Midfacial Combined Oral and Facial Defects

Large combination defects of the oral cavity and the external face create a challenge for the patient and the maxillofacial prosthodontist. Many of these patients previously have had numerous minor surgical removals and have had these tumors over a long period of time. In addition, when the integrity of the oral cavity has been compromised, food and air escape during swallowing, speech often is unintelligible, and saliva control is difficult52 (Figures 20-15 and 20-16).

Many facial defects currently are reconstructed with a combination of microvascular free flaps, tissue expanders, and the use of a maxillofacial prosthesis. The microvascular surgeon can incorporate techniques that create concavities that allow a facial prosthesis to maintain as much normal anatomy as possible in replacing the lost orbital contents, nasal structures, or auricular components (Figure 20-17).

Percutaneous osseointegrated implants placed in the superior or lateral orbital rim, inferior base of nasal bones and temporal bone are acceptable treatment modalities.53,54 Even in irradiated tissue beds, properly placed osseoimplants have been shown to be successful in many studies with 5-year follow-up.55 Consideration of tumor prognosis is an important factor in this patient population for selection of osseointegrated implant placement.

In the absence of osseointegrated implants, conventional retention of facial prostheses usually relies on skin adhesives. They are placed daily on the inner surface of the prosthesis and on the skin margins. Currently, silicone materials usually last up to 2 years if maintained properly, and if the skin margins are cleansed daily.

Patients requiring facial prostheses are recalled by the maxillofacial prosthodontist approximately every 6 months. Additional tinting can be applied, and hygiene instructions are reinforced at this time.

Figure 20-15. A, Total rhinectomy and anterior maxillectomy with obturator with magnet retention and cranial osseoimplant Hader Bar. B, Midfacial appliance with magnets and connecting clip bar attachments. C, Midfacial appliance in place.

A duplicate prosthesis is usually fabricated with the same mold so that, if deterioration or color wear occurs, the second prosthesis can be tinted easily for patient satisfaction.

Quality of life issues can be addressed adequately with well-informed patients and their families during and after fabrication of facial prosthe-ses. A comfortable, well-fitting and esthetic facial prosthesis will help restore a patient's self-image and allow them to return to society without loss of dignity.56,57

Figure 20-15. A, Total rhinectomy and anterior maxillectomy with obturator with magnet retention and cranial osseoimplant Hader Bar. B, Midfacial appliance with magnets and connecting clip bar attachments. C, Midfacial appliance in place.

Figure 20-16. A, Combined forehead and myomusculocutaneous flap reconstruction for a large resection of basosquamous cell carcinoma of the face. B, Silicone combined orbital-nasal cheek facial appliance.
Figure 20-17. A, Rectus abdominis free flap reconstruction for squamous cell carcinoma of cheek and nasal cavity. B, Silicone midfacial prosthesis post-microvascular reconstruction.

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