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Diagnosis and Treatment in Prosthodontics Second Edition
DIAGNOSIS AND TREATMENT IN Second Edition PROSTHODONTICS Edited by
William R. laney,
DMD, MS
Professor Emeritus Department of Dental Specialties Mayo Clinic College of Medicine Rochester, Minnesota
Thomas J. Salinas,
DDS
Associate Professor of Dentistry Department of Dental Specialties Mayo Clinic College of Medicine Rochester, Minnesota
Alan B. Carr,
DMD, MS
Professor of Dentistry Department of Dental Specialties Mayo Clinic College of Medicine Rochester, Minnesota
Sreenivas Koka,
DDS, MS, PhD
Professor of Dentistry Department of Dental Specialties Mayo Clinic College of Medicine Rochester, Minnesota
Steven E. Eckert,
DDS, MS
Professor Emeritus Department of Dental Specialties Mayo Clinic College of Medicine Rochester, Minnesota
Quintessence Publishing Co, Inc Chicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Istanbul, boollt Sao Paulo, New Delhi, Moscow, Prague, and Warsaw
..,..__
Library of Congress Cataloging-in-Publication Data Diagnosis and treatment in prosthcxlontics I ediled by William R. Laney ... (et ai.J. -· 2nd ed. p.; em.
Rev. ed of: Diagnosis and treatment in prosthooontics I William R. L aney Joseph A. Gibilisco . 1983. Includes bibl iographical references and index. ,
ISBN g78-0-86715-404-7 (hardcover) 1. Prosthodontics. I. Laney, William R., 1928· II. Laney, William R., 1928· Diagnosis and treatment in prosthodont ics. [DNLM: 1. Prosthodontics--methods. 2. Oral Surgical Procedures, Preprosll1etic--methods. WU 500) RK651.D5 2011 617.6'9--dc22 2011006322
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or
by
Contributors
Mayo Clinic College of Medi cine
Brent E. Larson, DDS. MS Professor Department of Diagnostic/S urgical Orthodontics University of Minnesota
Rochester, Minnesota
Minneapolis, Minnesota
Dusica Babovic-Vuksanovic, M D Chair and Associate Professor
Charles L. Loprinzi, M D Professor of Oncology
Department of Medical Genetics
Mayo Clinic College of Medicine
Mayo Clinic College of MediCine
Rochester, Minnesota
David J. Archibald, MD
Resident Otolaryngology
Rochester. Minnesota
David MacDonal d BDS. BSc(Hons). LLB(Hons). MSc. ,
Charles R. Carlson, PhD. MA. ABPP Professor of Psychology and Dentistry
DDS(Edin). FDSRCPS (Giasg). DDRACA (UK), FRCD (Can) Asso ciate Professor
College of Dentistry
Faculty of DentiStry
University of Kentucky
University of British Columbia
Lexington, Kentucky
Vancouver, British Columbia
Alan B. Carr, DMO, MS Professor of Dentistry Departmen t of Dental Specialties Mayo Clinic College of Medi ci ne Rochester. Minnesota
Canada
Kevin I. Reid, DMD Assistant Professor of Dentistry
Department of Dental Specialties Mayo Clinic College of Medicine Rochester. Minnesota
Mijin Choi, DDS. MS Clinical Assistant Professor Department of Prosthodontics
New York Universi ty College of Dentistry New York, New York Steven E. Eckert, DDS. MS
Kevin L. Rieck, DDS. MD Instructo r in Surgery Section of Oral and Maxillofacial S urgery Mayo Clinic College of Medicine Rochester. Minnesota
Department of Dental Specialties
Jana M. Rieger, PhD Associate Professor
Mayo Clinic College of Medicine
Institute for Reconstructive Sciences in Medicine
Professor Emeritus
Rochester. Minnesota
Department of Speech and Language Pathology
Robert L. Foote M D Professor ,
and Audiology Faculty of Rehabilitation Medi ci ne
Radiation Oncology Mayo Clinic College of Med icine Rochester. Minnesota
Canada
Rochester, Minnesota
Thomas J. Salinas, DDS Associate Professor of Dentistry Department of Dental Specialties Mayo Clinic College of Medicine
Sreenivas Koka, Dos. MS PhD Professor o f Dentistry D epartment of Dental S pecial ti es Mayo Clinic College of Medicine ,
Rochester, Minnesota
William R. Laney DMD. MS Professor Emeritus Department of Dental Specialties Mayo Clinic College of Medicine Rochester, Minnesota
University of Alberta Edmonton Albert a ,
Jan L. Kasperbauer, MD Professor of Oto laryngology Mayo Clinic College of Medicine
,
Misericordia Community Hospital
Rochester, Minnesota
John E. Schmidt, PhD Assi stant Professor of Psychiatry Mayo Clinic College of Medicine Rochester, Minnesota Kostandinos Sideras, MD Assistant Professor of O ncology Mayo Clinic College of Medicine Rochester. Minnesota
IX
Preface S ince publication of the first edition, many changes have occurred
8ectronic t echnology has provided for an improved diagnostic and
in the clinical practice of prosthodontics. While the human patient
treatment-planning capability. Imaging techniques and equipment
and related oraVperioral problems remain physically unchanged.
have evolved that provide more extensive and accurate information,
psychosocial attitudes toward dentistry and care deliverers have
which assist the clinician in decsion i making prior to and during
been altered as a result of shifts in societa l values and priorities.
treatment. COmpared to two -dimensional or flat-screen ima ges,
An enlightened and enti tled generation now places more e mp hasis
newer three-dimensional imaging and modeling have s ignificantly
on personal appearance, early relief from pain and inconvenience
enhanced the planning and delivery of surgical r estorative treatmen
in a timel y manner, as well as cost and cost sharing by third p arty -
contributors.
t.
In response to these developments, this second edition r equired the so lic itation of additional knowledge and expertise from experienced
Hard and soft tissue substance continues to be altered by disease
prosthodontic specialists and competent representatives from re·
and traumatic injury with genetic overlay imposed occasionally by
lated contributing disciplines. These relevant additions have provided
racial commingling and natural evolutionary processes. However,
a n enhanced scope and depth of subject matter on topics pertinent
the clinical management of tooth and bone loss and acquired and
to pr osthodontics.
congenital oral and peri oral defects has changed dramatically as a result of improved technical and procedural modalities and materials. The intro d uctiOn of BrAnemark's concept of osseointegration in
Acknowledgments
1982. with its accompanying biocompatible titanium hardware. has resulted in re ma rkable developments and ap proaches to restorative treatment with versatility of application
The authors would like to acknowledge their colleagues in oral and
and predictable outcomes.
and neck surgery for their dedication in helping compile the sub·
North America in
maxillofacial surgery, radiation oncology. and otolaryngolo gy/hea d
In addition to implant-support opportunities, probab ly more than
ject matter. Additional thanks are extended to the secretarial support
any other phase of restorative dentistry, the advances in ceramic
section o f the Department of Dental Sp ecialties at Mayo Clinic for
options and materials have contrib uted to satisfying pat ient demands
helping wi1h portions of the manuscript. Further acknowledgments
for more esthetic treatment outcomes. These applications relate
are extended to the authors wives and families for their understand·
primarily to fixed restoratio ns which now have more durability and a
ing of the time needed to accomplish this important project.
