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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 32-39

Functional and quality-of-life outcomes following maxillofacial prosthetic rehabilitation: A review of the current literature


Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia

Date of Submission11-Feb-2021
Date of Acceptance14-Feb-2021
Date of Web Publication29-Mar-2021

Correspondence Address:
Dr. Hanan N Al-Otaibi
Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, PO Box 270191, Riyadh.
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJO.INJO_10_21

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  Abstract 

Head and neck cancer patients are usually treated with surgical resection of the cancerous tissue, radiotherapy, and/or chemotherapy. This review summarizes the existing literature on head and neck cancer patients’ functional and quality-of-life outcomes following maxillofacial prosthetic rehabilitation. Prosthetic rehabilitation could be required as part of their treatment, or these patients may receive it later. Furthermore, the patients who have undergone prosthetic rehabilitation have demonstrated an improved quality of life, especially concerning the functional outcomes.

Keywords: Obturator, oral cancer, prosthetic rehabilitation, quality-of-life, surgical resection


How to cite this article:
Al-Otaibi HN. Functional and quality-of-life outcomes following maxillofacial prosthetic rehabilitation: A review of the current literature. Int J Oral Care Res 2021;9:32-9

How to cite this URL:
Al-Otaibi HN. Functional and quality-of-life outcomes following maxillofacial prosthetic rehabilitation: A review of the current literature. Int J Oral Care Res [serial online] 2021 [cited 2021 Apr 13];9:32-9. Available from: https://www.ijocr.org/text.asp?2021/9/1/32/312532




  Introduction Top


Head and neck cancer patients may be treated with different treatment modalities, such as primary chemoradiation therapy or primary surgical resection of the cancerous tissue and/or adjunctive radiotherapy or chemoradiation therapy. Improvements in cancer treatment over the last few decades have led to improvements in patients’ prognosis and a higher survival rate. Still, the effects on patient quality of life remain profound. The Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute recorded a 5-year survival rate of 64% during the period from 2006 to 2012 for oral cavity and pharyngeal cancer patients.[1] Treatment for head and neck cancer may affect patients’ jaws, tongue, throat, salivary glands, and/or the sensory parts of the head and neck. Following surgical resection of the cancerous tissues, patients may deal with subsequent functional problems, which may affect their speech, mastication, swallowing, and complications such as masticatory dysfunction, dysphagia, and dysarthria.[2],[3],[4],[5],[6]

Furthermore, the surgical resection procedure may lead to changes in the patients’ facial appearance and psychosocial function and may also affect their careers, which negatively affect their quality of life. Some functional problems may improve after maxillofacial-prosthodontics rehabilitation. However, some patients may need an intervention by a maxillofacial prosthodontist as part of their jaw rehabilitation during the microvascular reconstruction of the osseous structures of their oral cavity.[2],[3],[4]


  Functional Outcomes Related to Head and Neck Cancer Top


Quality of life

Patient quality of life is defined as their ability to independently conduct daily activities or be defined as a patient sense of well-being concerning different aspects of their life.[7],[8] The World Health Organization defines the quality of life as “an individual’s perception of his or her position in life in the context of the culture and value systems in which the patient lives to his or her goals, expectations, standards, and concerns.”[9] While the health-related quality of life is focussed on the impact of health status on their overall quality of life, it is a multi-dimensional concept with physical, mental, emotional, and social-functioning aspects.[10]

Head and neck cancer treatment may affect more than the patient’s quality of life; it may lead to dysfunction in speech, swallowing, facial disfigurements, or sensory impairments and chronic pain. Previous studies in the literature have evaluated the quality of life of head and neck cancer patients and identified patients complaining from high levels of emotional distress, disturbed body image, physical limitation, and impaired social relationships.[4],[11-13]

Patients’ perceptions of outcomes and satisfaction after reconstruction of cancer-related defect have been evaluated in several studies. Additionally, radiation-induced late toxicity significantly impacts patients’ health-related quality of life, especially swallowing and xerostomia.[14] Hagio et al.[15] evaluated the oral health-related quality of life (OHRQoL) for 50 patients who received maxillofacial prosthetic treatment after surgical repair of the defected maxilla, mandible, oral floor, and tongue. They reported progress in the OHRQoL after prosthetic treatment and improvement in the masticatory, swallowing, and articulatory functions. Similarly, Dholam et al.[16] also reported an overall improvement in head and neck cancer patients’ quality of life following prosthetic rehabilitation.

