Introduction

The cosmetic, functional, and psychosocial results of oral cancer treatment may combine to produce devastating effects on patients, especially if the tumor is extensive or the treatment particularly aggressive. Indeed, oral cancer is noted for the toll it exacts from patients, from both the disease itself and the effects of its treatment. A variety of functions can be affected, including speech, deglutition, management of oral secretions, and mastication. Thus, maxillofacial prosthetic rehabilitation is a cornerstone of efforts to restore the head and neck cancer patient’s oral functions and cosmesis following surgery to pre-treatment baselines.

Each year a proportion of new head and neck cancer patients will require maxillofacial prosthetic intervention. Most of these patients will be rehabilitated at major teaching institutions or designated cancer centers that include a multidisciplinary team. Perhaps half of new patients will be treated with definitive radiation without surgical intervention, but these patients also will require dental intervention (see Chapter VII) and follow-up throughout their lifetime. Thus, multidisciplinary teams are essential for head and neck cancer patients, especially as their treatment may result in loss of oral functions and cosmetic deformities.

With recent changes in the modalities of cancer treatment and reconstruction (e.g., the introduction of brachytherapy and microvascular free flap transfers), rehabilitation of the oral tissues takes on a new dimension. Conventional maxillofacial prosthetic rehabilitation usually will not be enough to restore the resultant hard or soft tissue defects. Thus, a multidisciplinary surgical team that includes dentists will increasingly be instrumental in the reconstruction of head and neck patients. The ultimate goal of rehabilitation, however, will remain the restoration of oral functions and cosmesis with the aim of providing an acceptable quality of life.

Successful rehabilitation and quality of life go hand in hand. Because patients vary in attitudes and adaptation, it is very difficult to predict the patient’s eventual quality of life prior to initiating treatment for an oral tumor. Furthermore, the use of newer techniques at surgical reconstruction makes the maxillofacial prosthodontist’s task even more challenging. It is important for the dental team to be experienced and to identify for the medical and surgical oncologists realistic goals and objectives for rehabilitation. At major cancer centers with rehabilitative teaching programs, it is not uncommon for the surgically resected head and neck patient to require 20-25 appointments for appropriate rehabilitative care in a 1-year period.

With multidisciplinary cancer therapy (ablative surgery, reconstructive surgery, radiation therapy, and/or chemotherapy) available, rehabilitative dentistry is essential for improving quality of life. Treatment plans for rehabilitative dentistry should be included in the overall cancer treatment plan; in many instances, the sequelae of ablative head and neck surgery and radiation therapy could be alleviated, minimized, or even eliminated altogether if there were appropriate planning for maxillofacial prosthetic and other dental interventions before treatment begins.

A. State of the Science

The strategy and techniques of rehabilitation of a head and neck cancer patient are directly related to the location of the cancer and to the extent and type of surgical intervention and radiation modalities used. Oral carcinomas not detected and evaluated in their early clinical stages usually invade contiguous structures, thereby setting the stage for extensive surgical procedures that are generally followed by radiation therapy.

Removal of extensive segments of the tongue, floor of mouth, mandible, and hard and soft palate as (1,2) well as the regional lymphatics usually mandates extensive rehabilitative management. Generally, maxillofacial prosthodontists restore maxillary resections with obturator prostheses. However, in many instances a soft palate speech bulb-obturator retained in the maxillae (for restoration of velopharyngeal function) or a palatal augmentation prosthesis (if tongue function is lost) is required for optimal rehabilitation. Currently, rehabilitation of a maxillectomy and/or soft palate defect via an obturator prosthesis is most effective in restoring function. Recent advances in microsvascular free flap tissue transfers have been used successfully to reconstruct composite defects of the mandible, buccal mucosa, and tongue. 3

Current rehabilitative practice is centered in five principles: (4,5)

1. The process of rehabilitation begins at time of initial diagnosis and treatment planning.

2. The dentition should be preserved if possible.

3. Rehabilitative treatment plans should be based on fundamental principles of prosthodontics, including a philosophy of preventive dentistry and conservative restorative dentistry.

4. Surgery before prosthetic rehabilitation may be indicated to improve the existing anatomic

configuration after ablative cancer surgery, reconstructive surgery, and/or radiation therapy. 5. Multidisciplinary cancer care is required to achieve the best functional, physical, and psychologic outcomes.

The need to treat tumors expediently often delays planning for rehabilitation. However, without a highly interactive and dynamic dialogue among health care providers during the initial treatment planning process, efforts to provide optimal rehabilitative care are impaired. Other health professionals-including social workers, vocational rehabilitation counselors, nurses, nutritionists, occupational therapists, physical therapists, speech pathologists, and dental hygienists-are also vital (5) members of the team. Because a team of this breadth is not typically encountered in the community setting, comprehensive rehabilitation is best managed in a medical center venue.

Factors affecting the cancer surgical treatment plan for oral cancer patients include the following: 1

•  prognosis and systemic status of patient;

•  potential size and site of defect;

•  potential nature of functional and/or cosmetic defect;

•  adjunctive therapy (e.g., chemotherapy or radiation) that may compromise the surgical result; and

•  anticipated changes to function and cosmesis, based on the cancer surgery and the availability, accessibility, and cost of rehabilitative procedures.

Planning for patients who need rehabilitation of the maxillofacial complex includes consideration of surgical defects associated with the maxilla, mandible, tongue, soft palate, and facial region, including the patient with a combined orofacial abnormality. The role and impact of radiation and chemotherapy also need consideration (see Chapter VII). (4)

Specific abnormalities result directly from the extent and nature of cancer treatment as well as the (6) patient’s functional and psychological ability to respond to changes induced by therapy. Thus, rehabilitation may be directed to hypernasality, mastication and deglutition dysfunction, control of oral secretions, compromised interarch