,
more li felike appearance.
1
viii
'
Robert Stewart, ODS. MS
Julian B. Woelfel, DDS
Clinical Assistant Professor of Dentistry
Professor Emeritus
University of Detroit Mercy
School of Dentistry
Detroit, Michigan
The Ohio State University
James M. Van Ess, oos. MD
Columbus. Ol1io
Assistant Professor of Surgery
John F. Wolfaardt , eos, MOent. PhD
Section of Oral and Maxillofacial Surgery
Institute for Reconstructive Sciences in Medicine
Mayo Clinic College of Medicine
Misericordia Community Hospital
Rochester, Minnesota
Professor
Christopher F. Viozzi,
DOS. MD
Assistant Professor of Surgery Section of Oral and Maxillofacial Surgery Mayo Clinic College of Medicine Rochester, Minnesota
Jonathan P. Wiens, oos. MSD Clinical Associate Professor School of Dentistry University of Detroit Mercy Detroit, Michigan
Faculty of Medicine and Dentistry University o i Alberta Edmonton. Alberta Canada
Table of Contents Foreword by George A Zarb Preface
vii
viii
Contributors
ix
1
Basic Concepts of Genetics
2
The Orthodontic-Prosthodontic Relationship
3
History, Laboratory, and Examination
4 5 6
1
Dusica Babovic-Vuksanovic
9
Brent E. Larson 17
William R. Laney and Sreenivas Koka
Oral-Systemic Interactions
39
Sreenivas Koka, William R. Laney, and Thomas J. Salinas
Oral and Maxillofacial Radiology
51
David MacDonald
Psychologic Aspects of Diagnosis and Treatment in Advanced Dental Care
71
John E. Schmidt and Charles R. Carlson
7
Temporomandibular Disorders and Orofacial Pain
8
Considerations in Treatment Planning
9 10
83
Kevin I. Reid
97
Alan B. Carr, Steven E. Eckert, and William R. Laney
Preprosthetic Surgery
115
Christopher F Viozzi
Bone Grafting and Ridge Augmentation Considerations Prior to Endosseous Implant Reconstruction James M. Van Ess and Kevin L. Rieck
129
11 12 13 14
Osseointegrated Implants and Implant Site Development
141
Kevin L. Rieck, Thomas J. Salinas, and James M. Van Ess
Surgical Defects of the Mandible and Maxilla
149
David J. Archibald and Jan L. Kasperbauer
Oral Complications of Chemotherapy and Radiation Therapy
163
Kostandinos Sideras, Charles L. Loprinzi, and Robert L. Foote
Radiation Therapy and Chemotherapy for Head and Neck Cancer
183
Mijin Choi
15
Restoration of Congenital, Developmental, and Acquired Oral and Perioral Defects
197
Thomas J. Salinas, Alan B. Carr, and William R. Laney
16
Contemporary Dental Materials and Their Application to Prosthodontics
233
Thomas J. Salinas and Julian B. Woelfel
17
Diagnosis and Management of Inadequate Denture Prostheses Steven E. Eckert
The Mutually Protective Complex: Occlusion and Fixed
18
Prosthodontics
263
Jonathan P. Wiens and Robert Stewart
19 20
Speech Pathology and Prosthodontic Applications Thomas J. Salinas, William R. Laney, Jana M. Rieger, and John F. Wolfaardt
Management of Patients with New Prostheses Steven E. Eckert
Index
333
318
293
249
Foreword Twenty-eight years have elapsed since I came across the first edition
it also preceded the osseointegration era; and the intervening
o f this superb text. I had al the time already made my personally
years between the two editions were overtaken by the remarkable
decisive journeys to two renowned US institutions of graduate edu
speed and excitement of the relevant scientific changes-biologic,
cation in my chosen field of interest. And just like many other would
behavioral, social, technologic-that have now come to dominate
be clinical academics-both then and now-1 benefrted enormously
the discipline.
from my extraordinary teachers' experience and their commitment
The editors are therefore readily forgiven for making us wait so
to clinical excellence. However, my acquired and presumed ability
long for this very welcome second editiOn. It significantly expands
to address the bigger picture of diagnosis
the original book's scope by its recruitment of those essential topics
as
well as treatment in
the discipline of prosthodontics had to be acknowledged as an in
sucl1
complete one. I had gradually realized that the rigor and focus that
concerns, imaging techniques. etc, that have informed and revised
underscored the era's guidance in specialized dental education was
the entire profession. It also makes it far clearer than ever before that
not automatically reconcilable with patients' systemic determinants
the discipline has not only benefited from the infomnation explosion but
and individualized needs. Dental treatment planning tended to be
that it has also convincingly embraced it. The net result is a renewed
hegemonic because handicraft and anecdotal traditions in
and elegant confimnation of the conviction that good prosthodontics
the discipline were dominant. Moreover. the additional objective of
is simply not reducible to tidy formulas or rigidly ordered credos, that
treatment interventions t o restore orofacial function was rarely de
i t demands scrupulous and eclectic observational skills, and that this
temnined by the exacting standards today's treatment outcome de
approach remains a wise and essential strategy to avoid what might
mands.
very well be unnecessary and misguided interventions.
overtly
as
genetics, adjunctive laborato1y examinations, psychologic
It was inarguably an opportune time tor a text that sought to proVide
This text makes a compelling case tor prosthodontics as a clinical
a synthesis of what was even more essential and comprehensive
dental specialty in the best scholarly tradition. I cannot think of a
for optimal management of the prosthodontic patient. and this
better one to make the profession appreciate what the discipline is
book's first edition addressed that big picture need in the scholarly
really all about.
manner that admirably reflected the Mayo Clinic's distinguished authorship pedigree. It quickly became a de rigeur assignment
George A. Zarb
for graduate students in the specialty
Professor Emeritus, University of Toronto
who were considering prosthodontics
as as
well as new graduates their career pursuit. But
Editor-in-Chief. International Journal or Prosthodontics
vii
Chapter
Basic Concepts of Genetics Dusica Babovic-Vuksanovic,
T:
e field of genetics has undergone rapid growth in recent
ears and greatly affected all areas of medicine. The compte
MD
• Does this patient have a hereditary disorder? o
on of the Human Genome Project. which identified the three
Does this patient have a simple condition or a complex disorder underlying the symptoms?
billion base pairs of DNA that compose a human genome, was a
o
Is there a need for evaluation of other family members?
