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27South Russian Journal of Cancer 2021, v.2, №2, p. 22-33 https://doi.org/10.37748/2686-9039-2021-2-2-3 CLINICAL CASE REPORTS
(fD
ORTHOPEDIC TREATMENT IN CANCER PATIENTS WITH MAXILLOFACIAL PATHOLOGY
I.V.Pustovaya*, M.A.Engibaryan, P.V.Svetitskiy, I.V.Aedinova, V.L.Volkova, N.A.Chertova, Yu.V.Ulianova, M.V.Bauzhadze
National Medical Research Centre for Oncology of the Ministry of Health of Russia, 63 14 line str., Rostov-on-Don 344037, Russian Federation
Relevance. Staged orthopedic treatment was used to improve the quality of life of patients who underwent radical maxillofacial surgeries for cancer.
Patients and methods. 197 patients receiving treatment for maxillofacial cancer were observed at the Department of head and neck tumors, National Medical Research Centre for Oncology of the Ministry of Health of Russia, in 19982018. All patients underwent radical surgical treatment resulting in postoperative defects of the upper jaw, soft tissues of the zygomatic-buccal-orbital region, nose, or auricle.
Results. Removable obturator prostheses with various supporting and retaining elements were made for 159 (80.7 %) patients. Individual facial prostheses were made for 38 (19.3 %) patients: 17 (44.7 %) - external orbital prostheses, 14 (36.8 %) - external nasal prostheses, 6 (15.8 %) - external zygomatic-buccal-orbital prostheses, 1 (2.7 %) - external auricle prosthesis. Combined prostheses were made for 4 patients - removable upper jaw obturator and nose prosthesis; removable upper jaw obturator and eye prosthesis. Combined prostheses were fixed to each other using magnets. The results of maxillofacial prosthetics were evaluated according to the aesthetic requirements of the patients and their quality of life. Maxillofacial prostheses allowed a complete restoration of chewing, swallowing, and speaking, restored facial deformation, and improved the appearance of patients.
Conclusions. Timely and comprehensive orthopedic treatment of patients with postoperative maxillofacial defects after radical surgeries for malignant tumors takes the main place in the complex of rehabilitation measures. Early elimination of extensive defects is aimed at maximum restoration of oral dysfunctions and appearance preservation. The apparent advantages of maxillofacial prostheses involve improvement of social adaptation and the quality of life of patients, which promotes complete rehabilitation and a return to socially useful activities.
Keywords:
oncology, rehabilitation, maxillofacial defect, combination defects, shaping prosthesis, facial prostheses.
For correspondence:
Irina V. Pustovaya - Cand. Sci. (Med.), maxillofacial surgeon of the Department of Head and Neck Tumors National Medical Research Centre for
Oncology of the Ministry of Health of Russia, Rostov-on-Don, Russian Federation.
Address: 63 14 line str., Rostov-on-Don 344037, Russian Federation
E-mail: ivpustovaya@yandex.ru
SPIN: 5913-8360, AuthorlD: 416789
Information about funding: no funding of this work has been held. Conflict of interest: authors report no conflict of interest.
For citation:
Pustovaya I.V., Engibaryan M.A., Svetitskiy P.V., Aedinova I.V., Volkova V.L., Chertova N.A., Ulianova Yu.V., Bauzhadze M.V. Orthopedic treatment in cancer patients with maxillofacial pathology. South Russian Journal of Cancer. 2021; 2(2): 22-33. https://doi.org/10.37748/2686-9039-2021-2-2-3
Received 04.02.2021, Review (1) 21.04.2021, Review (2) 23.04.2021, Published 18.06.2021
ABSTRACT
Южно-Российский онкологический журнал 2021, т.2, №2, с. 22-33 https://doi.org/10.37748/2686-9039-2021-2-2-3 КЛИНИЧЕСКОЕ НАБЛЮДЕНИЕ
ОРТОПЕДИЧЕСКОЕ ЛЕЧЕНИЕ У ОНКОЛОГИЧЕСКИХ БОЛЬНЫХ С ЧЕЛЮСТНО-ЛИЦЕВОЙ ПАТОЛОГИЕЙ
И.В.Пустовая*, М.А.Енгибарян, П.В.Светицкий, И.В.Аединова, В.Л.Волкова, Н.А.Чертова, Ю.В.Ульянова, М.В.Баужадзе
ФГБУ «НМИЦ онкологии» Минздрава России, 344037, Российская Федерация, г. Ростов-на-Дону, ул. 14-я линия, д. 63
РЕЗЮМЕ
Актуальность. Для улучшения качества жизни пациентов, перенесших расширенные онкологические операции челюстно-лицевой области, применяется этапная методика ортопедического лечения. Пациенты и методы. В отделении опухолей головы и шеи ФГБУ «НМИЦ онкологии» Минздрава России, с 1998 по 2018 гг. под наблюдением находились 197 больных, излеченных по поводу злокачественных опухолей челюстно-лицевой локализации. Всем больным выполнены расширенные радикальные операции, вследствие которых, образовывались послеоперационные дефекты: дефекты верхней челюсти, мягких тканей скуло-щечно-орбитальной области, носа, ушной раковины.
