Oral Rehabilitation Flashcards
What are some of the challenges of oral rehabilitation in head and neck cancer patients?
- Psychological issues- anxiety and depression
- Disfiguration
- Issues eating
- Issues speaking
- 50% don’t return to work
- Expensive to treat
What may be done in the dental assessment phase prior to starting cancer treatment?
- Plan extraction of teeth (strategic- keep key teeth)
- Reduce tori
- Instigate prevention- 5000ppmF toothpaste, diet modification, jaw exercises, perio therapy
- Impressions/scans
- Photographs
- Planning software- implants
What are the side effects of radiotherapy and surgery?
- Taste changes
- Xerostomia- caries
- Structural changes in teeth- changes in pulp space, difficulty with RCT
- Mucositis
- ORN
- Trismus
- Soft tissue changes
- PDL changes
What are the epidemiological features of ORN?
- Seen in patients as low as 30gy
- Incidence 5%
- Seen in tonsillar and retromolar region in patients with OPC
- Mandible is most affected- often precipitated by extraction
What can be done to provide patient with aesthetic and functional outcome without extraction?
Decorate tooth- add precision attachment
-> Denture fits well
What may implants be placed into?
remaining bone
vascularised bone grafts
What is the issue with soft tissue post resection?
- Free flaps are from areas outwith mouth (mobile, NK)
- Can lead to florid tissues
What are the different ways overdentures can be retained on implants?
Ball abutments
Bars
magnets
What are the ADV/DIS of implant retained overdentures?
ADV- Restore multiple teeth, easy to clean, easy to take in and out, improves retention
DIS- not splinted, removable
What are we looking for when doing maintenance appointment for people receiving cancer treated?
- Look for BOP
- Discomfort
- Bone levels- clinically, radiographically, on loading
What are co-axis implant bodies and their function?
Threaded implant that can have different fixture angulation (12, 24, 36)
- Utilise existing bone to maintain restorative platform at angle ensuring optimal aesthetic outcome
- Good for preventing trismus
What are the considerations when determining how to rehabilitate a maxillary defect?
- Dentate?
- Large or small
- Split thickness grafts
- Load bearing tissues
- Denture wearing
What are the functions of obturators?
- Separate mouth from nose
- Improve speech and eating
- Restore palatal contour
- Replace dentition
- Provide retention, stability and support for complete denture
What surgical enhancements can be done as part of Oral rehabilitation?
- Skin graft- keratinised tissue
- Access to defect- removal of turbinates
- Salvaging premaxillary segment
- Soft palate resection and velopharyngeal function
- Retention of key teeth
- Use of palatal mucosa
- Implant placement
What are the different obturators used in head and neck cancer patient;s journey?
Surgical obturator- fitted at time of surgery (screwed in)
-> Close wound and help patient leave hospital
-> Cover plate
Interim- has teeth, helps eat and speak in post operative and healing periods
Definitive obturator- precision retained denture
-> Aim to achieve peripheral seal
What is a glossectomy?
Tongue resection
What can be done in dentures when there is an issue with swallowing due to glossectomy?
Augment palatal aspect
- Acrylic on polished surface so that tongue can contact denture and help initiate first phase of swallow
What are the advantages of primary dental implants?
Quicker restoration
Good evidence for nasal/orbital protheses
Psychological help
Good if obturator likely to be compromised
Get out of hospital quicker- return to normal life
What are the disadvantage of primary dental implants?
May place in poor location due to scarring and healing
May have to wait for healing to get more bone volume
Implant survival and usefulness is improved by delayed placement in resected mandibles
Need patient to be present in surgery to make stents
What flap is used for zygomatic implant?
Zip
What should be assessed when planning for implants when carrying out oral rehabilitation?
- Assess motivation
- Assess how viable rehab will be without implants (consider use of 3D planning and surgical guide production)
- Compliance with attendance and co-morbidities
- Make suggestions of treatment
What can be done to help with the provisional when significant resection is required?
Use software to mirror defect side with non-defect side
-> 3D print a guide
What are the stages of ‘Jaw in a Day’
- Plan case
- Implants are placed into fibula
- This is attached
- Put provisional abutments on
- Patient wakes up rehabbed
- Converted into definitive prothesis
What are the different methods in digital driven jaw reconstruction?
- Navigation and robotics
- Planned functional reconstruction- fully guided and occlusion based
- Guided anatomical reconstruction
- Planned anatomical reconstruction- digitally planned but unguided
- Anatomical reconstruction- intra-operative intuitive surgery
Shape of bone should be based on where tooth should be rather than symmetry for jaw reconstruction from aesthetic profile point of view
Recommend surgical guides similar to fibula
What are the challenges with microvascular construction?
- Time
- Difficult surgical design
- Anatomical issues- tumour itself
- Implant positions
- Soft tissue
What would be the best practice in placing implants for oral rehab in cancer patients? (opposite of most current practice)
- Plan implant position
- Plan implants
- Put microvascular reconstruction in that position
Previously took 6 years to rehab now 2 years
Cheaper and quicker for patients
What may oral rehab for patients in future look like?
- Same day rehab without compromise of quality of success
- Secondary- navigated surgery with innovative implant placement to reduce surgical morbidity
** Issues with keratinised tissue grafts, time, hygiene costs