landmark event of the end of the 20th century. Genetic information is
•
What is the risk that the patient's children or siblings will inheri t the condition?
now being incorporated into all areas of clinical medicine. changing even basic concepts in evaluation of and therapy for patients. While science has yet to reach full comprehension of all gene functions and
•
Could the disease be managed or stopped in its early stages i f a timely diagnosis is made?
protein interactions we remain optimistic that opportunities soon will ,
be developed to p redict. prevent, and cure human diseases through
The answers to these questions
can
significantly affect a pa·
methods such as personal genetic fingerprinting and routine gene
tient's life. For example. if
therapy. Staying up to date on recent genetic developments and
ents with dental irregularities (eg, crowding) recognition of a gen·
applying this knowledge to patient care will become a necessary skill
eralized connective tissue abnormality would typically lead to a
for most clinicians.
series of p reventive measures including screening f o r aortic root
a
patient with Marian syndrome pres· ,
dilatation. In this patient, early diagnosis and appropriate treatment might be life-saving. Another example is a patient with osteomata
Genetics in Clinical Medicine
of facial bones, dentigerous cysts, or supernumerary teeth-pos· sible signs of familial adenomatous polyposis. Early identification of this hereditary disorder in the patient and his or her family would
The role or genetics in human disease is well-known. Some condi· lions are caused by single genes and inherited in a Mendelian pat·
live colectomy, thereby transforming a uniformly malignant and le
tern; the diagnosis. risk assessment, and counseling for the family
thal condition into a manageable one. The dental specialist often
usually simple for these conditions. 1·2 In other cases, recognition
may be the first t o see a patient with an unrecognized. complex
of an underlying genetic trail may be a challenge. and multidisci·
medical problem; a high index of suspicion and appropriate refer·
plinary evaluations and complex diagnostic testing are often needed.
rat may dramatically influence the well-being oi a patient and his or
Common quest1ons that general clinicians should ask include the
her relatives.
are
lead to necessary surveillance for colon cancers or even preven·
following:
1
1
i
B as ic Concepts of Gen eti cs
I
> a
J
J
)
LEGEND
1(1 )
1·)t)) 2
I
u 6
1(' 13
Ji 19
Fig 1·1
((' )f
3
)f IJ 7
?I )) )) 8
1(
.
14
0
9
' -'W ""'
10
II
n
16
Bt.
·-�
20
21
A normal, male, G·banded kal)'otype. (Courtesy of
5
J(
(
12
i(
IS
•
l( 17
u 22
0 Healll>y female
)
• Affected male e Affected lemale
()
b
1J
0 Female carrier of X-linked
.
eondrtion
'}
u
(J
18
)
('}
I
Or Gopalrao Velagaleti, Ried
Hete10zygote carri0< male
f) Hete10zygo1e carrier female
X
y
Healthy male
c
•
;>
•
()
)
Fig 1-2 Family trees demoostratill(J autosomal dominant (a), autosomal recessive (II).
Meyer. Daniel Kuffel. and Or Eric lhorland. Cytogenetic Laboratory, Mayo Clinic, Aoch· ester, MN.)
and X·finked (c) lraits.
Inheritance Patterns
drome), and some forms of ectodermal dysplasia. Disease expres
sion may vary significantly in affected people even within the same
Some examples of autosomal dominant conditions include Marian syndrome, von Hippel-lindau disease tuberous sclerosis, Gorlin
family, res ulti ng in different severity of disease in different individuals. Carriers of an autosomal dominant gene may not develop the p he notyp e at all. because some genetic traits have reduced penetrance. Alternatively, development of symptoms may be limited to late age, as is seen in so me neurodegenerative disorders that manifest in adul thood (eg, Huntington disease. spinocerebellar ataxias , or Alz· heimer disease). This behavior sometimes may give the impression that the disease is skipping generatiOns. In contrast to autosomal dominant conditions, for which one abnormal gene (or allele) is sufficient to produce disease, autosomal recessive conditions occur only in individual s who inherit two abnormal copies of a gene (FIQ 1-21:>). Usually. each parent iS a carrier of one abnormal copy or the gene. but they are a y s mptomatic because they also have a normal copy that prevents expression of the phenotype . The aut oso mal recessive t rait is often suspected when a disease occurs in several siblings or in consanguineous families. The risk for carrier parents to have an affected child is 25% in e ach pregnancy.
syndro me, some chromosomal
Examples of conditions that follow t his inheritance pattern include
Despite the availability of many sophisticated diagnostic tests, basic genetic prinCiples and the tra d�ional evaluation of the patient (medi· cal history, family h is tory and physical examination) remain essentia l. Genes can be d ominant or recessive and are located on one of the ,
autosomes (chromosomes 1 thro ug h 22)
or sex
chromosomes (X
orY)'"' (Fig 1-1). Careful analy si s of the family tree often provides a clue t o t h e di ag· no sis or suggests whether further investigation is warranted. When a genetic cause of the co ndit ion is unknown (le, diagnostic testing is not available). the family analysis becomes the p rimary tool used in g enet ic co u nseling. Autosomal dominant conditions are transmitted through multiple
generations of families. An affected individual has a 50% risk of passing the abnormal gene to each of his or her children (Fig 1·2a). ,
disorders (eg, velo-cardio-faeial syn-
·
J
Genetic Screening and Counseling
Table 1-1
'
_
Example
Inheritance pattern
Autosomal dominant
Recurrence risk"
Most craniosynostoses
Siblings: 50%
Sex differences None
Children: 50%
Autosomal recessive X-linked recessive
Most dysmo.phlc syndromes
None
Siblings: 25% Chlldren: 1 100
0.2-1.3
0..10d
7.6-10.4
10d-24
100
9.0..11.0
24 mo-12 y
8.8-10.8
> 12y
8.4-10.2
Carbondioxide (CO,) (mmolll)
22-32
Chloride (C� (mmot/L)
98-107
Creatinine (mgid�
Glucose (mgi1 mo
65-110
0..12 mo
3.5-6.0
> 12 mo
3.5-5.0
Protein. total (g/dL)
6.o-8.0
SOdu i m (Na) (miOOIIL)
135-14 4
Urea ntrogen i (UN) (mgldL)
Q-7d
3-12
>7d
8-20
21
3
History, Laboratory, and Examination
spected for ulceratrons, crusts. fissures, or other surface changes. No physical examtnati on IS complete without digrtal palpatron. Lat eral surfaces of Ihe face and temporal areas are palpated as the pa tient opens and closes the mouth to ascertain the extent of lemporal.
pterygoid, and masseteric function. Asking lhe patient to purse the lips gives an indication of the perioral muscular vigor and integr ity. To assess the smoothness and range of motion of the TMJs, the clini
cian should place t he Index fingers bilaterally over the preauricular areas as the palient opens from a closed position and moves the mandible anteropostenorly and laterally. Tenderness, onep1tus, and deviation are noted. The condyles can be further examined by plac ing the fiOQBf wi thin the external auditory meatus and palpat.ng the Cervical lymph nodes
anterior wan below the tragus. This examination often can suggest
Thyroid gland examined
potential problems 1n record•ng rnaxillomandibular relations. lnspecllng the neck and cerv�cal lymp h nodes is an Important part of the extraoral examination of the head and neck and logically fol
Fig 3·1 Left, Bimanual palpalioo of the neck should include examination of the cervical lymph nodes. Right, Clinician should palpale along the larynx tor Immobility and enlarge men! Examination of the U1yroid glancl includes palpatioll olllle lobe, which Is facilitated by !laving the patient swallow to e!evale the gland.
lows digital palpation {Rg 3- 1). A suggested routine includes pal pation for enlarged nodes In the jugular chain and in the parotid. submandibular, and submaxillary groups.