Обсуждение. Съёмные протезы с обтуратором на различных опорно-удерживающих элементах изготовлены 159 (80,7 %) больным. Индивидуальные лицевые протезы изготовлены всего 38 (19,3 %) больным. У 17 (44,7 %) - эктопротезы глазничной области, у 14 (36,8 %) - эктопротезы наружного носа, у 6 (15,8 %) - экто-протезы щёчно-скуло-глазничной области, у одного (2,7 %) - эктопротез ушной раковины. У 4 пациентов изготовлены комбинированные протезы: съёмный протез верхней челюсти с обтуратором и протез носа; съёмный протез верхней челюсти с обтуратором и протез глаза. Фиксация комбинированных протезов между собой осуществлялась при помощи магнитов. Результаты челюстно-лицевого протезирования оценивались в соответствии с эстетическими требованиями пациентов и качеством их жизни. Челюстно-лицевые протезы позволили полностью восстановить функцию жевания, глотания, речи, восстановить деформацию лица, улучшить внешний облик пациентов.
Заключение. Своевременное и полноценное ортопедическое лечение пациентов с послеоперационными дефектами тканей челюстно-лицевой области после расширенных операций по поводу злокачественных новообразований, занимает ведущее место в комплексе реабилитационных мероприятий. Раннее устранение обширных дефектов направлено на максимальное восстановление нарушенных функций полости рта, сохранение внешнего облика. Несомненным достоинством использования челюстно-лицевых протезов является повышение социальной адаптации больных, улучшение качества их жизни, что в свою очередь способствует полной реабилитации, возвращению к общественно полезному труду.
Ключевые слова:
онкология, реабилитация, дефект верхней челюсти, комбинированные дефекты, формирующий протез, лицевые протезы.
Для корреспонденции:
Пустовая Ирина Викторовна - к.м.н., врач-челюстно-лицевой хирург отделения опухолей головы и шеи ФГБУ «НМИЦ онкологии»
Минздрава России, г. Ростов-на-Дону, Российская Федерация.
Адрес: 344037, Российская Федерация, г. Ростов-на-Дону, ул. 14-я линия, д. 63
E-mail: ivpustovaya@yandex.ru
SPIN: 5913-8360, AuthorlD: 416789
Информация о финансировании: финансирование данной работы не проводилось. Конфликт интересов: авторы заявляют об отсутствии конфликта интересов.
Для цитирования:
Пустовая И.В., Енгибарян М.А., Светицкий П.В., Аединова И.В., Волкова В.Л., Чертова Н.А., Ульянова Ю.В., Баужадзе М.В. Ортопедическое лечение у онкологических больных с челюстно-лицевой патологией. Южно-Российский онкологический журнал. 2021; 2(2): 22-33. https://doi.org/10.37748/2686-9039-2021-2-2-3
Получено 04.02.2021, Рецензия (1) 21.04.2021, Рецензия (2) 23.04.2021, Опубликовано 18.06.2021
INTRODUCTION
According to epidemiological data, the incidence and mortality from oral cancer have been steadily increasing in Russia over the past decades. The morbidity rate of the Russian population in 2019 was 29.4 per 100 thousand people. In the Rostov region, the incidence rates are slightly lower than in Russia, but continue to remain at a fairly high level, amounting to 16.3 per 100 thousand of the population. The mortality rate from oral cancer in the first year of life from the moment of diagnosis in Russia was 32.4 %, in the Rostov region - 24.9 % [1]. The vast majority of cancer patients are of working age by the time the disease is established. Modern possibilities of surgical, combined and complex methods of treatment allow to save the lives of patients. However, extensive surgical operations, intensive radiation, cytostatic therapy, used by oncologists, lead to significant anatomical and functional disorders and complications that reduce the working capacity of patients [2]. It should be noted that due to disability, oncological diseases occupy the second place after diseases of the circulatory system, and the first place in terms of the severity of disability [3, 4].
