3.

11 
Maxillofacial Prosthodontics
Ghassan G. Sinada, Majd Al Mardini, Marcelo Suzuki

as teeth and anatomical landmarks of the jaws are usually used as refer-
BACKGROUND
ence for the prosthetic planning before and after the surgery. In general
The replacement of missing structures in the head and neck region has terms, the most commonly used scheme for identification of adult
been a concern for many centuries, with the fabrication of maxillofacial teeth involves the sequential numbering (from 1 to 32) starting from
prosthetic restorations being mentioned since the 16th century, with the right maxillary third molar (tooth number 1), and moving across
the first mention often credited to Ambroise Paré in 1541.1–3 Although to the contralateral third molar (tooth 16), starting again from the
the concern was often the restoration of a pleasing appearance, address- lower left third molar (tooth 17) across to the right mandibular third
ing the functional disruption was also part of the treatment, with clini- molar (tooth 32). All missing and impacted teeth should be counted
cians being able to achieve the desired outcome with varying degrees in this system. Anatomical structures of importance for retention and
of success. support of prostheses include the tuberosity, alveolar ridge, the hard
Maxillofacial prosthetics is often described as “the art and science palate on the maxilla, the alveolar ridge, the retromolar pad, and buccal
of anatomic, functional, or cosmetic reconstruction by means of non- shelf on the mandible.
living substitutes of those regions in the maxilla, mandible, and the An essential principle in prosthodontics is the determination of the
face that are missing or defective because of surgical intervention, trauma, correct physiologic maxillo-to-mandibular position.4 This relationship
pathology, developmental or congenital malformation.”2 must always be determined before we can determine the correct align-
Maxillofacial prosthetic rehabilitation is best understood when the ment and occlusal position of a prosthesis. The maxilla is affixed to the
treatment is put in context with the overall patient care. In order to skull and the mandible can be considered a moving entity. As such, the
achieve the desired outcome, head and neck surgeons, plastic surgeons, functional movements of the mandible constitute the most fundamental
oral surgeons, and the maxillofacial prosthodontist should all be involved basis for ideal prosthesis design. Therefore, we must consider the enve-
in the treatment plan process, so proper site preparation in anticipation lope of function as it is not merely an academic exercise. The range
of prosthetic reconstruction can be successful. The concept of multi- and limits of mandibular movement are indirectly related to the limits
disciplinary care is very evident in the management of patients who imposed by the postsurgical anatomy. Surgery affects the maxilloman-
will require maxillofacial prosthetic rehabilitation, as this interaction dibular ligaments, bone, muscle, and the temporomandibular joints.
will facilitate the fabrication of a prosthesis, which can restore the patient How much or how little varies from person to person and is affected
to near normal function and esthetics in many cases. by the surgery.
The general goals when dealing with maxillofacial patients should It is also important for those involved in treatment to be able to
be to restore form, function, and esthetics.1–4 Prosthodontic rehabilita- recognize the oral pathology resulting from poor oral health status.
tion aims to create maintainable health for the total masticatory system. For example, advanced periodontal disease, gross dental caries, and
This means freedom from disease in all masticatory structures, a healthy excessive plaque and calculus formation are indicators of poor oral
maintainable periodontium, stable temporomandibular joints, stable hygiene. These findings should be noted when referring the patient
occlusion, healthy maintainable teeth, comfortable function, and of to the clinician who will perform a thorough radiographic and dental
course, optimum esthetics. Practicing without a clear and comprehensive examination. Commonly in trauma patients previous dental casts are
understanding of these goals exacts a costly penalty in missed diagnosis, not available, so this examination may include acquisition of impressions
unpredictable treatment results, and lost productive time.5 from dental and facial structures as needed. The casts fabricated from
Prosthetic reconstruction of the trauma patient can be difficult due these impressions can be used as aids in the treatment planning and
to the deformity created and the loss of vital structures. Oftentimes the posttreatment rehabilitation. Furthermore, the identification of hopeless
construction may not be accomplished without several revisions on teeth (i.e., severely decayed, extensive fractures) that need to be extracted
the site. Initial treatment will always involve closing the wound and will be made as well as weighing the need for any restorative treatments.
stabilizing the patient, so prosthetic reconstruction does not become a Assessment of available soft and hard tissue can also be done at this
relevant aspect of treatment until several months after the initial appointment and, if possible, further advance imaging is obtained to
incident.6–8 evaluate available bone for future placement of osseointegrated dental
implants.
Preservation of tissue at the time of surgery should be carefully
ORAL AND DENTAL ANATOMY EVALUATION examined, as it may require further revisions of the surgical site, as the
It is important for the medical personnel treating head and neck patients remaining tissue can create challenges during prosthetic reconstruc-
(otolaryngologists, plastic surgeons, and speech pathologists, among tion.8,9 It is important for the surgeon and the prosthodontist to under-
others) to understand the oral cavity and dental anatomy, so they can stand the limitations of each case to better prepare the site for future
identify and accurately communicate findings with their dental colleagues, prosthetic reconstruction.6,8,10

