Long-Term Dental Care for Post-Maxillectomy Patients

Providing dental care for patients with a history of maxillary neoplasm and surgical resection can be daunting for general dentists and specialists alike, particularly due to the scarcity of maxillofacial prosthodontists in many communities.^1–3 Helping post-maxillectomy patients to effectively manage their routine dental care will ultimately improve their overall oral health and quality of life.⁴

Most tumors of the maxilla occur in the palate and paranasal sinus; they can be either benign or malignant. Maxillectomy, which involves the surgical removal of part of the maxilla, is generally sufficient for treating benign tumors.^1,5,6 For malignant tumors, however, maxillectomy may be followed by adjuvant therapies such as radiation therapy and/or chemotherapy. Depending on the location and extent of the tumor, maxillectomies can involve resection of the hard palate, soft palate, alveolar ridges, dentition, and, in more extensive cases, may encroach upon adjacent structures such as the eye and nose.^1,4,5

A maxillectomy creates a defect, which involves an oronasal or oroantral communication from removing the partition between the oral cavity and the nasal passages or sinuses, respectively.^1,6,7 If this defect is not closed, comorbidities will arise.⁸ For small maxillary defects, primary closure can be achieved by approximating adjacent oral mucosa (Figure 1A and B).^1,6 However, for larger defects, primary closure is not advised, but instead, surgical closure with pedicled flap or free flap is used to replace the missing tissues (Figure 1C and D). Pedicled flaps are rotational flaps from donor sites for small to medium posterior dentoalveolar defects. For more extensive defects, a free flap transfer is a microvascular procedure transplanting tissues from one site in the body to another with anastomosis of the vasculature.^9,10

Surgical reconstruction alone is capable of restoring basic oral functions when few or no teeth are involved with the resection. When more teeth are removed, or when the patient is already edentulous, a combination of surgical and/or prosthetic rehabilitation should be considered with or without the assistance of dental implants.^1,5 Prosthetic rehabilitation of a maxillary defect is achieved using an obturator, which is a maxillofacial prosthesis designed to close the integrity of the oral and nasal compartments (Figure 2).^4-6 The obturator facilitates speech and swallowing by replacing the tissues lost due to the disease process, thereby reducing nasal regurgitation and correcting hypernasal speech.⁷

An advantage of prosthetic rehabilitation over surgical reconstruction is that the obturator is removable, providing the patient with access to maintain hygiene of the maxillary defect (Figure 3).^1,8 Furthermore, providers have direct visual access into the sinuses, enabling better surveillance for potential tumor recurrences.¹

Implants play a crucial role in providing enhanced retention, stability, and support for dental prostheses following maxillary tumor ablation. Implants should be placed concurrently with the maxillectomy, which is referred to as either primary, immediate, or same-stage implant placement. Radiation therapy can compromise the vascularity and healing capacity of the surrounding tissues, affecting the success rate of dental implants, and increase the risk of osteo­radio­nec­rosis.^11,12 Secondary implant placement in patients with a history of head and neck radiation therapy should be me­ticulously planned after reviewing the radiation dosimetry. Collaboration with a multidisciplinary team is essential.¹¹

If the maxillary defect is closed via surgical reconstruction, implants can be placed to support either a fixed or removable prosthesis. When surgical reconstruction uses a bone-containing free flap, such as the fibula, conventional dental implants are often employed. In fact, a comprehensive treatment approach known as “jaw in a day” can be utilized, wherein maxillectomy, free flap surgical reconstruction, implant placement, and delivery of a fixed implant-supported provisional prosthesis are all performed on the same day.^13,14 In cases where surgical reconstruction is achieved using a free flap without bone, such as the radial forearm, zygomatic implants can be placed for remote anchorage in a technique called the zygomatic implant perforated flap.¹⁵

In situations where the maxillary defect is not closed, conventional dental implants cannot be placed directly over the defect due to the absence of alveolar bone. Instead, a combination of zygomatic implants and off-axis implants can be utilized in remote sites.¹ Especially for zygomatic implants, splinting with an early loaded implant-connecting bar as soon as possible post-placement optimizes cross-arch stabilization and enhances force distribution. This is transitioned to a definitive implant-connecting bar with obturator prosthesis after adequate healing (Figure 4).