Salivary glands The lateral structures of the face and the penrnand!bular area are
Physical Examination
best examined wrth bimanual manipulation {Fig 3-2). Nodular or indurated surfaces
1n
the V1Cin1ty of the mandtbufar angle are sug
gestive of parotid leSions. Lesions deep in the cheek are difficult to
The face and mouth are relatively s.mple to examtne because their component structure s are readily accessible to visual inspect ion ,
by means of a forefinger placed intraorally and the opposite hand
digital palpation, percuss1on, and radiographic record1ng. Any ap
placed extraorally, should be a routine procedure. Obviously, the
proach to the actual examination should be systematic and routine
purpose of the examination is to distinguish the normal from the
for each examining cli n ician. Printed forms may be helpful to record
abnormal. The parotid duct {Stensen's duel) i s usually clearly iden
findings because they provide an ouUine that minimizes oversight
tifiable in trao r a lly, and manipulation of the gland should elicit a flow
and encourages thoroughness.
of watery ftuid. Diagnostically, it is advantageous to locate nodes or
detect: therefore, careful palpation of the buccal mucosa and skin.
The common tendency when conducting an i ni tia l examination is
swelling relative to the musculature of the area. Circumscrrbed Ia·
to proceed with the intraoral phase without givi ng much consider
sions are readily movable whereas inflamed tissues or structures ag
ation to the body as a whole. In preliminary deliberato i ns, an astute
gressively 1nvolved by neoplastiC disease are relatively fixed. The pa
observer notes the patiSnt's relative body proportiOnS. weight. pos ture, gait, degree of functional coordination, and any obvious abner·
tient may provide subjecllve Information by reacting to patnful st1mu�
malit1es or deform1Ues. A closer look at the head and neck should
early indiCation of Inflammation. but 1t is also associated with tater
reveal signifiCant aspects of facial compositiOn. asyrTllmelries, sk1n
stages of malgnant diSease.
texture, complexion, expression in the eyes, breathing, functional
The submandibular gland is readily identified by intraoral and ex traoral palpation. It can be examined by gently rolling the glandular
habits of teeth clenching . twti ching, and other neuromuscular invol· un tary manipulations.
Extraoral examination
or
by failing to respond to palpation ol the tissue. Pain 1s usuaJy an
substance belween the fingers, and its patency can be noted by the salivary flow. Irregular or firm structures within the duct or possible at· a t ched lymph nodes should be examined. Inflammation, purulence, a hard mass within the duct, and pa in suggest the presence of a salivary stone
(calcification) and the need for further eval uat i on by Imaging.
Regardless of the examination seque nce . the perioral structures
A quantitative and qualitative evaluation of the saliva is very Im
should be assessed first. A general evaluation is made of the fa·
portant t o prognos1s, partiCularly for the patient with complete den·
ciaJ contours and support provided by the denlillon. Characteristcs i
tures. Salivary flow from the parotid duct is primarily serous, the flow
such as abnormal swellings. deformities, tes.ons. discolorahons. and
from the sublingual and submandibular glands is mixed ITlUCillOUS·
general bony contours are noted. The tips, ears. and nose are in-
serous, and the products o f the palatine glands are purely mUCinous.
j
Physical Examination
a Fig 3-2 (a) lntra01a1 and exuooral palpation of the salivary glands torpatMiogic change. The tollSillar area should also be inspected visually. (b) SubmaxiUary gland examinalioo with bimanual digital palpatioo. (Courtesy of Dr Dan E. Tolnl A. Fenton A. Mericske·Stern R Prosthodontoc Treatment for the Partially Edentulous Patient. St Louts: Mosby, 2004. 6. Zarb GA Or
Pharmacologic Interactions in the Oral Cavity Medications inducing hyposalivation
Interferon-a iS a cytokine with a wide range of systemic effects that particularly affect the immune system. RCTs appear to have reached a reasonable consensus that interferon-a improves patients' subjective assessment of xerostomia; however, conflicting data have been published regarding benefits on reducing hyposalivation.42 Current dosage recommendations for patients with primary SS who are looking for relief from xerostomia are 150 IU of interferon-alpha
A dry mouth
seem s
to be one of the most common side effects
to be taken in lozenge form three times a day.
of medication use; over 400 medications depress function of the salivary glands.m� Different medications induce hyposalivation by different mechanisms that interfere with parasympathetic signaling.
Drug-induced intrinsic discoloration of teeth
Some do this by inhib�ing adrenergic neuroeffector junction activ ity, others by lowering central connection activity of the autonomic
Teeth are especially prone to drug-induced changes from birth to
nervous system, and still others through anticholinergic effects.
approximately 8 years old. Effects of drugs on tooth development
The clinician must stay aware of new and existing medications and
include discoloration that can be difficult to reverse by noninvasive
possible medication interactions. Currently, the following families of
means such as vital bleaching.70 Depending on the teeth and tissues
medications have representatives that interfere with salivary gland
affected, direct or indirect restorations may be necessary.
function: antidepressants, antihistamines. antihypertensives, anti psychotics. antiarrhythmics. anticonvulsants . diuretics. antiparkin sonians, antiemetics, antiarthritics, anJHnflammatones, and anx
Fluoride
iolytics. In addition, chemotherapy can lead to hyposalivation and
Optimum fluoride intake results in esthetically unaffected teeth that
changes in the quality of the saliva produced. Fortunately, in most
are
patients, salivary function returns to normal or close to normal after
improved enamel strength. However, excess fluoride exposure dur·
chemotherapy ends. unless doses were exceedingly high or pro
ing tooth development leads to hypomineralized enamel and chang·
longed use occurred.
es in appearance lhat range from small white flecks at cusp tips lo
relatively resistant to the formation of caries lesions because of
larger opaque areas t o darkly stained pitted areas.
