Palatal augmentation prostheses （PAP） have been used as oral appliances for compensating defects of tongue-palate contact during swallowing and articulation. In the 23rd Educational Symposium of the Japanese Association of Maxillofacial Prosthetics in 2018 at Tokushima, three lecturers （prosthodontist, dental technician and speech language pathologist） gave talks about how to maximize the effect of PAP in rehabilitation. As an introduction of their review articles, the chairman of the symposium gave a brief summary of the “standpoint on oral appliances in rehabilitation” and “mechanism for improving chewing and swallowing by oral appliances.”
The palatal augmentation prosthesis （PAP） is an intraoral prosthesis designed to improve tongue-palate contact during speech and swallowing in patients with tongue resection or impaired tongue mobility. In patients with postoperative oral cancer, a PAP is often applied primarily to improve swallowing function since safe and adequate nutrition intake may have a direct impact on postoperative prognosis. Recently, with advances in treatment techniques and more patients returning to work following treatment, there is an increasing need for improving speech function for efficient communication. During rehabilitation for speech disorders in this group of patients,
co-operation between dentists and speech-language-hearing therapists is crucial. This article summarizes the general knowledge of speech disorders in oral cancer patients, and introduces speech rehabilitation techniques when applying PAP in these patients.
In the super-aging society of Japan, the number of people aged over 75 years old is increasing, which means an increase in older people who need long-term nursing care. Therefore, community-based integrated care systems encompassing medical care, welfare, and nursing care are important to support their living. Dentists are welcome to join the care with a multidisciplinary team approach, because most of the patients need dysphagia rehabilitation due to disease. Dysphagia rehabilitation in Japan is often performed with a transdisciplinary team approach, and dentists play an important role in performing swallowing examination as well as prosthetic treatment, including a palatal augmentation prosthesis （PAP）. The focus of a PAP is the oral stage of swallowing and the PAP can recover the bolus formation and transportation from the oral cavity to the pharynx by the tongue. The detailed techniques for making a PAP remain unclear due to differences in the decline of tongue function. However, there are several important points when using a PAP in dysphagia rehabilitation. In particular, it is essential to evaluate tongue function before and after the delivery of a PAP. The present article describes dysphagia rehabilitation and PAP, focusing on the transdisciplinary team approach so that dentists can join the team smoothly.
Dental technicians cannot directly provide therapeutic services to patients in the team approach for dysphagia rehabilitation with prosthetic appliances such as a palatal augmentation prosthesis （PAP）. However, dental technicians can contribute to rehabilitation by fabricating the PAP in cases where the palatal contour designed by the dentist should be precisely reproduced. There are various types of PAP such as the palatal plate type, denture type, solid type and hollow type. The type of PAP should be chosen based on tongue motor function, purpose of rehabilitation, state of dentition, and so on. For designing the PAP, tongue contact impression is taken on the palatal surface of the prosthesis with tissue conditioning materials or soft plate wax. Although most steps of PAP fabrication can be performed by conventional techniques for dentures and dento-maxillary prostheses, the dental technician should minimize polymerization to prevent deformation of the PAP contour. Additionally, close communication with the dentist as well as efficient fabrication are required in order to provide the PAP promptly to the patient. In this paper, technical considerations for fabricating PAPs and the points requiring attention in the team approach are described from the viewpoint of dental technicians.
Background: Although maxillary prostheses have been regarded as the first choice for closure of acquired maxillary defects, their priority has become the subject of discussion because of recent advancements in reconstructive surgery. The aim of this review paper is to compare the utility of prostheses and surgical reconstruction for the functional rehabilitation of patients with maxillary defects. Methods: A systematic literature survey was conducted by the Japan Medical Library Association based on keywords for PubMed and Ichushi-web presented by the Clinical Practice Guideline Committee of Japanese Academy of Maxillofacial Prosthetics. After secondary screening, related articles were extracted and their structured abstracts were created for discussion. Results: Randomized controlled trials and meta-analyses were not found, and many of the searched articles were clinical studies based on an accumulation of several cases to one hundred cases. In addition to 31 extracted articles, three articles older than 1995 from the Clinical Guideline of Maxillofacial Prosthetics 2009 and three Japanese articles about the classification of maxillary defects were included in the review. Conclusions: It is necessary to fully consider the type of defect （part, size, etc.）, and the number of residual teeth or related factors such as tumor therapy when choosing the prosthetic or surgical approach. Maxillary prostheses are useful in the case of partial maxillectomy which is equivalent to or less than subtotal maxillectomy with preservation of the orbital floor, unilateral defect of the hard palate and/or alveolar process, and with residual teeth in the maxilla. For larger defects and edentulous jaws, the combination of reconstructive surgery and implant is useful for functional recovery, but finally it is desirable to restore function by wearing a maxillary prosthesis after reconstructive surgery.
Background: Implant therapy can be an effective option for prosthetic treatment for intractable cases with maxillary defect. The aim of this review was to elucidate the effectiveness of implant therapy for patients with maxillary defect. Methods: A systematic literature survey was conducted by the Japan Medical Library Association based on keywords for PubMed and Ichushi-web presented by the Clinical Practice Guideline Committee of Japanese Academy of Maxillofacial Prosthetics. After secondary screening, relating articles were extracted and their structured abstracts were described for discussion. Results: RCTs and meta-analyses were not found, and many articles were clinical reports based on a single case report or case accumulation study. After the second screening, 17 papers were extracted. From these papers, implant-supported maxillary prostheses tended to be applied to edentulous patients with large maxillary defects where stability and retention of prosthesis could not be established by conventional prostheses. Improvement of masticatory performance and speech intelligibility by implant-supported maxillary prostheses was better than that by conventional prostheses. However, the success rate of implant therapy remains controversial. Conclusions: Implant-supported maxillary prostheses have higher stability and retention than conventional maxillary prostheses, which might be useful to improve the masticatory performance and speech intelligibility of post-maxillectomy patients.