The quality of life of cancer patients is equally comparable to its duration. Therefore, simultaneous reconstructive operations have become an integral part of the surgical treatment of patients with locally advanced forms of maxillofacial cancer. Reconstructive and reconstructive operations are associated with numerous difficulties. After radical operations, courses of radiation and chemotherapy, there is an abundant amount of scarring and trophic disorders, which leads to poor tissue engraftment. The elimination of acquired defects of the maxillofacial region in such patients dictates the need for plastic surgery in several stages. For patients, waiting periods for subsequent surgical interventions are quite tedious [2, 4]. In this regard, the rehabilitation of oncostomatological patients over the past decades has not lost its relevance. What can be more important for the patient if he can not fully take food, can not appear in society [5]?
Currently, due to the introduction of implantation technologies, the orthopedic method of treatment in cancer patients with maxillofacial pathology has become more widespread, as it allows to eliminate tissue defects and restore impaired functions in a short time [2-7].
The success of orthopedic treatment largely depends on the coherence and mutual understanding of the surgeon and the orthopedic dentist. When analyzing the literature data, it can be concluded that in the practice of most dental organizations, specialized dental care for cancer patients is not carried out. There is a complete lack of social support and a well-established routing scheme for this category of patients. All this has not only medical, but also social significance [2].
In orthopedic dentistry, there is a fairly extensive selection of materials for the production of jaw and facial prostheses. Until the 50s of the last century, facial prostheses were made of metal, porcelain, ivory, celluloid and rubber [2, 8]. Each material has its own characteristics that allow you to use them for specific tasks. Modern removable jaw structures are made of new polymers (soft, hypoallergenic and durable): acry-fries, nylon, acrylic (plastic). Most often, acrylic is used for removable dentures, as an alternative to the materials of the previous generation. In terms of cost, it is not expensive, it has a wide palette of colors, which allows you to choose natural shades more accurately for each patient.
Over the past decades, great advances have been made in the field of facial prosthetics due to the appearance of materials that better mimic living tissue. Such materials include siloxanes. The results of experimental and clinical studies conducted in CRIDMS showed that silicone prostheses are biologically inert, retain elasticity, strength, and do not change shape [2]. Three-dimensional modeling and rapid prototyping technologies are being actively implemented.
There are two types of prosthetics of defects: direct and sequential. Direct prosthetics consists in the fact that the prosthesis is made before the operation and installed immediately after the surgical intervention. Subsequent prosthetics include such prosthetics, when the prostheses are made 2-3 weeks after the operation (early prosthetics) or 3-4 months later (later prosthetics) [4, 5, 7].
The most important tasks of orthopedic treatment are:
1. Closure of the postoperative defect;
2. Restoration of chewing, swallowing, speech;
3. Maintaining the patient's appearance;
4. Psychocorrective therapy.
Clinical case description
In the department of head and Neck Tumors of the National Medical Research Centre for Oncology of the Ministry of Health of Russia, from 1998 to 2018, 197 patients were treated for locally common malignant tumors of the maxillofacial localization. All patients underwent extended radical operations, as a result of which postoperative defects were formed: defects of the upper jaw, soft tissues of the zygomatic-buccal-orbital region, nose, and auricle.
The distribution of patients found that among the observed patients, 152 men (77.2 %), 45 women (22.8 %). The age of the patients ranged from 22 to 70 years.
The distribution of patients by gender and age is shown in Table 1.
As can be seen from Table 1, the overwhelming majority of patients (175 (88.9 %) people) were persons of working age, i.e. up to 41-60 years.
In all patients, the diagnosis of a malignant tumor was verified morphologically. According to the histological structure, all tumors were of epithelial origin: squamous cell carcinoma (with/without keratiniza-tion) was found in 112 (64 %) patients, basal cell
carcinoma - in 24 (14 %), estesioneuroblastoma - in 18 (10 %), cylindroma - in 21 (12 %).
