Dental implantation for restoration of posttraumatic deformities: avulsion injuries.

Soft and hard tissue defects of the cranio- and maxillofacial area, especially after an avulsion injury, are challenging to reconstruct. Sophisticated soft and hard tissue transfer techniques have allowed satisfactory reconstruction of the gross anatomic structure. However, these methods do not allow optimal restoration of fine anatomic detail or function. The advent of dental implants and modified dental implants for craniofacial applications has allowed maximization of cosmetic and functional restoration. Prosthodontists are capable of fabricating subunits of the cranio- and maxillofacial area with fine detail, reproducing the coloring, texture, and idiosyncrasies of a patient's native skin. Dental implant technology has allowed these prostheses to be bone anchored, yielding a reproducible and stable attachment. This method of attachment in turn allows flexibility in the design of the prosthesis, to maximize restoration, and imparts an increased sense of confidence to the patient. Illustrated are six examples demonstrating the versatility of dental implants in the reconstruction of avulsion injuries of the cranio- and maxillofacial complex.

Do palatal lift prostheses stimulate velopharyngeal neuromuscular activity?

The purpose of this investigation was to evaluate the ability of palatal lift prostheses to stimulate the neuromuscular activity of the velopharynx. Nasendoscopic evaluations were audio-videotaped preprosthetic and postprosthetic management for 25 patients who underwent placement of a palatal lift prosthesis for velopharyngeal dysfunction (VPD). These audio-videotapes were presented in blinded fashion and random order to three speech pathologists experienced in assessment of patients with VPD. They rated the tapes on the following parameters: VP gap size, closure pattern, orifice estimate, direction and magnitude of change, and qualitative descriptions of the adequacy of VP closure during speech. VP closure for speech was unchanged in 69% of patients and the number of patients rated as improved or deteriorated was nearly identical at about 15%. Postintervention gap shape remained unchanged in 70% of patients. The extent of VP orifice closure during speech remained unchanged in 57% of patients. Articulations that could impair VP function improved in 30% of patients, deteriorating in only 4%. Results of this study neither support the concept that palatal lift prostheses alter the neuromuscular patterning of the velopharynx, nor provide objective documentation of the feasibility of prosthetic reduction for weaning.

Management of the hypodynamic velopharynx.

Velopharyngeal dysfunction (VPD) resulting from an adynamic or hypodynamic velopharynx is an unusual pathology that poses vexing management problems for the Cleft Palate team. Correction of VPD has the potential for airway compromise. Endoscopically, this pathology is recognized by a large velopharyngeal (VP) gap size, which demonstrates little or no dynamic activity of the posterior or lateral pharyngeal walls nor of the velum in response to speech tasks or connected speech. Because of a paucity of literature defining the entity, a retrospective review of 175 patients who were treated for VPD at our center was undertaken. Analysis of management failures revealed an unexpected concentration of patients with hypodynamic or paretic VP mechanisms as documented by nasendoscopic assessments. A subpopulation of 41 (23%) patients with this characteristic was studied to define the patients at risk, to determine etiologic factors, and to critique intervention outcome among various surgical and nonsurgical managements. Results showed that the phenomenon of VP hypodynamism occurred more frequently in patients with submucous cleft palate (p = .014) and with VPD in association with malformation syndromes (p = .009) than in patients in other diagnostic categories. Conversely, VPD not associated with clefting occurred with greater frequency in the nonhypodynamic group than in the hypodynamic group (p = .002). Composite (surgical and prosthetic) primary management failure occurred in 42%. Between one and three procedures were necessary to achieve an acceptable speech result. We present a management algorithm and provide data regarding realistic expectations for various treatment outcomes in patients with this complex disorder, which have not, to date, been previously described.

Immediate mandibular reconstruction and placement of dental implants. At the time of ablative surgery.