458
 CHAPTER 3.11  Maxillofacial Prosthodontics 459

Fig. 3.11.1  Bulky free flap reconstruction, preventing the possibility of

prosthetic reconstruction.
Fig. 3.11.2  Teeth opposing the reconstructed site contacting the free
flap reconstruction. This can cause severe damage to the tissue and
should be avoided.

Assaults, motor vehicle collisions, falls, and gunshot wounds are the
major causes of fractures in the head and neck area. The resultant defect INTRAORAL PROSTHETIC REHABILITATION
can significantly impact the patient functions, as the separation between
the oral and nasal cavity can be compromised, causing air leakage during The maxillofacial prosthetic rehabilitation is usually achieved in three
normal functions.6,7 different phases: surgical, interim, and definitive. This process usually
Ideally, the defect created can be reconstructed with primary closure. is completed within a year, depending on the clinical situation and
This is the best outcome for the patient, as little to no disruption will treatment needs.
occur. However, the defect created can be too big for primary closure The surgical phase occurs at the time of surgery; in the case of the
to occur, and hard and soft tissue transfers to reconstruct the area are maxilla, when a surgical obturator is placed to reestablish the separation
not possible due to concerns regarding morbidity of the donor site, between the oral and nasal cavities, while restoring proper palatal contour.
cost of the procedure and hospitalization time, patient desire to avoid This is a very important procedure, as the prosthesis will help maintain
further surgery, or other health problems. In these situations, recon- proper speech and swallowing function immediately after surgery, thus
struction with a prosthesis is indicated.2 decreasing the need for a nasogastric tube, and speed recovery and
During the initial fracture reductions and reconstruction, it is impor- discharge from the hospital. The surgical obturator will also serve to
tant to preserve as much as possible of the existing structures.2,3,4,6,8 For maintain proper lip and cheek support during the initial healing, and
instance, if the patient is edentulous, the hard palate is responsible for decrease the facial contracture that can happen due to scarring of the
primary retention, support, and stability of a prosthesis. Without com- tissues. Finally, this prosthesis will serve to maintain a split-thickness
promising the surgical outcome, surgeons should be encouraged to skin graft in place, which is part of site preparation for prosthetic recon-
preserve as much of the hard palate and alveolar bone as possible. On struction. In the case of traumatic injury, this step is usually not possible
a dentate patient, besides the preservation of bone, maintaining key as the fabrication of the surgical prosthesis cannot be accomplished
teeth can dramatically improve prosthetic outcome, as the remaining prior to the surgery.
dentition can be used for retention and stability. After initial healing has taken place (10–14 days), the surgical obtu-
As is often the case, a revision surgery may be required to further rator is replaced with an interim obturator. While a surgical obturator
improve the reconstruction or address some common problems (i.e., may not have replaced any missing teeth as a result of the surgery, the
excessive tissue scarring and contractures) to help the patient regain interim obturator will most likely have teeth so the patient can slowly
normal or close to normal function. During this revision procedure, attempt to return to normal function. This prosthesis will be adjusted
if prosthetic reconstruction is going to be recommended, the consid- constantly as the surgical site heals, and the defect created will be chang-
eration for lining the surgical site with keratinized tissue should be ing in size and shape. The adjustments will require addition or removal
made, as a split-thickness skin graft placed during the surgical proce- of material accordingly, so optimal separation between oral and nasal
dure – after a few weeks of maturation – can be easily maintained by cavity is maintained.
the patient, in addition to being a stable area for the prosthesis. Also, Once the healing of the surgical site has been completed, the fabrica-
during closure of the wound, the surgeon should remove any tissue tags tion of the definitive obturator begins. This prosthesis will further
or redundant tissue, as these structures can prevent proper prosthetic enhance esthetics and function.
extension.2–5 In cases of mandibular involvement, the initial evaluation is very
If reconstruction using free tissue flaps is planned, an attempt should similar to that of the maxilla. However, it is important to emphasize
be made to keep the flap from being too bulky, as this extra tissue will that proper maintenance of the alignment of the remaining segments
require subsequent surgical revisions to allow proper space for the fab- after the fracture reduction is a crucial step for subsequent prosthetic
rication of a prosthesis (Figs. 3.11.1 and 3.11.2). rehabilitation. If the alignment of the remaining mandible to the glenoid
It is important also to emphasize that in an ideal situation, a team fossa and the temporomandibular joint is disrupted, damage to the
approach will be used from the beginning of treatment. This will result surrounding areas will occur and the patient’s normal mandibular
in the best outcome for patient rehabilitation.2,3,4,6,7,8,11 motions will be affected, resulting in an improper occlusion. As a
460 SECTION 3  Secondary Reconstruction and Restoration