Defects in the tissues of the maxillofacial region formed after surgery were diverse, and depended on the localization of the tumor process, the volume of the operation. Depending on the nature of the defect, the observed patients were divided into four groups (Table 2).
The largest number of patients with postoperative defects of the upper jaw, reported with the nasal cavity and maxillary sinus, was observed in 134 (68 %) patients. The lowest number of patients with combined postoperative defects of the upper jaw, combined with facial defects - in 4 (2 %) patients. Isolated postoperative defects of the face without a combination with defects of the upper jaw (defects of the nose, auricle, orbital, zygomatic-orbital, zygomatic-buccal-orbital region) - in 34 (2.6 %) patients. Postoperative defects without communication with the nasal cavity and maxillary sinus - in 25 (12.7 %) patients.
In patients who had part of the hard palate removed, a message appeared between the oral cavity and the nasal cavity. There were violations
Table 1. Distribution of the patients by their age and gender
Gen-der
Age of patients (years) Total
20-30 31-40 41-50 51-60 Above 61 Abs. number
Male 3 4 30 103 12 152 77.2
Fem. 0 0 14 28 3 45 22.8
Total 3 4 44 131 15 197 100.0
% 1.5 2.0 22.4 66.5 7.6
Table 2. Distribution of the examined patients according to the defect features
Defect features Total
Abs. number %
Postoperative defects of the upper jaw, without communication with the nasal cavity and maxillary sinus
25
12.7
Postoperative defects of the upper jaw, communicating with the nasal cavity and maxillary sinus 134 68
Combined postoperative defects of the upper jaw, combined with facial defects 4 2
Isolated postoperative facial defects without combination with upper jaw defects 34 17.3
Total 197 100
of swallowing, speech in the form of nasal voice. There were no cosmetic violations. In cases where resection of the upper jaw was performed (removal of the alveolar process and hard palate), more pronounced functional and cosmetic disorders appeared. In such patients, there was a sinking of the soft tissues of the cheek on the side of the operation, leading to facial asymmetry. The most pronounced facial deformity, chewing, swallowing and speech disorders were observed in those patients who underwent total resection of the upper jaw. When resection of the upper jaw with exenteration of the eye socket, along with pronounced functional disorders, significant cosmetic defects of the face were observed. Pronounced disfigurement was observed in patients who underwent resection of the upper jaw with excision of the surrounding soft tissues of the face (cheek, upper lip, nose, eye socket).
Orthopedic treatment was carried out according to the generally accepted method [6, 7, 9]. At the first stage, before the operation, in the presence of preserved teeth, a protective plate or plate prosthesis was made. Sometimes the old prostheses of this patient were used, after their preliminary correction. At this stage, it was necessary: to ensure the possibility of a full meal through the oral cavity; to fix the tampon in the postoperative cavity, creating a reliable separation between the oral cavity and the wound surface; to preserve speech.
On the 10th-15th day after the operation (the second stage), a jaw structure was made, which formed the bed of the obturating part of the permanent prosthesis during subsequent prosthetics. The forming prosthesis made it possible to reliably eliminate the oronosal and oroantral connections, significantly improve chewing, swallowing, diction, and prevent the development of facial scarring.
A month after the operation (the third stage), the final hollow prosthesis-obturator was made. This design made it possible to completely restore the functions of chewing, swallowing, speech and preserve the appearance of the patient. In each specific case, depending on the specifics of the clinical situation, the production time of the final prosthesis varied from 1.5 to 5 months. The final orthopedic structure with an obturator was made taking into account all
the nuances found at the stage of manufacturing the forming prosthesis.