The outcomes of surgical reconstruction for patients who have undergone extensive tumor resection of the mandible and associated soft tissue have been less than desirable for many reasons: lack of cancer cure, radiation problems, as well as inadequate functional reconstructive results. These patients traditionally have undergone multiple surgical procedures for restoration of the surgical deformity. With the advent of new donor sites and successful transfer of microvascular hard and soft tissue, one can restore the largest defects created during cancer excision. Combining these techniques with biocompatible dental implants and reconstructive bone plates, technology has advanced to the point of predictable outcomes. The restoration of appearance, mandibular function, and mastication is mandated by patients. Dental implants are now placed in vascularized bone reconstruction of the mandible immediately at the time of ablative surgery. This obviates the need for additional surgical reconstructive procedures, adjunctive hyperbaric oxygen therapy, and problems associated with the placement of dental implants in irradiated tissue.

Fibular and iliac crest osteomuscular free flap reconstruction of the oral cavity.

A method for reconstruction of oral cavity soft tissues using segmentally or axially supplied free muscle flaps harvested as a unit with their bone components is presented. Both fibular/soleus and iliac crest/internal oblique free flaps are documented, and the pros and cons of each donor site are presented. Twenty-one patients, 17 with cancer or osteoradionecrosis and 4 with benign or congenital conditions of the mandible, have undergone this operation. Ten bone grafts were simultaneously embedded with osseointegrated implants. All free flaps except one survived and resulted in a smoothly mucosalized oral lining. Six patients have had their implants successfully uncovered, all of whom are wearing prostheses. Four other patients are using tissue-borne prostheses. Transfer of free, nonbulky muscle flaps for mucosalized oral soft-tissue reconstruction is feasible in selected patients using first the fibular and, second, the iliac donor site; this soft-tissue technique also contributes to prosthetic dental rehabilitation.

Prostheses for oral burn patients.

The problems caused by scarring from burns to the tissues that surround the oral cavity were discussed. Seven types of stents used to prevent microstomia from burns were reviewed.

A simplified method of treating septal defects.

A simple method to make silicone obturators for nasal septal perforations is presented. The simplicity of the technique and the acceptance by the patient make it a useful treatment modality in a maxillofacial prosthetics practice.

Applying basic prosthodontic principles in the dentulous maxillectomy patient.

The formulation of a design for a removable partial denture framework must be approached in a logical, organized fashion, whether the framework is conventional or designed to support an obturator. The number of abutment teeth, their relationship to one another and to the other teeth in each arch, the location of the fulcrum line if unilateral or bilateral extensions are to be used, the need for direct and indirect retention, and the quality and quantity of the support for the extension bases must all be considered. The occlusal scheme and esthetics should also be considered. Once the design is formulated, careful preparation of the mouth, good impressions, proper fitting of the framework, a good altered cast impression when necessary, careful adjustments at insertion, and patient instructions concerning care and maintenance of the prosthesis will increase the chances of success. All the basic principles must be considered and applied to the unique requirements of the maxillectomy patient.

A method for obtaining the reverse image of an ear.

A method was described in which the morphology of a patient's remaining ear and its spatial relationship were duplicated on the contralateral side. The technique used parallel lines transferred to casts, a vertical camera capable of making reproductions of three-dimensional objects, and tracing paper.

An evaluation of the cure of acrylic resin by three methods.

An investigation was designed and carried out to compare methyl acrylic resin processed by three methods--boiling, in the heat platen press, and a 9 hour, 75 degrees C cure. The material was cured in certain thicknesses in the heat platen press and by boiling without porosity. All samples cured for 9 hours at 75 degrees C had no porosity. The value of the heat platen press as a time-saving device and its applications in a maxillofacial laboratory were discussed.

Intraoral adenoid cystic carcinoma.

A case report of adenoid cytic carcinoma of the palate is presented. The clinical manifestations, diagnostic criteria, surgical resection, and prosthetic reconstruction of the patient are discussed.

Application of various removable partial denture design concepts to a maxillary obturator prosthesis.

A patient with a relatively minor yet common acquired maxillary defect was provided with three obturators of differing design. His subjective evaluations and the relative merits of the designs were discussed.