Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 175e180

REVIEW

Patient satisfaction with maxillofacial prosthesis.Literature review

Marcelo Coelho Goiato*, Aldieris Alves Pesqueira, Cristina Ramos da Silva,Humberto Gennari Filho, Daniela Micheline dos Santos

UNESP e Sao Paulo State University, Aracatuba Dental School, Department of Dental Materials andProsthodontics, Brazil

Received 21 April 2008; accepted 20 June 2008

KEYWORDSMaxillofacial prosthesis;Patient satisfaction;Obturator maxillary

* Corresponding author. Address: MJose Bonifacio, 1193, CEP 016015-0Tel.: þ18 3636 3287; fax: þ18 3636 3

E-mail address: goiato@foa.unesp.

1748-6815/$-seefrontmatterª2008Britdoi:10.1016/j.bjps.2008.06.084

Summary Obturators and facial prostheses are important not only in rehabilitation andaesthetics, but also in patient re-socialisation. The level of reintegration is directly related tothe degree of satisfaction with rehabilitation. So, the maxillofacial prosthetics must providepatient satisfaction during treatment. This study aimed to search information in database andconduct a literature review on patient satisfaction with maxillofacial prosthesis. The problemsexperienced by these patients may decrease when specialists keep the patient on regular inspec-tion. Rehabilitation through alloplasty or prosthetic restoration provides satisfactory conditionsin aesthetics and well-being and reinstates individuals in familial and social environment.ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Cancer surgery, malformation or trauma may cause broadfacial defects that cannot be covered by patients becauseof their exposed site. Such defects lead to functionaldeficits and enormous psychological strain and requirerehabilitation at all ages.

The prosthetic rehabilitation is a surgical alternative infunctionaleaesthetic facial reconstruction when theconventional reconstructive surgery cannot be appliedeither because of the psychophysical conditions of thepatient or because of an excessive substance loss.1

arcelo Coelho Goiato, Rua50, Aracatuba, SP, Brazil.

246.br (M.C. Goiato).

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Studies on the quality of life of patients with head andneck cancer showed high levels of emotional anguish,physical limitations, disturbances in body image anddamage in social relations. However, studies on changes inperceived quality of life after prosthetic rehabilitation arelimited.2,3

The purpose of this study was to evaluate patientsatisfaction with obturator and facial prosthesis.

Materials and methods

A Medline (PubMed) search from 1967 up to and includingJune 2008 was conducted for articles published in thedental literature, and limited to human trials, using the

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 2 Obturator prosthesis.

176 M.C. Goiato et al.

search terms ‘maxillofacial prosthesis’, ‘patient satisfac-tion’, ‘positive life evaluation’, ‘head and neck cancer’,‘health-related quality of life’, ‘obturator maxillary’ and‘facial prostheses’.

Manual searches of the bibliographies of all full-textarticles and related reviews, selected from the electronicsearch, were also performed.

Results and discussion

Obturators and facial prostheses are important for reha-bilitation and aesthetics as well as for patient re-socialisation. The level of reintegration is directly relatedto the degree of satisfaction with rehabilitation. Therefore,the maxillofacial prosthetist must emphasise patientsatisfaction during treatment.4

Almost 5% of all cancers affect mouth structures,tongue, oropharynx, nasopharynx and larynx.5 After exci-sion of these lesions, problems regarding chewing, swal-lowing and speech may appear. Furthermore, changes inappearance, psychosocial function and vocational statusmay affect the quality of life of these patients aftersurgical intervention.6

The problems created by maxillectomy defect arenotably mastication, speech, olfactory and gustatory sen-sations.7e10 These patients also experience problems suchas seepage of nasal secretions into the oral cavity, poor lipseal, xerostomia,8 exophthalmoses and diplopia.9,11 More-over, the patient develops aesthetical and psychologicalproblems12 (Figures 1 and 2).