We used the method of manufacturing a post-resection prosthesis with an obturating part according to E.Ya. Vares [5]. It was as follows: the anatomical impression was removed with a standard spoon. A thermoplastic mass was applied to the spoon, over which a two-layer (inner and outer) gauze cloth soaked in 0.9 % sodium chloride solution was applied. The impression spoon was inserted into the oral cavity and pressed against the postoperative defect. With the help of active and passive movements, the edges of the impression were formed along the border of the transition fold, in the area of the defect. The spoon was removed from the oral cavity until the final solidification of the mass. Next, the excess mass and the outer gauze cloth were removed. On the surface of the impression made of thermoplastic mass, covered with an inner layer of gauze, a corrective layer of silicone impression mass was applied. The spoon was inserted into the oral cavity and pressed against the jaw until the mass was completely polymerized. In order to reduce the severity of the pain syndrome and to suppress the gag reflex when taking the impression, the postoperative defect was treated with a local anesthetic solution (a spray of 10 % lido-caine solution). After casting the plaster model, the necessary places of isolation were covered with adhesive plaster, the preserved teeth, and the areas of undercuts were filled with wax. According to the obtained model, a rigid individual tray was made in the laboratory. The tray was adapted on the upper jaw with a thermoplastic material and an individual spoon was made. Occlusal rollers made of thermomass were glued to the rigid base of the spoon. An individual spoon was stored in the oral cavity. A functional impression was taken. Thus, the soft tissue support of the postoperative defect was formed, the height of the lower face was fixed, and the central ratio of the jaws was determined. The model of the upper jaw was cast again from this impression and a plastic base with supporting and retaining clasps was made. In the clinic, the finished structure was stored in the oral cavity. If necessary, its correction was carried out.
It should be noted that when studying working models, it is always important to determine the boundaries of: the scar ring; the prosthesis on the remaining part of the upper jaw and, in the area of the postoperative defect space; the edges of the buccal-labial support. Also, it is necessary to take into account the features of the pliability of the mucous membrane, preserved bridles, cords and formed scar elements.
The hollow obturating part of the replacement prosthesis was made according to the method of Ya. M. Zbarzh [10]. The placement of the teeth made it possible to balance the occlusal contacts as much as possible. The finished removable plate prosthesis with an obturator was adapted in the oral cavity. The design allows you to correct or restore the phonetics, restore or bring the deformed face closer to the "ideal".
According to the literature, intraosseous or magnetic implants allow you to create a reliable fixation of prostheses. In cancer patients with defects of the upper jaw, the formation of scars occurs, a large mass of the bone skeleton of the jaw is lost. The radical doses used in radiation therapy do not allow the use of dental implants for fixing dentures, especially in the first year after the completion of antitumor treatment [5].
To fix the jaw prostheses, the most commonly used support-retaining solid multi-link clamps made of kobolto-chrome alloy and bent wire clamps were used in our patients. Telescopic crowns and attachments were also used. These devices evenly distributed the load, provided a sufficiently high aesthetic and functional effect, and if necessary, radiation and chemotherapy, could be freely removed from the oral cavity. To ensure reliable fixation of the prosthesis and its stabilization under functional loads, tissue areas in the defect area were used, into which the obturating part of the prosthesis made of elastic plastic was inserted.
If the orthopedic method of treatment was carried out late after the resection of the jaw, then the postoperative scars formed prevented full-fledged prosthetics. Massive, non-stretchable scar tissue displaced the prosthesis and contributed to the rapid loosening of the remaining teeth, which were necessary for fixing the prosthesis.
Often, after storing replacement dentures in the oral cavity, as well as in the process of adapting to them, prosthetic stomatitis develops. To prevent inflammatory complications in our patients, we used dental film pads that have antimicrobial, anti-inflammatory and wound-healing effects: adhesive and solcoseryl-containing therapeutic-adhesive pads. These films, which are tasteless and odorless, swelled in the oral cavity and had bilateral adhesion (to the mucous membrane of the prosthetic bed and to the base of the resection prosthesis). The elastic base of the film pads provided cushioning of the chewing pressure on the prosthetic bed, which was the prevention of injury, inflammation and excessive resorption of the bone skeleton.
Prosthetics of the lower jaw was a more complex task and was carried out in 2 patients due to removable (clasp and collapsible with pilots) prostheses. Extensive excision of the soft tissues of the oral cavity during radical surgery is usually accompanied by a reduction in the prosthetic bed. In such clinical situations, for full-fledged prosthetics, it is necessary to perform additional surgical intervention in the volume of plastic surgery of the vestibule of the oral cavity. Patients do not always give their consent to such an operation.
Below are various options for removable orthopedic structures (Fig. 1-5).