Medications to treat hyposalivation and its effects
Tetracycline Mothers who take tetracycline (or a derivative) during the second or tl1ird trimesters of pregnancy may have children whose teeth are
Pilocarpine is a muscarinic-stimulating cholinergic agonist with para
significantly discolored and which appear initially as yellow and then
sympathomimetic properties, nesulting in increased muscle tone
turn to gray or gray-brown over time. Parents should avoid giving
o f various tissues o f the gastrointestinal (GQ tract. As a mimic of
tetracycline to children under the age of 8 years to prevent disco!·
acetylcholine, pilocarpine stimulates secretion from the salivary and
oration of the permanent dentition. Tetracycline or oxytetracycline
lacrimal glands.'e Patients should be monitored for sweating or Gl
leads to yellow teeth, whereas chlortetracycline produces gray
disturbances, and the drug should not be administered t o patients
brown teeth.'6
References
7. Scuty C. Carrozzo M. Oral mucosal disease: l.Jchen planus. Br J Oral Maxil lo fac Surg 2008;46:15-21.
Minocycline Minocycline is a tetracycl1ne denvahVe used to treat a variety Ollnlec tious or inflammatory conditions. In contrast to tetracyclrnes. which affect tooth color during development, mil'lOCycine may mfrequently cause tooth discolorallon after tooth development has ceased.80 The mechaniSm for thiS elfect IS unclear. Furthermore, mlflOC:ydlne af
fects soli tissue pigmentation. causing a1terat1ons in the skin. thyroid gland, naUs, bone. sclera, conjUnctivae, and g1ng1vae.••JO Some re ports suggest that g1ngival d•scolorat1011 is a result of changes to the underlying bone. and purple-black discoloration of gingiva has been observed, often in the area covenng the hard palate.83
8. Yaooet
KB. Egan CA. P 40 mm 4. Lateral movements;, 7 mm 5. If S·cUNe deviation is presen t, then joint must be silent
noise
t.
10-intraart iculaf d isorder. (Adapted fromMderson et at �1
increased muscle tenSion were good predictors of jaw pain."' As
tors,31 recognizing that chronic temporomandibular pain. like other
with TMDs in general. the cause of Axis I disorders is not known
musculoskeletal pain syndromes. is frequently identified as a persis
but has often been attributed to malocclusion, a hypothesis that
tent dull ache'" that i s aggravated by use of the jaw.
contemporary standards of investigation have not supported.2-211
The clinician should ask a standard series of questions to begin to rule out TMD. A jaw disability checklist may be a helpful tool
Axis /, Groups II and J/1 disorders
(Box 7-1 ).1'1 Oth er questions that may assist the c linician include the following:
Axis I. Groups 11 and 111 disorders are related to alteration of soft tiSSLte anatomy within the TMJ or degenerative joint changes (see
1. Are you able to open your mouth as well as you think you
Table 7-1 ). The cardinal signs of internal anatomical alterations of soft tissue in the TMJs include decreased range of mandibular mo
2. Do you feel your bite has changed?
tion and joint noises w�h mouth opening and closing. Patients may
3. Does your jaw make clicking, grating, or grinding sounds? If so,
report prominent clicking or grinding sounds with jaw use. These
should be able to?
is this noise accompanied by pain?
disorders may not necessarily be associated with pain. so it should
4. Does your jaw lock or catch?
not always be assumed that a patient's clicking TMJ is the source of
5. Have you been told
pain. Symptoms of mandibular dysfunction may also include "catch
or are you aware of clenching or grinding
your teeth while awake or sleeping?
ing" or locking of tile jaw. Clinicall y reliable criteria (Table 7-2) al
low the clinician to determine the anatomical status of a par ticular
It any of these questions is answered in the affirmative, the
TMJ with a great degree of accuracy.29 These clinical criteria do not
developing differential diagnosis then should include TMD. A
make reference to pain, which may or may not be present in any of
complete history and clinical examination may then follow, uSing
these diagnostic scenarios. The clinical reliability of the criteria was
criteria presented in the RDC.15 Stohler provides a treatment
tested against radiographic findings, which are not predictive of pain
algorithm based on responses to the Graded Chronic Pain Scale, a
in TMDs. 30 The methods of esta blishing a diagnosis depend in part
seven-item questionnaire assessing pain intensity and impact of pain
on accurate assessment of range of motion (see Rg 7-3).
on usual activities.:!$
Clinical history of TMD
Examination
Diagnosis of TMDs is contingent both on obtaining a comprehensive
The examination should include palpation of the preauricular (TMJ)
history and, t o a lesser extent, on physical examination findings and
areas and the masseter muscles in addition to the anterior, middle,
reproductions of the patient's pain comp la int. It is crucial to ask the
and posterior areas of the temporal muscles. Although much has
patient to highlight the area of discomfort by pointing with one finger
been published to guide clinicians in this technique, no universal
rather than fanning the entire hand over the face. which precludes
technique has emerged as the gold standard."" One useful tech
the ability to attempt to locate the site of discomfort. It is equally
nique is to palpate the muscles of mastication and the preauricular
important to present the patient with a choice ot verbal pain descrip-
regions with a moderate amount of pressLtre while asking the patient
861
J
Temporomandibular Disorders
Tabl e 7_3 What activities does your present jaw probl&m prevent or llmft yoo from doin g? o Chewing
Considerations
Pain
High
Low Sharp, electric, burning. paroxysmal,
Constant ache/tightness
interm»tent, spontaneous pain
Sharp pa1n with jaw use
o
DrinlOtolac Surg 2008:37:535-541 19. ShahaAR. Preopetauveevaluauon ol the manoo1:>1e n patoents '"'lh carcnoma olthe lloorOI mouth. Head Neck 1991;13:398-402. 20. Ciemo BW. IZ2afd M. � EA. Fwan N. Corlllanson oll!RJone graft. A donocal ex
lerlSIOular bone �alt. Plast Aeconstr Surg t 988:81: 378-385. 27. Shpitzer T, Neligan PC, Gullane PJ, 01 al. Oromai\OibtA3J reconstructiOn with the fibular free
nap. AnaJysos of 50 consecutive flaps. AICh OtOiaryngol Hood
Neck Surg 1997:123:939-944.
ity
Neligan
Boyd
B. Gullane P. Gur E. Freeman J. Leg onorotd· and functKlfl following fibular free flap h orvesl. Ann Plast Surg 1997:38:
28. Shpotzer T.
P.
dtlQ-464. 29. Wet FC, Seah CS, Tsai YC. IJu SJ, Tsal MS. FltlUia osteoseplocutaneous
flap for reconstruCiion ol composllo mandol:>ular detects. Plasl Reconstr Surg 1994;93:294-304. 30. Futran ND.
Farwel DG. Smith RB. JOhnson PE. Funk GF. Def•�111e manage
ment d severe faoal trauma ut.t.zing tree tiSSUe transfer OIOiaryngol Head Neck Surg 2005;132:75-85. 31. Futran ND. Retrospectove case seroos 01
� and secondary microvas·
cular rroo tiSsue tr.nsler reconsttuetioro o t mldlaoal defects J Prosthel Dent 2001 ;86:369-376. 32. Muzaffar AR. Adams WP Jr.