Background: The aim of this review was to elucidate the effectiveness of prostheses with implant therapy for patients with mandibular defects. Methods: A systematic literature survey was conducted by the Japan Medical Library Association based on keywords for PubMed and Ichushi-web presented by the Clinical Practice Guideline Committee of Japanese Academy of Maxillofacial Prosthetics. After the secondary screening, related articles were extracted and their structured abstracts were described for discussion. Results: Although randomized controlled trials and meta-analyses were not found, 28 papers were extracted after screening. Overall, objective and subjective measures （e.g. occlusal force, masticatory efficiency and food acceptability questionnaires） were significantly increased with implant-supported mandibular prostheses. However, speech and swallowing function were not improved in cases with tongue or oral floor resection. Success and survival rates of implant therapy were ninety percent or more on mandibular reconstruction with autogenous bone grafts. Conclusions: These results suggest that implant-supported mandibular prostheses that can secure the stability of the upper fixed/removable structure are more effective for recovering masticatory function compared with conventional mandibular prostheses.
This study investigated three assessments of food-mixing ability （a＊） values under different chewing instructions using color-changeable chewing gum and examined the associations of a＊ values with food-comminuting and perceived chewing ability in order to evaluate masticatory function in maxillectomy patients. According to set criteria, 40 maxillectomy patients were enrolled in this study. Objective food-mixing ability （a＊） was assessed using color-changeable chewing gum with three different chewing instructions: a＊ 60, chewing 60 strokes; a＊ 100, chewing 100 strokes; and a＊ 1min, chewing for 1min. The time-taken and number of strokes were recorded. Objective food-comminuting ability as an index of masticatory performance （MP） was assessed using gummy jelly. Perceived chewing ability rated as a masticatory score （MS） was assessed using a food intake questionnaire. Spearman’s rank correlation coefficients were analyzed between a＊ values, MP, and MS. Of the three different food-mixing ability assessments, a＊ 1min showed the highest multiple correlations with MP and MS compared with a＊ 60 and a＊ 100. The food-mixing ability test with the 1-min chewing instruction was better correlated to the food-comminuting and the perceived chewing ability in maxillectomy patients, suggesting the potential utility of such assessment.
A 41-year-old male underwent right maxillary bone resection and a dento-maxillary prosthesis was delivered. During maintenance, he was diagnosed with obstructive sleep apnea （OSA）, so an oral appliance （OA） was fabricated and the patient was followed up for two years. The Apnea Hypopnea Index （AHI） without the dento-maxillary prosthesis （WP） was 37.9, with the dento-maxillary prosthesis （P） was 12.2, and with the OA was 1.8. After wearing the OA for two years （OA2）, AHI with OA became 15.4. Sleep stage （N2） WP was 73.0％. OA2 with OA became 62.5％. Sleep efficiency of WP was 66.8％. OA2 with OA became 96.0％. Arousal Index of WP was 18.2. OA2 with OA became 96.0. The results of a sleep test showed that AHI, SpO2min, and sleep efficiency all improved by wearing the OA, and the patient was satisfied with the effects of the OA. When OSA worsens, it is necessary to apply a lower jaw forward traction type OA. We will continue to check oral health and work carefully with medical doctors.
Bears, which are large wild animals, usually attack the maxillofacial area using the fore-foot and teeth. The resulting severe facial injury needs cosmetic reconstruction and oral rehabilitation. The following report describes a case of severe facial injury which was treated by lower lip reconstruction and prosthetic rehabilitation. The patient was an 82-year-old man. He was attacked by a wild bear in the mountains. Lower lip reconstruction with a free forearm flap was performed 10 months after emergency surgery. He was satisfied with the cosmetic reconstruction, but the oral functions such as occlusion and speech were not fully recovered. Treatment with dental implants was impossible because a scar on the lower lip and oral mucosa prevented mouth-opening. A dental prosthesis was prepared and subsequent oral functional examinations revealed that his oral function had sufficiently improved. In the treatment of facial injuries, it is essential to restore not only aesthetic features, but also good oral function.
A 70-year-old male was referred by a head and neck surgeon for preoperative examination of maxillary left gingival carcinoma. After surgery, he had a defect in his left-side maxillary bone. A maxillary denture with obturator prosthesis was made because of the presence of a chin defect in the nasal cavity and maxillary sinus on the left side of the maxilla. Due to the mobility of the denture abutment teeth, an enamel bonding resin splint was used. Multiple I-bar Roach clasps made of cobalt chromium alloy were adopted as abutment devices for the maxillary denture, and the bracing arm was installed on the palatal side. After wearing the denture, a speech intelligibility test was performed and a questionnaire on food was answered to evaluate the denture. The results showed partial improvement. The mobility of the maxillary anterior teeth adopted as the abutment teeth showed improvement after 3.5 years of use. In this case report, despite the loss of balance in the number of teeth of the upper and lower jaws following surgery, we obtained good progress by reinforcing the denture abutment, thus showing a useful method to protect the remaining teeth.