When the soft palate is involved, a determination should be made

whether the remaining soft palate will be useful in the prosthetic reha-
bilitation or not. Usually, the remaining soft palate is nonfunctional,
and its removal will allow for easier access to the pharynx and the
fabrication of the prosthesis. In short, the normal velopharyngeal closure
occurs with the medial and anterior movement of the lateral and pos-
terior pharyngeal walls contacting the posteriorly and superiorly lifting
velum. Lateral soft palate defects can be easily restored with the addition
of a pharyngeal extension to the prosthesis. Small mid-soft palate defects
are generally harder to restore, especially when located close to the
junction of the hard and soft palate. These patients will usually have
problems with fluid leakage due to the mobility of the area during
Fig. 3.11.3  Panoramic X-ray showing the fibula free flap reconstruction function.
of the mandible. A total soft palatectomy can facilitate the prosthetic rehabilitation,
as it will create a static velar prosthesis. The appliance will be molded
to the moving posterior and lateral pharyngeal walls at the anterior
consequence, the prosthetic reconstruction will be less than ideal, if extent of their movement during speech and swallowing, creating an
not impossible. appropriate seal during these functions.
To maintain proper alignment of the mandibular segments during The decision to maintain or remove the soft palate should be dis-
mandibular surgery, the utilization of fixation plates and screws is a cussed when further surgical revisions are being planned, as this can
commonly available technique.12 If no mandibular reconstruction is affect the success of the prosthetic outcome. Clinical experience and
being planned due to the amount of tissue loss, the removal of the understanding of the prosthetic soft palate rehabilitation can better
condyle and the remaining ramus on the affected side should be com- prepare the surgeon for making the final decision of whether to remove
pleted, to prevent the medial migration towards the maxilla, and decrease or maintain the remaining soft palate.
the chances of complications due to compromised function and pros-
thetic rehabilitation.2–4
TONGUE EVALUATION
Reconstructive surgery using free flaps and bone transplantation
has greatly improved the surgical outcome for patients requiring Lesions to the tongue are usually one of the most challenging problems
a surgical procedure, which will affect the continuity of the man- both surgically and prosthetically. Loss of part or all of the tongue will
dible12 (Fig. 3.11.3). Virtual surgical planning utilizing CT scans can disrupt proper swallowing, speech, and saliva control, in addition to
also allow the members of the surgical and reconstructive team to the possible facial disfigurement caused by the injury. The majority of
rehearse the procedures to be done, and evaluate the outcome. This injuries are a result of falls, seizures, blunt force mechanisms, or an
has become an invaluable tool, allowing for the fabrication of indi- iatrogenic cause. Often, the injury created is minor and no treatment
vidualized reconstruction plates,13 cutting guides for the harvesting of may be indicated, as the wound will heal on its own.24
bone grafts,14,15 and stents for the placement of osseointegrated dental An understanding of how normal speech is produced is important