Hallog JM. Rohnch RJ, B'yl'd HS. Maxjary re
constiUCtiOn: FmcbOnal and aeslhehc consideratoons
F'last Reconstr Surg
1999:104:2172-2183. 33. Olsen let These results support further study of pentoxifylline in patients in
The soft tissue necrosis of oral cavity mucosa that occurs after high
whom soft tissue necrosis develops after a course of radiation
doses of radiation therapy may be at1ributed to the obliteration of
therapy.
small blood vessels or to severe mucositis with ulceration. Irradiated
Most bone exposures will heal spontaneously after conservative
epithelium is thinner than normal and appears pale and atrophic. It
treatment. Although small areas of bone exposure Qess than
also has telangiectatic vessels. The irradiated mucosa is more sus
1 em) generally heal spontaneously after a periocf of weeks
ceptible to mechanical injury and to the noxious effects of alcohol
to months, larger areas of bone exposure may persist and result
and tobacco. Soft tissue necrosis usually begins with breakdown of
in bone necrosis, followed by sequestration. If the bone is rough
damaged mucosa. resulting in a small ulcer. Most soft tissue necro
or protrudes above the level of the gingiva. an oral surgeon may
ses occur within 2 years after radiation therapy. Occurrence after this
remove it to promote healing. An oral surgeon can also perform local
time is generally preceded by mucosal trauma. The risk of soft tis
debridement of mocferate- sized necrosis, if indicated. Patients who
sue necrosis increases with larger fraction sizes, higher total doses,
wear dentures should refrain from using them or have them modi·
larger volumes of irradiated mucosa, and the use of an interstitial
lied to provide relief over the site of exposure. Pain is not a common
implant.
symptom; if present, it can usually be controlled with analgesics or
The mandible and maxilla will tolerate rather high doses of
a local anesthetic applied with a cotton-tipped applicator, if needed.
radiation therapy without serious problems, as long as the tissues
Antibiotics frequently reduce infection and discomfort within a few
overlying the bone remain intact. If sott tissue necrosis develops in
days but should be continued for 2 l o 3 weeks. Hyperbaric oxygen,
the mucosa overlying the mandible or maxilla. the underlying bone
along with antibiotic therapy and local debridement, may help
may become exposed. This can lead t o serious injury, resulting
promote healing. Mandibular resection should be reserved as the
in ORN. Patients at highest risk for ORN appear to be those with
last resort for the patient with intractable pain, recurrence of severe
tumors involving the gingiva or bone; those who continue to smoke
infections, fracture. or trismus.
or drink after radiation therapy; and those who receive high doses
Most bone problems develop within 3 to 12 months after radia·
o f radiation therapy, large treatment volumes. large fraction sizes.
lion therapy. but some risk persists for many years, especially if
or interstitial implants. Compared with the maxilla, the gingiva of the
the patient undergoes dental extractions. Necrosis is most likely
mandible has a rather tenuous blood supply, placing the mandible at
to occur after extraction of mandibular teeth, although this is
greater risk of exposure and necrosis. If exposed. necrotic bone may
infrequent i f special precautions are taken. TI1e edentulous patient
become infected. The necrotic process may then extend to involve
has a lower overall risk for bone necrosis compared with the
adjacent bone for a considerable distance. Severe necrosis can then
dentulous patient.
develop and lead to orocutaneous fistulae and pathologic fractures.
175
i
�3
Oral Complications of Chemotherapy and Radiation Thera py
Taste alterations
Malignancy
Loss of taste occurs rapidly and early in the course of radiation ther
The carcinogenic effect of ionizing radiation 11as long been recog·
a py to the oral cavity. Most patients report that the sense of taste
nized. The latent inteNaJ between radiation therapy and the develop·
is essentially nonexistent by the third or fourth week of treat ment .
ment of cancer varies from several to many years. Kogelnik et al'64
After the completion o f radiation therapy, most patients report some
reviewed the charts of 1, 163 patients from the MD Anderson Can
t aste improvement within 1 to 2 months. Full recovery of taste usu
cer Center who had suNived a minimum of 5 years after treatment
ally requires 2 to 4 months. In some patients. taste never returns
for head and neck cancer without recurrence. Follow-up for these
to normal, at least in part because of xerostomia. Allhough some studies have suggested that zinc therapy may be useful in improv
patients ranged from 7.5 to 25.5 years. Patients were treated with
ing taste acuity. a randomized clinical trial did not show any benefit
(n
for zinc over a placebo.•03 Amifostine may protect against taste loss
cers in the primary tumor site (1.8% vs 2.7%}. within the immediate
caused by irradiation. "4•11•
vicinity of the primary tumor (4.2% vs 3.1 %}, or at sites remote from
surgery alone (n =
826}.
=
337) or radiation therapy with or without surgery
For these respe ctive groups, the inc i den c es of new can·
the primary tumor but still within the oral cavity or pharynx (4.7% vs 5. 7%) were very similar. It was concluded that moderate-dose or
Trismus
hig h- dose radiation therapy did not produce any new squamous cell carcinomas of the mucous membranes. Similar findings have been
Etiology
reported elsewhere.•65.•60
Causes of trismus include (1) fibrosis of the mas ticatory musculature after high-dose radiatiOn therapy to the oral cavity or oropharynx (2)
before their deve opment, and the difficulty of obtaining reliable l long-term follow-up data make the task of estimating tl1e true risk of
surgical scarring. and (3) advanced carcinomas involving the ptery
this problem difficult. However. most series include 1 or 2 cases of
goid or masseter musculature. The temporomandibular joint (fMJ}
radiation-induced bone sarcoma per 1 ,000 5-year survivors. If one
is relatiVely resistant to ankylosis caused by radiation therapy, but
were to
the risk of injury increases if the joint is invaded by tumor. The use
term suNivors and an estimated 5-year suNival rate of 40% for all
of large daily treatment fractions also appears t o increase the risk of
patients with head and neck cancer who received radiation therapy,
trismus.
it is calculated that 1 case would be induced per 1 ,250 patients
The rarity of radiatiOn-induced sarcomas, the long latent period
,
assum e
malignant in duction in 1 patient of every 500 long·
treated. A review of lhe Mayo Clinic experience showed no difference in suNival between patients with ra diation-indu ced sarcomas of the
Prevention and treatment High-energy x-ray beams and sophisticated
mandible or maxilla and those with non-radiation-induced sarcomas multiple-field tech
niques should be used whenever possible to reduce the total dose
of the same site (45% 5-year overall suNivaQ. Because
some
patients
with
radiation-Induced
osteogenic
of radiation to the TMJ and the muscles of masti cation. Patients
sarcomas of the mandible or maxilla can be cured. the risk of death
treated with both surgery and radiation therapy have a greater risk
from a radiation-indu ced sarcoma after a course of radiation therapy
for trismus than patients treated with just one modality. For these
is minimal and is very similar to the risk of death a patient accepts
high-risk patients and those in who m trismus has developed before
when
treat ment daily jaw-stretching exercises may increase the interarch
surgery. or major head and neck cancer surgery.