Dental Care for Post-Maxillectomy Patients

Patients who have undergone maxillectomy require specialized dental management to address their unique oral needs, maintain oral health, monitor their condition, and provide dental treatment modification when needed. Following rehabilitation, recare examinations should occur every 3 months during the first year to ensure timely detection of any complications. Based on the patient’s risk assessment and history of radiation therapy, this is continued indefinitely, or reduced to every 6 months for lower risk individuals.¹⁶

The recare examination should include an oral cancer screening, starting with an extraoral assessment by visual inspection and palpation of the neck, facial soft tissues, and lymph nodes.¹ An intraoral examination includes evaluation of the dentition and examination of the soft tissues of the palate, cheeks, tongue, floor of mouth, and throat for abnormalities or lesions.

Familiarity with the anatomy associated with maxillary defects can assist the clinician in distinguishing normal from abnormal findings. If the maxillary defect was not surgically closed, the nasal turbinates may be visible (Figure 5A and B). The inferior turbinates should be removed during resection to facilitate the extension of the obturator into the defect area.

A properly tailored maxillary defect involves the use of a split-thickness skin graft — a 0.3 mm thin slice above the level of hair follicles and harvested from the thigh (Figure 5C).^1,17 This technique creates a more suitable keratinized denture-bearing surface for an obturator prosthesis. If the maxillary defect has been surgically reconstructed, a full thickness cutaneous, adipose and muscle flap is visualized resembling the donor site in color and presence of hair (Figure 1C and D), but can be bulky in thickness.^8,10

In patients with suboptimal hygiene, dried mucus can often be observed within the maxillary defect, appearing as dark, scab-like accumulations (Figure 6A). These accumulations are harmless and can be gently removed from tissue surface by applying a cleaning solution of a 1:1 mixture of hydrogen peroxide and chlorhexidine to reveal normal mucosa or skin (Figure 6A and B).

During hygiene appointments, the passage of water into the defect should be minimized, particularly when using an ultrasonic scaler. When cleaning the mandibular teeth, the obturator prosthesis should be kept in place. When cleaning the maxillary teeth, placing a 4×4 gauze covering the defect site and using a high-volume evacuator can minimize water and enhance patient comfort and safety during the appointment.

If the patient presents with an implant-retained prosthesis, the implants should be cleaned according to standard recommendations.¹⁸ Removal of a fixed implant prosthesis or implant-connecting bar should be considered if the patient demonstrates difficulty in maintaining proper self-care.¹⁸ Effective cleaning can be achieved by using a 2×2 gauze soaked in chlorhexidine, an interproximal brush, or floss with a stiff threader to clean the intaglio surface of the prosthesis or bar. The walls of the maxillary defect should also be cleaned of dried mucous.

At home, teeth and implants should be brushed normally for 2 minutes, two to three times a day following meals, and flossed every day. For patients with a fixed implant prosthesis or implant-connecting bar, threading floss or 2×2 gauze underneath is recommended daily. Dental irrigators are also helpful.

Patients should be instructed to remove the obturator and refrain from wearing it during sleep to allow the tissues to rest. Patients who have undergone radiation therapy should follow a lifelong preventive routine of applying 5,000 ppm fluoride daily, either by toothbrushing or using custom-fitted trays, to prevent caries.¹⁶ When the obturator prosthesis is removed, it should be gently brushed with soap and stored in water.

The nasal passages and sinuses should be irrigated daily. Nasal irrigation with saline solution through the nasal passages and sinuses clears out mucus and flushes out debris and allergens. To clean the walls of the maxillary defect, an oral swab or a 2×2 gauze around a fingertip is dipped in the cleaning solution to gently cleanse the area.