implants.15 in the rehabilitation process, so the prosthetic treatment can be tailored
The placement of a split-thickness skin graft in conjunction with to address the specific impairment the patient is experiencing.25 In the
vestibuloplasty surgery will help reestablish a stable tissue foundation case where the anterior portion of the tongue is lost, a significant inter-
for the prosthesis.2–4 These procedures, along with the utilization of ference with speech intelligibility will be noted. In such a scenario, a
osseointegrated implants, have made the fabrication of a stable man- consultation with a speech pathologist is an extremely valuable tool
dibular prosthesis a predictable treatment modality.15–20 for the successful rehabilitation of the patient.2,3,26 In most cases the
Prosthetic rehabilitation follows a similar pattern to that applied to defect created is small and mobility of the tongue is not greatly affected.
the maxilla. A surgical prosthesis would usually be in place to help For such conditions the prosthesis of choice may be a palatal augmenta-
stabilize a split-thickness skin graft and to recreate the vestibule in tion prosthesis.2,3,27 This prosthesis will have the palatal portion recon-
preparation for the final prosthesis. The interim prosthesis will help toured to compensate for the lack of appropriate movement after the
reestablish the occlusal relationship and help the patient learn how to trauma. Further follow-ups with the speech pathologist will help deter-
function and maintain the prosthesis. The final or definitive mandibular mine the areas where the prosthesis will need to be further adjusted,
prosthesis will be fabricated once complete healing is achieved and the to optimize the patient’s speech and swallowing.
site is mature for reconstruction. If the patient is missing the majority of the tongue bulk, a prosthesis
replacing it will need to be individually evaluated in an attempt to
determine its success,26,27 but usually the prognosis is poor28 due to the
SOFT PALATE EVALUATION impairment to normal functions the loss of the tongue will create. In
When a defect involving the soft palate is present, the first decision this scenario, the surgical reconstruction with a free flap, to add bulk
needs to be a determination if surgical reconstruction is possible or to the floor of the mouth, can improve function by creating bulk in
not, as disruptions to the soft palate will cause severe problems with the oral cavity to decrease resonance,29 and can also facilitate the pros-
speech and swallow and as a consequence, severely impair the patient’s thetic rehabilitation by decreasing the needed extent of the palatal
overall quality of life.21 augmentation prosthesis to contact the remaining tongue.
Soft palate reconstruction is often difficult, and although surgical
techniques involving free tissue transfers have been developed and uti-
lized to address these defects, rehabilitation with a prosthesis can deliver
EXTRAORAL EVALUATION
a successful and predictable result; although the results are not com- Extraoral defects can involve severe tissue loss and deformity. Vehicular
parable to preoperative baseline measurements.22,23 collisions (car, motorcycle, bicycle), assaults, and gunshot wounds are
 CHAPTER 3.11  Maxillofacial Prosthodontics 461

