion engages skin lined maxillary sinus and enhances retention.
  • 24. Completed prosthesisOne piece prosthesis of acrylic resin (1968)
  • 25. a b c de f gÑ  A typical midfacial prosthesis. a: Midfacial defect. Lateral walls are skin lined. b: Intraoral portion. Note magnetic attachments. c and d: Intraoral portion inserted. The lateral extensions engage the skin lined areas in the defect. e and f: Intraoral and extraoral prosthesis. f: Both prostheses in position.
  • 26. Margins can be hidden with facial hair
  • 27. Implant retained midfacial defects a b ca: Large combination oral facial defect. b and c: Implantshave been placed in the right maxilla and anterior mandibleto retain and stabilize oral prostheses c. implants in supra-orbital rim help retain the facial portion.
  • 28. Implant retained midfacial defects Completed prosthesis
  • 29. aa: Large midfacial defect in edentulous patient. Two implantshave been placed. Note lateral and superior walls of maxillarysinus lined with skin grafts.a b c db: These areas (arrows) were engaged by the oral prosthesis to providesupport and stability.c: Oral and facial prostheses.d: Tissue bar with magnetic attachments secured. Oral prostheses inposition. Oral prosthesis derives its support and stability from skin linedwalls of maxillary sinuses. Implants used to retain facial portion.
  • 30. Completed Prosthesis
  • 31. Defects with a lateral componentv  Lateral portion reconstructed with a flapv  Midfacial portion best reconstructed with an oral facial prosthesis
  • 32. Large Midfacial DefectsRole of flaps v  Rebuild the lateral portion v  Do not rebuild the upper lip v  Restore the oral defect, the midfacial portion and upper lip with a prosthesis .
  • 33. Implant retainedmidfacial defects
  • 34. v  Visit ffofr.org for hundreds of additional lectures on Complete Dentures, Implant Dentistry, Removable Partial Dentures, Esthetic Dentistry and Maxillofacial Prosthetics.v  The lectures are free and available upon registering for the sitev  Our objective is to create the best and most comprehensive online programs of instruction in Prosthodontics