Xerostomia

Xerostomia or dry mouth can affect head and neck cancer patients due to surgical removal of the salivary gland or as a complication of radiotherapy.[17] Dzioba et al.[18] reported that the radiation therapy used during head and neck cancer treatment negatively affected dry mouth scores over time. Xerostomia can affect patients’ normal oral functions because of insufficient wetting and reduced lubrication of the oral mucosa and ingested food. Additionally, the oral mucosa will be dry and atrophic, causing recurrent ulceration and injury.[19],[20] Radiation-induced xerostomia can further increase the risk of dental caries. It is recommended that patients receive high concentrations of neutral fluoride during the radiation treatment and continue with fluoride application after radiation therapy throughout their life.[21],[22]

Speech

Speech is strongly affected after surgical resection of patients’ tongue, alveolar ridge, hard palate or soft palate, and also following radiotherapy.[23],[24] Symptoms such as dry mouth and mucositis will result in difficulty for the patient to articulate speech rapidly.[25] Evaluation of speech outcomes can be done with three objective clinical measurements: the quality of the resultant speech in general, the social impact of the speech disorder on the listener, and the palatopharyngeal system’s physiologic function. The most common measurements are the perceptual evaluation of speech intelligibility by an unfamiliar listener, acoustic assessment of the patient’s resonance balance (oral versus nasal speech), and determination of palatopharyngeal orifice opening by aeromechanical evaluation of the patient’s generation of nasal flow and oral and nasal pressure during the speech.[23],[24]

Trismus

Head and neck cancer patients may complain of trismus, which refers to the limited ability to open the mouth (< 35 mm).[26] Trismus can occur as a complication of surgery in the temporomandibular joint (TMJ) area, tumors infiltrating the muscles of mastication and their nerves, or due to tissue fibrosis after radiotherapy which affects the masticatory muscles and the ligaments around the TMJ.[27],[28] Trismus can make prosthetic rehabilitation difficult in affected patients. It also complicates many aspects of the patient’s life, including difficulty in eating, speaking, and maintaining good oral hygiene. Many studies have also reported that trismus significantly impacts patient HRQOL.[29],[30],[31],[32]

Swallowing

Dysphagia is related to tissue fibrosis and masticatory dysfunction due to loss of tongue mobility, teeth extraction, resected mandible, or scarring of the labial mucosa and can also occur due to radiotherapy.[33],[34] Disorders in the normal swallowing mechanism can cause silent aspiration, deep penetration, and a more significant than usual residue after swallowing and/or reflux. Problems with swallowing can also lead to recurrent aspiration pneumonia and feeding tube dependency.[35],[36],[37]


  Maxillofacial Prosthodontic Rehabilitation Top


Head and neck cancer patients may need maxillofacial prosthodontic rehabilitation as part of their rehabilitation process to improve their functional outcomes after cancer treatment. Extraoral or intraoral prostheses may be used to improve the functional problems commonly encountered in cancer patients after surgical resection, such as facial prosthesis, obturator, palatal left prosthesis, palatal augmentation prosthesis (PAP), lingual augmentation prosthesis (LAP), and/or a mandibular tongue prosthesis.

Facial prosthesis

The facial defects that occur secondary to cancer resection or trauma can lead to functional deficits and enormous psychological strain that requires rehabilitation. These patients commonly try to avoid meeting people due to limitations in communication and social interaction, and they have more negative personality characteristics than other patients.[38]

Facial prostheses can improve the overall aesthetics and may also enhance the function of patients who have lost an eye, nose, ear, or part of the face.[39] Newton et al[40] reported that a facial prosthesis helps patients in their process of adjustment to the loss of part of their face. Prosthetic rehabilitation can be used as an alternative to surgical intervention. It can improve patients’ self-esteem with facial disfigurement, increase the level of function, and help them resocialize. The patients’ level of satisfaction with facial prosthesis directly affects their social integration level.[41],[42],[43]

The standard material that has been used for a facial prosthesis is silicon elastomer due to its strength, durability, flexibility, chemical inertness, and ease of handling. It can also be matched and blended more easily to the patient’s face by adding pigments and hair. The thin edges become transparent and enhance the blending and camouflage with the patient’s face; however, this material demonstrates changes over time.[44],[45],[46],[47] Markt and Lemon[48] recorded a high level of satisfaction in 76 patients who received extraoral maxillofacial prosthesis. The patients reported wishing that the prosthesis would last longer with improvements in color stability and its retentive mechanism. Brandão et al.[49] evaluated the long-term duration of the facial prosthesis. They found that color alterations of the prosthesis were the most common reason cited for obtaining a new prosthesis (27.4%). A decline in patient dissatisfaction with the facial prosthesis over an increased duration of use has also been reported.[43]