In patients with combined postoperative defects, prosthetics began with the elimination of the upper jaw defect. After setting up a post-resection removable jaw structure, defects in the eye socket and soft tissues of the face were compensated with a facial prosthesis. Ectoprosthetics in each individual case was a complex and time-consuming process that required an individual approach. Success was achieved only when all the anatomical features of the face were taken into account.
The replacement of the defect of the external nose presented great difficulties, since the postoperative deformity of the face led to such changes that it was not always possible to restore the former appearance of the patient.
For prosthetics of the defect of the auricle, a wax template was used, which was obtained by making a cast from the opposite auricle or from the auricle of
another person, according to the configuration approximately corresponding to the object of prosthetics.
In our department, in order to eliminate the aesthetic disadvantage, exoprosthesis was performed using the domestic silicone material "Ectosil" [4, 11].
The technique of manufacturing facial prostheses consisted of the following stages:
• Examination and examination of the patient. Attention was paid to: the asymmetry of the face, nasolabial folds; the closing of the lips; the condition of the eye of the defective side and the pupil line; the defeat of the nose; anthropometric landmarks of the face; the color of the skin; the condition and formation of postoperative scars, etc.
• Removing the impression of the face from the elastic material;
• Production of a plaster model based on an impression;
• Sculptural modeling of ectoprosthesis made of wax;
• Supply of a wax template in the clinic;
• In case of eye socket defects, the selection and installation of an eye prosthesis on a wax template;
• Determination of the base color of the prosthesis by the color of the skin of the face;
• Production of painted silicone prosthesis;
• Reproduction of eyebrows, eyelashes, and hair fragments.
For minor facial defects, a spectacle frame, theater glue, and retention points were used for fixation. In the case of combined defects of the face and upper jaw, fixation was performed by connecting the facial prosthesis with the jaw prosthesis using locking devices or magnets.
The results of maxillofacial prosthetics were evaluated in accordance with the aesthetic requirements of the patients and their quality of life. The assessment
Fig. 1. Protective dividing plate.
Fig. 2. Clasp prosthesis of the lower jaw with solid multi-link clasps.
Fig. 3. Removable plate prosthesis with obturator with dentoalveolar plastic clasps to restore the defect of the upper jaw half.
Fig. 4. Removable plate prosthesis with a hollow obturator for the restoration of a total defect of the upper jaw with a missing tooth row.
of the general condition of patients was evaluated by the Karnovsky index (0-100:) or the ECOG scale (0-4 points) (Tables 3-4).
Photos of clinical examples of facial prosthetics (Fig. 6-10). All the patients whose photos are shown in the drawings signed their consent to the processing of personal data and permission to take photos.
The service life of removable dentoalveolar and facial prostheses is limited to 3-4 years, after which they need to be replaced. The need to manufacture new prostheses is dictated by unsatisfactory fixation or violation of the sealing of the oral cavity, the patient's desire to have replacement prostheses, etc.
In 40 patients, at various times after the primary dentofacial prosthetics, orthopedic structures
Fig. 5. Removable plate prosthesis with a hollow obturator to restore the defect of the hard palate with the preserved dentition.
Table 3. Karnovsky index
Normal physical activity, the patient doesn't need special care
1оо %
9о %
во %
The condition is normal, there are no complaints and symptoms of diseases
Normal activity is maintained, but there are minor symptoms of the disease
Normal activity is possible with additional effort, with moderate symptoms of the disease
Restriction of normal activity while maintaining complete independence of the patient
7о %
бо %
The patient serves himself independently, but is not capable of normal activity or work
The patient sometimes needs help, but mostly serves himself
бо %
The patient often needs help and medical care
The patient can not serve himself independently, care or hospitalization is necessary
4о %
зо %
2о %
1о %
Most of the time the patient spends in bed, special care and outside help is needed
The patient is bedridden, hospitalization is indicated, although a terminal condition is not necessary
Severe manifestations of the disease, hospitalization and supportive therapy are necessary
Dying patient, rapid progression of the disease
о %
Death
Table 4. Assessment of the patient's status on the ECOG scale
0 The patient is fully active, able to perform everything as before the disease (90-100 % on the Karnovsky scale)
The patient is not able to perform heavy work, but can perform light or sedentary work (for example, light homework or clerical work, 70-80 % on the Karnowski scale)
The patient is treated on an outpatient basis, is capable of self-care, but cannot perform work. More than 50 % of the waking time is spent activelyin an upright position (50-60 % on the Karnowski scale)
The patient is capable of only limited self-care, spends more than 50 % of the waking time in a chair or bed (30-40 % on the Karnowski scale)
Disabled, completely unable to self-serve, confined to a chair or bed (10-20 % on the Karnowski scale)
1
2
3
4
Fig. 6. Patient K., 70 years old. Diagnosis: Skin cancer of the lower eyelid of the right eye, art. III, T3N0M0. The patient underwent surgery -removal of the tumor with exenteration of the orbit on the right. An individual silicone endoprosthesis of the right orbit was made.