The optimal reconstructive therapy of maxillary defectsremains controversial.7,13 Several therapeutic approacheshave been published, including prosthetic obturators, non-vascularised grafts, local flaps, regional flaps and freetissue transfer.14e16 Reconstruction of maxillary defects byeither reconstructive surgery or an obturator prosthesisdepends on patient characteristics, such as age, medicalhistory and defect size.13,17e19 Surgical flap reconstructionprovides definitive correction of the abnormal oronasalcommunication, but requires technical expertise and is, ingeneral, associated with increased procedure time and thepossibility of donor morbidity at the flap harvest site.7,20

Figure 1 Anterior view of the anatomical defect followinga partial maxillectomy in an edentulous patient.

In contrast, fabrication of an obturator prosthesisshortens the procedure time and offers the possibility ofimmediate and adequate dental rehabilitation. The surgicalsite can be easily examined after removing the obturatorprosthesis, and tumour recurrence may be detected ina timely manner. Obturators can be used for provisional ordefinitive rehabilitation.16,20e22 Commonly used materialsfor the fabrication of obturator prostheses are silicone,polymethyl methacrylate (PMMA) and titanium.23

Kornblith et al.24 reported that satisfactory functioningof the obturator prosthesis significantly contributes toimproved psychological well-being and the quality of lifefor maxillectomy patients. Therefore, the use of maxillo-facial prosthesis can bring good cosmetic and functionalresults; however, to perform this surgery can be a challengeto the professional.

Obturator prostheses must fulfil certain functions suchas facilitating food, protect wound or keep the defectivearea clean, increase trauma healing, help remodelling andrebuilding of palatine contour, promote speech andimprove aesthetics25e29 (Figures 1, 2 and 3). The retentionof an obturator depends on factors such as direct or indirectretention promoted by the remaining teeth, defect size,tissue retention available around the cavity and develop-ment of muscular control.30 These requirements areimportant to treatment success, since these increase thequality of life of patients after maxillectomy.24,31e34

The maxillary obturator is a useful aid in the rehabili-tation of speech and that immediate, provisional and finalobturators are all important in the rehabilitation of speechin patients with post-surgical partial defects.34e37

Complete rehabilitation of a maxillectomy patient canbe achieved using a multidisciplinary team approach,involving both surgical and prosthetic personnel.

For these patients, an obturator prosthesis can re-establish the separation of the oral cavity from the sino-nasal cavities, restoring speech and swallowing function. Indentate patients, support, stability and retention of suchan obturating, removable prosthesis relies on the remaininghard and soft tissues19,30,38,39 (Figures 4 and 5). The largerthe surgical resection, the greater the loss of mucogingivalsupport, which in turn results in increased unfavourableforces acting on the remaining abutment teeth.18,30,40 Since

Figure 3 Oral rehabilitation with obturator prosthesis. Figure 5 Oral rehabilitation with an obturator removablepartial dental prosthesis.

Patient satisfaction with maxillofacial prosthesis 177

the advent of osseointegration, the combination ofimplants and prosthetic obturators has proven to be bene-ficial, especially in the rehabilitation of the edentulousmaxillectomy patients.40e43 This treatment option providesadditional support and retention to a conventional obtu-rator and renders such a procedure beneficial to thepatient.44

The method most common for manufacturing obturatorsis with the palatal contours shaped while the acrylic resin ispolymerised. A tray handle is added to the palatal surface.The tray is adjusted to facilitate intra-oral placement, anda posterior extension is added to the remaining third of thesoft palate with a resilient lining material, which is posi-tioned close to the posterior and lateral pharyngeal wallsfor optimal functional outcomes.10

The prosthetic rehabilitation may improve function andself-esteem of patients after the re-establishment of facialdeformations, resulting in considerable cosmetic impair-ment (Figures 6 and 7). A surgical reconstruction is gener-ally very difficult and often fails to provide satisfyingresults.45e47 Facial prostheses have the advantage of notonly improving the patient’s appearance, but also enabling

Figure 4 Anterior view of the anatomical defect followinga partial maxillectomy in a partial edentulous patient.

early rehabilitation, making it possible for the inspection ofthe affected area, shortening surgery and hospitalisationtime, lowering treatment cost and allowing the patientearly psychosocial re-integration48 (Figure 8).