Several techniques have been reported in the literature to retain the facial prosthesis, including engaging hard or soft tissue undercuts, eye-glasses, skin adhesives, or attachment to osseo-integrated craniofacial implants.[50],[51] Chang et al.[41] compared the patients’ perception of treatment between two groups of patients who received facial prosthesis to restore their facial defect: the first group was restored with adhesive-retained prostheses, whereas the second one was restored with implant-retained prostheses. They reported a highly significant level of retention and ease of use related to implant-retained facial prostheses during daily activity, which resulted in greater use of the prosthesis. Wondergem et al.[52] also recorded higher satisfaction levels for patients who received implant-retained facial prostheses (e.g., ear, nose, or orbit) compared with adhesive-retained prostheses. It was noted that some patients might develop skin reactions to the medical skin adhesives used to retain facial prosthesis. A skin-prep protective dressing can be used as a waterproof barrier that is non-irritating and can protect the skin from the adhesive, trauma, and abrasion. Kiat-amnuay et al.[53] reported that the application of the dressing before attaching the maxillofacial prosthesis could increase the retention strength of the used adhesive.

However, an orbital defect cannot be easily restored with surgical reconstruction, unlike other areas of the face. Patient rehabilitation with orbital prostheses can restore the patient’s appearance after surgical resection. de Oliveira et al.[42] evaluated the quality of life of 45 patients who received orbital implant-retained prostheses. They concluded that extraoral prostheses with the bone anchorage technique could provide a high patient satisfaction level.

Obturators

Reconstructions of maxillary defects range from obturators, vascularized grafts, local flaps, regional flaps, and microvascular free flap transfer.[54],[55] Surgical reconstruction of the defects depends on several factors, such as defect size, patient age, and medical history.[56],[57] It also requires exceptional technical expertise associated with longer procedure times and increased risk of donor site morbidity.[58],[59] Surgical reconstruction can provide patients with complete correction of oronasal communication; however, with an obturator, the patient can have immediate and adequate dental rehabilitation in a shorter period. Moreover, a prosthetic obturator can offer easy inspection of the surgical site to detect any cancer recurrence.[60]

Prosthetic rehabilitation can restore the separation between the sinonasal and oral cavities, restoring the contour and the form of the defect area, leading to the restoration of speech and swallowing of the affected patient to a functional level.[61] The rehabilitation can be either provisional or definitive.[59],[62] The appliances for rehabilitation can be constructed with different materials, such as silicon, titanium, and poly-methyl-methacrylate.[63] Therefore, the obturator can improve the patient’s functional outcomes.[64] Its retention depends on multiple factors such as defect size, remaining dentition, attachment to dental implants, the available tissue retention around the defect, and the development of muscular control.[65],[66],[67] It is hard to produce acceptable obturators for cases related to large defects, due to the potential inclusion of the facial skin or orbital contents and the lack of manual dexterity, visual deficiency, or trismus that may produce difficulty in obturator manipulation.[58]

Maxillary obturator

Usually, patients with resected osseous or soft tissue structures of the maxilla have oronasal communication that affects their speech, swallowing, and mastication, resulting in low speech intelligibility with a high incidence of hypernasality and food and liquid escaping through the nasal cavity.[61] This type of defect needs to be restored to separate the oral and nasal cavities to improve the patients’ functional outcomes. A maxillary defect can be restored either by surgical reconstruction of the defect or by using a maxillary obturator to fill the space of the resected osseous and soft tissues, which will restore speech intelligibility and reduce hypernasality.[68],[69],[70],[71],[72]

Obturator prostheses have been found to improve the patients’ quality of life with maxillary defects.[73] Maxillary obturators can be immediate, provisional, or definitive; all types are important in speech rehabilitation.[58],[70] The immediate or surgical obturator can provide a matrix for surgical packing; by covering the wound after resection, it will reduce the risk of oral contamination and will allow the patient to achieve adequate speech and swallowing immediately after the surgery. This generally improves the patients’ psychological state immediately. It has been reported that patients who have a more alveolar process and teeth will achieve better functional outcomes with a maxillary obturator. Clear acrylic has been recommended for the surgical obturator material to allow visibility of the underlying tissues at the time of insertion and later during the healing period.[61] A surgical obturator with the surgical packing material can be removed approximately 10 days after surgery and replaced with a provisional obturator. The provisional obturator can serve the patient until the healing process is completed after 3–4 months or maybe extended after radiation therapy, then, the definitive one can be fabricated.[61]

Rieger et al.24] compared the speech outcomes of 12 patients who underwent partial maxillectomy procedures and were evaluated at three different intervals: before surgical resection and after resection with and without the obturator. They found a significant difference between speech without the obturator and the preoperative result. In contrast, no significant differences between the preoperative speech and postoperative speech with the obturator were observed.