Fig. 7. Patient L., 65 years old. Diagnosis: Cancer of the trellis labyrinth on the right, art. IV, T4N0M0. The patient underwent surgery - removal of the tumor with exenteration of the orbit and excision of the soft tissues of the face on the right. An endoprosthesis of the right zygomatic-buccal-orbital complex was made.
Fig. 8. Patient S., 71 years old. Diagnosis: Nasal skin cancer, art. I, T1N0M0, locally advanced cancer recurrence after radiation therapy. The patient underwent surgery -total resection of the external nose. A prosthetic nose was made.
Fig. 9. Patient K., 72 years old. Diagnosis: Skin cancer of the right auricle, art. III, T3N0M0. The patient underwent surgery - resection of the auricle on the right. The prosthesis of the right auricle was made.
Fig. 10. Patient O., 58 years old. Diagnosis: Cancer of the upper jaw on the left with spread into the orbit, art. IV, T4N0M0. The patient underwent an operation - a half resection of the upper jaw with exenteration of the orbit on the left. The first stage is a removable upper jaw prosthesis with a hollow obturator, the second -an ectoprosthesis of the left orbit.
were re-manufactured. Over time, there was a biological destruction of the material, which led to a change in the configuration and size of the obturating part of the upper jaw prosthesis. As a result, there was a need for a corresponding change in its shape and volume, and the restructuring of the system of supporting and fixing elements.
In 52 patients, the prostheses were relocated according to the method of updating the basis. In these cases, the old prosthesis was used as an individual spoon. From the surface of the base of the prosthesis, which is facing the prosthetic bed, a layer of plastic was removed with a cutter. A uniform layer of elastic correcting mass (speedex, silagum, panasil) was applied to the prosthesis) and under the dosed pressure of the opposite dentition, the impression was taken. Then the prosthesis together with the impression mass was packed in a cuvette with gypsum, and the impression mass was replaced with a base plastic by polymerization. If it was impossible to correct all the shortcomings of the prostheses (the wrong shape of the arch, the unsatisfactory color of the teeth) by one relocation of the prosthesis, then in such cases a new dentoalveolar prosthesis was made.
DISCUSSION
There were 197 patients under our supervision. As a result of the performed radical operations, isolated and combined postoperative defects of the supporting and soft tissues of the maxillofacial region were formed. Removable prostheses with an obturator on various supporting and retaining elements (clasps, attachments, telescopic crowns) were made in 159 patients.
Individual facial prostheses were made in only 38 patients. In 17 (44.7 %) - ectoprostheses of the orbital region, in 14 (36.8 %) - ectoprostheses of the external nose, in 6 (15.8 %) - ectoprostheses of the buccal-zygomatic-orbital region, in one (2.7 %) - ecto-prosthesis of the auricle. Combined prostheses were made in 4 patients: a removable upper jaw prosthesis with an obturator and a nose prosthesis; a removable upper jaw prosthesis with an obturator and an eye prosthesis. The combined prostheses were fixed together using magnets.
Prior to the start of orthopedic treatment, patients had a significant decrease in physical activity with the
predominance of the role of physical problems in the restriction of vital activity. There was also a decrease in social activity with an increased role of emotional problems in limiting their life activity. The existing defects of the middle zone of the face led not only to "physical" disability, but also caused a state of pronounced psycho-emotional discomfort in patients. Low indicators on the criteria of general perception of health, vital activity and mental health allowed us to state the moderate nature of the pathological condition and the lack of sufficient compensatory capabilities.