In this patient population, all restorative dental work can be performed, but with caution. Any direct or indirect restorations on abutment teeth for a removable prosthesis must be carefully executed to avoid altering the prosthesis fit. A poorly fitted obturator may lead to complaints of nasal regurgitation and hypernasal speech post-procedure. If the provider is uncomfortable retrofitting an existing removable prosthesis to the new restoration, the patient should be referred to a maxillofacial prosthodontist.

Placing a 4×4 gauze into the defect site and using a high-volume evacuator are key. A pharyngeal drape or throat pack must be used and any small intraoral instruments should be ligated to prevent aspiration. Indirect restoration try-ins should ideally be done with the patient sitting up.

Dental surgeries in patients who have received head and neck radiation should only be performed after careful discussion with radiation oncology and a dental medicine, dental oncology, or maxillofacial prosthodontist. Radiation therapy induces hypovascularity, hypocellularity, and hypoxia in bone tissues, thereby increasing the risk of osteoradionecrosis following procedures involving alveolar bone.^11,12 Special attention should be given to teeth located within high-dose radiation fields, and nonsurgical dental treatment options should be considered to reduce the risk of osteoradionecrosis. This nonsurgical treatment recommendation can include root canal treatment, coronectomy, and an amalgam dome with careful monitoring, as an alternative to extraction.¹¹

A prosthesis evaluation should be conducted at all recare appointments. All fixed implant prostheses in maxillectomy patients with surgically closed defects can be treated like any other conventional fixed implant prosthesis. Removable prostheses, such as obturators, should be assessed for proper support, stability, and retention.

If no implants were placed on the side of the resection, there is lack of support, and the prosthesis may depress into the defect under load. Occlusion should be carefully checked and adjusted to ensure that there is light contact over the defect in centric occlusion to avoid placing excessive stresses on the remaining natural abutment teeth.

If the patient experiences minor obturator loosening, the metal clasps can be adjusted, similar to adjustments made for removable partial dentures. However, if the patient complains of nasal regurgitation and hypernasal speech, a reline may be necessary to improve the seal, or a new prosthesis if significant modifications are required (Figure 7).

Additionally, if a patient with a long history of obturator use experiences sudden difficulty seating the prosthesis, this could be a sign of tumor recurrence (Figure 8). In such scenarios, the patient should be referred back to his/her oncologist or maxillofacial prosthodontist.

Conclusion

Caring for post-maxillectomy patients is a critical aspect of cancer survivorship. Beyond surgical reconstruction and prosthetic rehabilitation, these patients require lifelong dental care to maintain oral health and monitor for potential complications.

References

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3. American Academy of Maxillofacial Prosthetics. Maxillofacial Prosthetics. Available at: maxillofacialprosthetics.org. Accessed October 3, 2024.
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15. Butterworth CJ, Lowe D, Rogers SN. The Zygomatic Implant Perforated (ZIP) flap reconstructive technique for the management of low‐level maxillary malignancy–clinical & patient related outcomes on 35 consecutively treated patients. Head Neck. 2022;44:345-358.
16. Featherstone JD, Crystal YO, Alston P, et al. Evidence-based caries management for all ages-practical guidelines. Front Oral Health. 2021;2:657518.
17. Park S, Chao D, Blackwell KE, Jayanetti J. Modified vestibuloplasty of the zygomaticoalveolar crest to gain intradefect support for an obturator prosthesis. J Prosthet Dent. 2023;129:946-950.
18. Bidra AS, Daubert DM, Garcia LT, et al. Clinical practice guidelines for recall and maintenance of patients with tooth-borne and implant-borne dental restorations. J Am Dent Assoc. 2016;147:67-74.

From Decisions in Dentistry. October/November 2024;10(6):36-41.