Using the maxillary obturator to restore maxillary defects has a high positive correlation with patients’ oral health quality of life and can provide them with satisfactory function.[74] It has also been reported that instrumental speech evaluation for patients with a maxillary obturator appears to be illuminating not only for speech outcomes but also for patient satisfaction levels.[23]

Rieger et al.[68] compared patients who received maxillary obturators to restore their maxillary defect and patients who underwent maxillary surgical reconstruction with fibular free flaps in terms of facial attractiveness and speech. They found no differences between the groups regarding these parameters.

However, Genden et al.[75] reported higher satisfaction scores in speech, comfort, convenience, and social interactions for patients who underwent surgical reconstruction for their hard palate defects with radial forearm flaps when compared with patients who just received a prosthetic obturator. Some patients were unsatisfied with their maxillary obturator and found it inconvenient and uncomfortable to wear. It requires removal and cleaning and sometimes needs adhesive to maintain its place. Also, patients need to wear it whenever they want to drink or speak. If the obturator fails to produce its objective, the patient may suffer from nasal leakage, hypernasality, and liquids’ reflux into the nasal cavity.[75],[76],[77]

Pharyngeal obturator

The separation between the oropharynx and nasopharynx is vital for patient speech and swallowing. The soft palate is an essential element of the velopharyngeal mechanism. Defects in the soft palate affect the patient’s quality of life and need to be reconstructed.[40],[78] Prosthetic reconstruction can be successful for small-sized defects, while the residual velopharyngeal complex movement is preserved.[79] Patients with no movement of the residual velopharyngeal complex will suffer from an inability to control nasal emissions.[61]

A pharyngeal obturator, also known as a speech aid prosthesis or speech bulb prosthesis, can be used to gain more control over the nasal emissions during speech and eliminate the nasal leakage during swallowing. Similar to a maxillary obturator, the patient can be provided with an immediate, provisional, and definitive pharyngeal obturator. It is difficult to restore function with the prosthesis when more than half of the soft palate is missing.[61],[80]

Surgical reconstruction of the palate with defects with radial forearm free flaps has been accomplished. Seikaly et al.[81] evaluated 52 patients who underwent surgical reconstruction of the soft palate via different techniques (e.g., primary closure, pharyngeal flap, radial forearm free flap). The surgery provided patients with oropharyngeal and nasopharyngeal separation while maintaining nasal patency to restore normal intelligibility and resonance speech. Majority of the patients (91%) also had their swallowing function restored, returning to their regular oral diet.

Palatal lift prosthesis (PLP)

PLP can be used for palatopharyngeal incompetency patients (defined as adequate dimensions of the soft palate but still failing to close) to improve their speech problems.[61] This intraoral prosthesis fits the patient’s maxillary arch and lifts the soft palate.[82] Therefore, it displaces the soft palate to the level of normal palatal closure, allowing oronasal separation in patients with defects in the soft palate due to cancer, neurodegenerative disease, or stroke.[82] It improves patients’ functional results by reducing hypernasal speech and the nasopharyngeal reflux caused by velopharyngeal incompetency. It further enhances the patient’s swallowing by eliminating the functional blockage at the oropharyngeal isthmus, which facilitates food bolus transport from the oral cavity to the pharynx.[82]

Palatal augmentation prosthesis

PAP can be fabricated after partial or complete tongue resection as part of patients’ deglutitory and articulatory rehabilitation. The patients’ speech and swallowing are significantly changed after surgical resection of cancerous tissue from their tongues. This impairment is mainly due to the inability of the tongue to touch the hard palate, teeth, and alveolar ridge. Therefore, this maxillary intraoral prosthesis can fit the patient’s hard palate to reduce the free space between the roof and the floor of the oral cavity. This re-establishes the palatal vault at the lower level, which will lead to improvements in the palatolingual contact during articulation and deglutition. This improves deglutition by enhancing the oral to pharynx bolus transportation and basal tongue pressure.[78],[83]

Lingual augmentation prosthesis

LAP is a type of mandibular intraoral prosthesis used to improve swallowing after tongue resection. It can be fabricated for patients who have dysphagia symptoms, such as difficulty in food transportation and collection of bolus residue after swallowing on the floor of their mouth. It also serves patients who have difficulty in anterior tongue movement and with difficulties in touching the anterior teeth’ lingual surface.[84] PAP and LAP can be used together to improve the patient’s swallowing function by reducing the gap in the superoinferior and anterior directions.[83]