,
undergoing
chemotherapy,
general
anesthesia.
general
or interincisor distance. A number of devices can be used, includ
An association also has been noted between radiation therapy and
ing commercially available jaw-stretching tools and less-expensive
thyroid tumors. The latent period is usually I 0 to 30 years. Almost
stacked tongue blades, tapered corks. or clothespins. These devices
all reported cases have followed low doses of radiation therapy
are inserted between the teeth to increase the interincisor distance
(from less than 6 cGy t o 1 ,500 cGy), well below the doses used for
until gradual increases are encountered. The exercises should be
squamous cell carcinomas of the head and neck. In contrast, doses
done for 4 minutes four times daily. Additio nal tongue blades can
greater than 2,000 cGy to 3,000 cGy are associated with a very low
be added or a thicker aspect of the cork can be placed between
risk of induction of thyroid neoplasia. This is likely because higher
the teeth every few days t o increase the interincisor distance and
doses of radiation t11erapy either completely destroy follicular celts or
stretch the muscles of mastication. The rate of advancement should be approximately 1 mm every other day and should be monitored to
at least render the survivi11g cells incapable of division. Not all thyroid l neoplasms that deveOP after radiation therapy are malignant. and
ensure the distance approaches an amount that permits adequate
many of the malignant neoplasms that do develop (papillary and
hygiene measures and reasonable bolus manipulation. Any sudden
follicular carcinomas} are readily curable with surgery. Thus, the
degree ot restri ction In mandibular opening is suspici ous for recur
risk of radiation-induced carcinoma should not be a major factor in
rence or other infratemporal fossa disease.
determining treatment approaches for the typical patient with head
and neck cancer.
1
176
j
Oral Complications of Radiation Therapy
Fig 13-4 Tongue depressing stent for balloon catheter. {a) Wax template is fitted to
determine opening and fit to teeth. (b) Maxillary defect is susceptible to mocosltls at the air-tissue Interface. (c) Wax pattern ol the stent shows where the balloon catheter would enter. (d) Wax pattem before processing to acrylic resin. (e) Completed stent and balloon catheter.
Prevention and treatment of radiation-induced
ticiently to the target volume. Historically, this was alded by the use
oral complications
of positioning devices such as stents and shields. The trend toward using computed imaging and IMRT for treatment of head and neck cancer has somewhat decreased the need for shielding devices.
Need for guidelines
However. the use of tissue bolus materials and positioning devices is still required to make the treatment effective.
Investigators surveyed Dutch radiation therapy centers that per
The target tissue may involve a relatively superficial area, or it may
form irradiation of patients with head and neck cancer to determ•ne
be more centrally and deeply located. As such, the treatment beams
which prevention and treatment regimens are used for oral sequelae
may be projected from multiple directions to mini mize dose to tt1e
resulting from head and neck radiotherapy. •e7 Survey questions in
superficial areas of the skin and vital structures such as the spinal
cluded queries about screening, care before and during radiation
cord. Movable structures such as the tongue and mandible may b e
therapy, care during postradiation therapy, and the composition of
positioned outside o f the treatment field by the use of a positioning
the dental team who evaluated and treated the patients undergoing
stent (Rg 13-4). These stents often depress both the tongue and
radiation therapy. Unfortunately, these investigators found a great
mandible away from the treatment area to minimize the exposure in
diversity among the institutes' approaches to prevention and treat
the treatment area and decrease the risk or incidence of radiation
ment of oral sequelae in patients with head and neck cancer. Dis
induced mucositis. Further incorporation of gold seed markers
turbing findings included a lack of well-defined guidelines in many
is useful to ensure reproducible treatment orientation between
centers. absence of a dental team at some centers. absence of an
treatment sessions.
oral hygienist on some dental teams, and the observation that many
Superficial lesions requiring radiotherapy can be most efficiently
patients were not referred to the dental team in a timely manner. The
treated by incorporating the use of a tissue bolus material to allow
development of a general standard protocol for the pev r ention of
optimal location of the beam energy at the surface. Often, these
oral complications was recommended tor all head and neck cancer
materials are made of either wax or acrylic resin, permitting delivery
radiation therapy centers.•EB Similar deficiencies are likely present at head and neck cancer
of a focalized and effective dose to the treatment area (Fig 13·5). Shielding devices can be made o t prevent the radiation from af
radiotherapy centers within the United States. It is strongly recom
fecting tissues behind the prop osed target tissue . These devices
mended that dedicated teams be assembled to administer aggres
often are made primarily of acrylic resin surrounding a central core
sive care to pati ents receiving radi ation therapy to the oral mucosa.
of a shielding alloy such as Wood's metal (Fig 13-6). It is critical that
These teams should institute preventive measures and treat symp
the thickness of acrylic resin be proportional to the planned energy of
toms as early as possible.
the beam. Acrylic resin tt1at sufficiently surrounds \118 alloy minimizes scatter, thereby preventing fonnation of mucositis. Energies used to
Stents, shields, carriers, and positioning devices
treat head and neck tumors are approximately 6-MV photons. and require at least 7 mm of acrylic resin around the alloy to absorb scatter.
One goal of radiation therapy of head and neck tumors is to confine
Brachytherapy is also used occasionally to treat specific areas
the treatment to only the area planned for treatment. This minimizes
ot t118 head and neck and recurrent lesions. Often. radioisotopes
the side effects noted earlier and allows treatment to be directed ef-
are used. which emit gamma radiation from their radioactive decay
177
1 3lOral Comp lic ations of Chemotherapy and Radiation Therapy
Fig 13·5 (a) Bolus of wax used to contrOl deptll of treatment of supe11icial skin lesion of face. The tub Ing is used for airway exchange. {band c) CT image shOwing lhe wax bolus alongsi�e lhe skin. Fig 13·6 (a)A wax template is to be created for a shield:ng slenl !hal "nil prolect the longue and other struc tures behind the target tissues of basal cell carcinoma of the upper Up. (b) Steo t fabnca"on on casts of max lila and mandible. {c) Wood·s metal i s pouree into the stent. (d)Resolution of lesion after 3 weeks of treatmeol wilh stent in place.
Fig 13·7 (a} Brachytherapy
using ce·
slum in tile catheter for treatment of in lranasal Kaposi sarcoma. (I>) Computed vault for delivel)' of ra�ioactive isotope. (c) Acrylic resin slenl wilh catheter re· ceptacle.