Jaw prostheses with an obturator made it possible to completely restore chewing, swallowing and speech of patients. Separating dentures with a dental row allowed to minimize postoperative psychological and speech therapy disorders, dysfunction of the musculature and temporomandibular joint. Facial prostheses allowed to restore the deformity of the face, improve the appearance of patients. Silicone ectoprostheses are almost invisible on the face, securely fixed, well imitated the color and texture of the skin of the face. Their weight was light, and not felt by the patients.
By the end of orthopedic treatment, the patients showed an increase in the overall perception of health, increased physical and mental performance. Maxillofacial prosthetics had a positive effect on the" psychogenic component " of the pathological condition. I gained confidence in myself, in my abilities. The circle of professional and everyday communication has been restored.
CONCLUSION
In time and complete orthopedic treatment of patients with postoperative defects of the maxillofacial tissues after extended operations for malignant neoplasms, occupies a leading place in the complex of rehabilitation measures. Early elimination of extensive defects is aimed at the maximum restoration of the disturbed functions of the oral cavity, the preservation of the external appearance. The undoubted advantage of using maxillofacial prostheses is to increase the social adaptation of patients, improve their quality of life. All this has a beneficial effect on the mental health and contributes to full rehabilitation, a return to socially useful work.
Authors contribution:
Pustovaya I.V. - collection, analysis and interpretation of data. Research concept and design, manuscript writing, material processing. Technical editing, bibliography design, preparation of illustrations.
Engibaryan M.A. - technical and scientific editing.
Svetitskiy P.V. - scientific editing.
Aedinova I.V. - surgery assistance, material processing.
Volkova V.L. - surgery assistance, collection and analysis of data.
Chertova N.A. - surgery assistance, material processing.
Ulianova Yu.V. - surgery assistance, analysis and interpretation of data.
Bauzhadze M.V. - surgery assistance, collection of data, preparation of illustrations.
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Information about author:
Irina V. Pustovaya* - Cand. Sci. (Med.), maxillofacial surgeon of the Department of Head and Neck Tumors National Medical Research Centre for Oncology of the Ministry of Health of Russia, Rostov-on-Don, Russian Federation. SPIN: 5913-8360, AuthorlD: 416789
Marina A. Engibaryan - Dr. Sci. (Med.), head of the Department of Head and Neck Tumors National Medical Research Centre for Oncology of the Ministry of Health of Russia, Rostov-on-Don, Russian Federation. ORCID: https://orcid.org/0000-0001-7293-2358, SPIN: 1764-0276, AuthorlD: 318503, Scopus Author ID: 57046075800
Pavel V. Svetitskiy - Dr. Sci. (Med.), professor, scientific director of the Department of Head and Neck Tumors National Medical Research Centre for Oncology of the Ministry of Health of Russia, Rostov-on-Don, Russian Federation. ORCID: https://orcid.org/0000-0001-5198-9873, SPIN: 6856-6020, AuthorID: 735792, Scopus Author ID: 6603343526
Irina V. Aedinova - Cand. Sci. (Med.), oncologist, Department of Head and Neck Tumors National Medical Research Centre for Oncology of the Ministry of Health of Russia, Rostov-on-Don, Russian Federation. SPIN: 9904-0539, AuthorID: 734387
Viktoriya L. Volkova - Cand. Sci. (Med.), oncologist, Department of Head and Neck Tumors National Medical Research Centre for Oncology of the Ministry of Health of Russia, Rostov-on-Don, Russian Federation. ORCID: https://orcid.org/0000-0003-2674-0755, SPIN: 8289-6300, AuthorID: 290072
Nataliya A. Chertova - Cand. Sci. (Med.), surgeon, Department of Head and Neck Tumors National Medical Research Centre for Oncology of the Ministry of Health of Russia, Rostov-on-Don, Russian Federation. SPIN: 7051-4574, AuthorlD: 473541
Yuliya V. Ulianova - Cand. Sci. (Med.), surgeon, Department of Head and Neck Tumors National Medical Research Centre for Oncology of the Ministry of Health of Russia, Rostov-on-Don, Russian Federation. SPIN: 1276-9063, AuthorlD: 457370
Mamuka V. Bauzhadze - Cand. Sci. (Med.), oncologist, Department of Head and Neck Tumors National Medical Research Centre for Oncology of the Ministry of Health of Russia, Rostov-on-Don, Russian Federation. SPIN: 5315-3382, AuthorlD: 734578