Mandibular tongue prosthesis

The tongue plays an essential role in multiple vital functions, such as swallowing, speech, and mastication.[85] However, following partial glossectomy or total glossectomy procedures, these functions may be compromised, leading to psychosocial challenges.[85],[86] These patients can receive surgical reconstruction or prosthetic rehabilitation treatments for their defects. Mandibular tongue prostheses are one of the treatment options for patients who have undergone total glossectomy. It is an intraoral prosthesis that can fit the mandibular arch, replacing the tongue.[85],[87],[88] It is not preferred in patients who have undergone partial glossectomy or patients with irradiated and resorbed mandibular jaws; palatal maxillary prosthesis is considered a superior treatment option for these individuals.[89] A palatal maxillary prosthesis can provide more stability; however, it will affect the resonance and swallowing when large.[90]

A patient with a mandibular tongue prosthesis will produce intelligible sounds and can consume a regular diet with better food bolus management.[85] Generally, the outcomes reported from prosthetic rehabilitation using tongue prostheses will lead to the recovery of affected patients’ psychological status with an improved quality of life.[86]

Following surgical resection of larger portion of the tongue, a musculocutaneous microvascular free flap is used for surgical reconstruction to restore the patients’ functional outcomes and their quality of life.[18] Several previous studies have evaluated patients’ swallowing ability and tongue mobility after surgical tongue resection and reconstruction. Swallowing impairments have been reported in patients who underwent changes in their tongues’ structural anatomy.[91],[92],[93] Hara et al.[92] evaluated 23 patients who underwent surgical tongue resection and reconstruction with radial forearm free flaps and lateral upper arm free flaps. They found decreased tongue mobility (except for the tongue tip) for all patients, with a more significant mobility decrease in patients who underwent anterior or posterior tongue resection than patients with medial tongue resection. They further reported a significant negative impact on swallowing caused by poor tongue control in patients who underwent anterior resection of the oral cavity.

Brown et al.[6] also evaluated the swallowing and tongue mobility in 15 patients who underwent resection of the anterior two-thirds of their tongues and were reconstructed with radial forearm free flaps. The patients were evaluated at four different time intervals over 1 year. They reported no evident problems in patients’ swallowing or tongue mobility, even 1 year after surgery.

Prosthetic rehabilitation followed by free flap reconstruction

Microvascular free fibular flap reconstruction of defects in the maxilla or mandibular jaws with prosthetic rehabilitation achieves successful re-establishment of functions related to the osseous structures of the oral cavity. Dental implants can be inserted at the time of the surgical jaw reconstruction, reducing the time needed for dental rehabilitation.[94] Gbara et al.[95] evaluated the long-term results of 30 patients who underwent maxillary and mandibular jaw reconstruction with microsurgical fibular grafts combined with dental implants. The authors reported that the procedure led to satisfactory functional and aesthetic results.

Kumar et al.[96] evaluated the implant- and peri-implant-related outcomes for implants supporting dental prostheses following mandibular reconstruction with free fibular flaps. They reported more marginal bone loss associated with two implants supporting overdentures when compared with four implants supporting overdentures. However, outcomes were within the acceptable limits of success criteria, and no clinically significant differences were observed between the two groups for peri-implant soft and hard tissue factors. Digitally planned surgical design and simulation for fibular free flap reconstruction have been used during jaw reconstruction. They are reportedly associated with better speech outcomes than standard surgical reconstruction or maxillary obturators.[97]

Implant-retained prostheses that restore intraoral defects after surgical tumor resection have a beneficial effect on masticatory performance and masseter muscle activity on the reconstruction side. When comparing implant-retained prostheses with a non-implant-retained prosthesis, a significantly greater level of improvement in the prosthesis function and patient satisfaction has been observed.[98]

The healthcare providers’ psychological attitudes toward their patients are directly related to the patients’ reported satisfaction, especially with onco-surgical facial lesions when no suppressive or repulsive feelings are expressed. Therefore, healthcare providers should not be focussed only on the clinical part of patient treatment, but also assess the patient’s quality of life issues to provide more outstanding patient care and satisfaction.[99],[100]


  Conclusion Top


Patients may suffer from functional problems with head and neck cancer and various treatment modalities are available to cure them. The maxillofacial prosthetic rehabilitation approach can improve functional outcomes related to head and neck cancer patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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