Fig. 3.11.4  Placement of mandibular implants and removal of recon-

struction plate after healing. Removal of reconstruction plates can facilitate
the placement of implants, since fixation screws are not interfering with
osteotomies for implants.
Fig. 3.11.5  Maxillary and mandibular casts mounted on semiadjustable
articulator (Hanau Wide-Vue, Whip Mix Corp., Louisville, KY) and teeth
arrangement of mandibular prosthesis.

the major causes of facial injuries. However, improvements in safety

(use of seat belts, air-bags, and helmet wear) have dramatically reduced
the numbers of facial trauma associated with vehicle injuries, with
minor trauma as a result. Assaults usually produce facial fractures easily
managed with “routine” maxillofacial reconstructive surgery.
Gunshot wounds produce more severe tissue loss and deformity.
An entry and an exit wound will be created, with damage caused initially
by the speed of the projectile, followed by bone fragments serving as
secondary projectiles, causing further soft tissue damage on the exit
wound. The type of firearm, location of the initial contact, and angle
will further affect the defect created.
As noted earlier, the first concern should always be the stabilization
of the patient and reduction of fractures when possible. Surgical revi-
sions and reconstructions (prior to any prosthetic consideration) will
be paramount to the successful rehabilitation of such patients, as well
as proper psychological support.
Other possible causes of facial wounds are burns (electrical or acid),
Fig. 3.11.6  Prosthesis in place. Note the accurate reproduction of teeth
which often cause severe deformation with little to no tissue loss. These
relationship.
wounds may cause deformities that cannot be addressed with plastic
surgery or prosthetics, and consideration should be given to a larger
procedure (alloplastic transplantation) to restore the patient.
CONCLUSION
The common goal of the surgeon and prosthodontist should be to
OSSEOINTEGRATED DENTAL IMPLANTS preserve and restore. The postsurgical condition of the mandible and
The location of osseointegrated dental implants should be driven by the maxilla, the remaining musculature, and the oral mucosa is of major
the prosthetic needs of the treatment30 (Fig. 3.11.4). This will ensure importance. These are the foundation tissues that must support every
proper occlusion and function. Dental implants help in the retention rehabilitative prosthodontic effort. Dental complications are directly
of fixed,30 removable30 or extraoral prostheses.31 The most common proportional to the degree that these tissues are compromised by surgery.
design of dental implants is the root-form design.30,32 Implants can be Surgical preparation for prosthodontic rehabilitation provides better
placed in one or two stages. In general, the first stage is the placement results. A combined clinical evaluation should include:
of the implant in bone. Once placed, the site is closed and the implant 1. Assessment of existing oral structures and their function.
is left covered and healing for 3 to 6 months for optimal osseous growth 2. Retaining or removing teeth.
around the implant. This phenomenon is called osseointegration, which 3. Placement of osseointegrated implants.
is defined as “intimate bone contact to the surface of an implantable 4. Creating and maintaining intraocclusal space within the oral cavity.
biomaterial, detectable under optical microscope observation.”33 The 5. Providing as much immobile tissues on load-bearing areas as
second stage will have the implants uncovered and a healing cap or possible.
screw will be placed to allow for their use in the prosthetic phase of In prosthodontic rehabilitation, surgical preparation and planning
the treatment (Fig. 3.11.5). from the start of the case leads to more successful outcomes. The team
Osseointegrated dental implants have been utilized routinely in should understand how surgery can impact the oral health of the patient.
dentistry for years, and their use for the rehabilitation of maxillofacial Whether to retain or remove teeth should be based on the defect in
defects has become a common treatment choice to overcome the chal- the area and what is best to restore that defect. The focus should be on
lenges in anatomy, and the lack of a stable tissue bed for prosthetic the prosthodontic rehabilitation to achieve function, and that in turn
rehabilitation15–18,34,35 (Fig. 3.11.6). guides the surgical plan.
462 SECTION 3  Secondary Reconstruction and Restoration

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