However, difficulties with facial prostheses occur due tosoft tissues layer, quality of prosthesis retention, colourchange and reactions of the skin with the adhesives.4,49 Thepatient’s acceptance of the facial prostheses can beincreased significantly by aesthetic, quality of retentionand stability of the prosthesis.4

Modern materials for external prostheses include vinylplastisols, PMMA, polyurethanes, latex and silicone elasto-mers.50 Silicone elastomers are the material of choicebecause of chemical inertness, strength, durability andease of manipulation.50 However, silicone elastomers andpigments exhibit a colour change over time.51 McKinstryfound that patient satisfaction with external prosthesesdeclined within the first 3 years of service.52 Thisphenomenon may be attributable to the fact that froma patient’s perspective, colour change is one of the mostimportant parameters when evaluating the performance ofan external prosthesis.53e55

Traditional means of retaining facial prostheses haveinvolved the use of medical-grade skin adhesives, solvents,eyeglasses, the use of hard and soft tissue undercuts andother modalities.56 Unfortunately, this treatment was oftenwrought with difficulties associated with retention,stability, adverse tissue reactions, discolouration andprosthesis deterioration, inconvenience of use or applica-tion, poor hygiene, discomfort and lack of acceptance.53,54

Percutaneous craniofacial implants in craniofacial recon-struction have minimised some of these disadvantages andhave provided patients with predictable aesthetics anddurability, improved retention and stability of the pros-theses.55,56 Parel et al.57 reported in 1986 that the use ofimplants in maxillofacial prosthetics was the most signifi-cant advance in the field of facial prosthetics in the past 25years.

Bone-anchored facial prostheses have been used withgood cosmetic results since the late 1970s.58 Many studiesshowed that most of the patients benefit from this proce-dure in various ways.59e61 These implants, on which the

Figure 6 A patient with a nasal basal cell carcinoma.

Figure 8 A patient with a nasal prosthesis.

178 M.C. Goiato et al.

facial prosthesis is anchored, consist of two parts: theimplant itself for enosseous fixation with an abutmentpenetrating the skin and a retention system embedded inthe base of the facial prosthesis. As a main retainer, usuallyeither a bar splint or a magnetic attachment is used.

The satisfaction and quality of life of patients withimplant-retained facial prostheses in auricular and orbitalregions are greater than those with adhesive-retainedprostheses.2,62

Figure 7 A patient before resection of the malignant nasaltumour.

In addition, the satisfaction of the patient is directlyrelated to the dentist’s psychological attitude with regardsto gaining his confidence. In prosthetic treatment, greatunderstanding and co-operation on the patient’s part areneeded. According to their moral sensitivity, thesepatients are individuals who are resentful about the lesionand generally have complexes. The professional, when incontact with the patient, must not show any feelings ofsurprise or repulsion, especially in the face of oncosurgicallesions. To the contrary, in any case, the professional willshow optimism as regards the treatment to be started andthe results expected to be achieved. This attitude willboost the mutilated patient’s morale, and he/she willeven show enthusiasm about co-operating with thetreatment.4

In the past, the absence of validated questionnaireswas one of the major problems in evaluating the qualityof life and satisfaction of maxillofacial prosthesiswearers. Additionally, this type of prosthesis is unusualand the lack of data leads to a subjective result. Most ofthe studies of quality of life include a heterogeneous andreduced sample, which requests a greater longitudinalcomparison.

The problems experienced by maxillofacial prostheseswearers are reduced, since a specialist team applies all thepractice and experience and maintains a regular follow-up.The patients’ prosthetic rehabilitation allows for satisfac-tory aesthetic recuperation and well-being, while psycho-logical therapy allows for patients’ re-insertion in socialand familiar environment to make them feel more happyand safe.

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