Fig 13-8 (a) Trealment of scalp angiosar coma. (IIJ Catneter cap used for ra�ioactive isotope delivery.
and can be pl aced a t a specified proximit y to the tumor bed for
invasive in nature. Recent large-scale trials have d emonstrated that
a specific dose based on timed exposure. Positioning stents are
chemotherapy and r adiotherapy in conjunction wi th tumor-ablative
helpful to direct the spatial location of these point sources for
surgery are more effective i n controlling disease than surgery and ra
repeated exposures. The stents configure the uninvolved tissue at
diotherap y atone. Because of the trends in using this combined ther
a specific distance from the target tissue and can be automatically
apy and contemporary chemotherapeutic agents. the sequelae of
loaded from a computed vault that contains the radioactive source
common side effects precipitate often within this patient population.
(Figs 13-7 and 13·8).
Several approaches t o h an dling this complex array of treatments and their associated side effects have been presented as guide lines. As continued development of radiot herapy techniques move
Summary Combined-modality therapy of head and neck cancers or cancers of other origin is effective in con t rolling tumors that are advanced or
1781
forward, these sequelae may continue to change in their frequency
of occurrence. The goal of disease control with these mod alities is state oi the art and should be approached with the knowledge of management of their accompanying complications.
References
References 1. Peterson DE. Keefe DM. l�-oonlrolled, srudy of iseganan for the IGduction of SlOfi'IIIIIIIS on patients receM>Q stomatoloxoe OhemOlherapy. Leuk Res 2004:28:559-565. 26. Yuen KY. woo PC. Tal JW. Lie AK. LI.Jk J. Liang R. enects of c:ta uthromy · cin
on
oral mucosll1S in bone marrow transplant r�ients. HaematOiogoea
2001;86:554-555. 29. Herrmann RP. Trom M.
CoOr\01' J. Cannell PK InfectiOns in pallents 1nonagod
at home Cfurlng autologous stem coli trOflsplantation lor lymphoma and mul tiple myeloma. Bone Mwow TranspiOI'It 1999;24:1213-1217. 30. Feld R The role ofsurveillance c:uttures ., patoe nts likEly to develop chemolheN. J Cern EdUc: 2002.66:903-91 1. 32.. Mahood OJ. Dose AM. L.oprinzl CL. et a1. lnhlboloo of OU(I(Ot.OliCit·nOOced stomatms byoral CI)'Olt1er8py. JOn Onool1991:9:449-452. 33. Casonu S. F9defl A Fedeli SL Cetalano G Oral COOling (�herap�. an ot· fectl\'11 treatment tor the plll\'eOtoon 01 5·11uorouraoHnduced slOp/iC811ons • Loss oJ seal ((:(eates nasal speech and leakage of loodliq l uids) • lack of retention or looseness • lnabitity to place prosthesis because of contracture Of lateral scar band • Discomfort caused by mucosills (radiolhefapy o r chemotherapy). pros thesis pressu re. too-aggressive defect cleafling
Fig 15-16 (a) WebmtXO of 1O·mm sa p c.ng between s and IJle OPPOSing 111e sofl ts ue covering the bone i OCClusion (not the opposing ridge)
Size and shaPe:
Intraoral form
Exhibits a rounded superior surfaoe With nearly parallel buccal and lnguaJ surfaces at least 1 height from vestibule
em n
Provides a minmum bulk for Implants of 10 mm in width and 15 mm In height
Bulk
Provides a 10.mm vestibular depth and distension that allows independent movement of the cheek and toogue relative to the mandible
Ridge coveeations lor proslhellc speech appli ances in cleh palate. Plasl Reconstr Sorg Transplant Bull 1962;30:663-669. 39. Gr'ayson BH. Sanuago PE. Brecht LE. Cutling CB. PresUfg,cal nasoal· veotar molding In 1ntan1s wrth Cleft lop end palate. Cteh Palate CIMIOfac J
37. Kuijpened from lOng·term ObServations in tha fleory and Practice of Fored Proslh odontiCS. ed 8. & Louis: Medico Dental Media International. 1989. 175. Rosenstief SF, Land MF, Fujimoto J (eds). Contemporary Fi�ed Prosthodon· tics. ed 2 . Stlouis: Mosby. 1995. 176. Mack PJ. A theoretical
and Clinical investigation Into Uie taper aChieved on
crown and Hllay preparations. J Oral Rehabil 1980;7:255-265. 177. Wiskott HWA, Nicholls Jl, Belser UC. The relat10nsh1p betvveen abutment taper and resistance of cemented crowns t o dynamic load111g. fnt J Prostho
203. McGuire MK. Nunn ME. Prognosis versvs actual outcome Ill. The effective· ness of clinical parameters in accurately predicting tooth survival. J Periodon tol1996;67:666-674. 204. Ante 11-1. The fundamental principles or abutments. Mich State Dem Soc Bull 1926:8:14-23. 205.
Nyman S. Lindhe J.Lundgren D. The role of occlusion foeU1e stability of fixed bridges in patients wiUi reduced periodontal tissue SUPPOft. J Clin Periodon·
tol 1975:2:53-66. 206. Stein RS. PontiC-residual ridge relationship: A researc/1 report. J Prosthet Dent 1966:16:251-285. 207. Zitzmann NV. Mannello CP. Berglundh T. The ovate ponitC design: A llisto·
dont1996:9:117-130. 1 78. Dodge ww. Weed RM, ea.,. RJ, BuChanan RN. The effect or convergence angle on retention and resistance form.Quintessen ce lnt 1985:3:191-194. 179. Wiskott HWA. Nicholls Jl. Belser UC. The effect of tooth
cemented zi2G the lateral dimension of the obturator in the various conditions (above, on, and below the area
of posterior pharyngeal wall activity) did not change significantly as the position varied. This finding was contrary to the hypothesis of the
,
follow-up studies showed improved palatopharyngeal
use of a palatal lift include (1J inability to attain adequate retention, (2) presence of a spastic or stiff soft palate that does not tolerate elevation, and (3) lack of cooperation on the Contraindications to the
part of the patient.
inv estigators that the lateral dimension of the nasopharynx wo utd be
Hardy et al compared the use of the p alatal lift in 11 children with
the level where the posterior and lateral pharyngeal wall activ
cerebral palsy to the results obtained with pharyngeal flap s urgery
less at
ity takes place. compared t o above or below it.
in 6
c hildren with
cerebral palsy.85 Of the 6 chldren treated surgi i
cally only 3 made suffiCient speech gains to justify considering the ,
procedure a success; prosthetic management of t 0 of the 11 chil
Palatal lift
dren was judged to be successful. Anticipated difficulty i n tolerati ng the lift because of increased gag reflex
was
not experienced. Even
palates related to neurologic
though some of the children displayed gross invol untary head move
disease or in patients with su rgically repaired clefts where a fairly long
ments, the prosthesis did not irr itate the posterior pharyngeal wall
soft palate remains essentially nonfunctional for closure, a conven
during head flexion; nor were any instances noted of inflam mation
tional obturator prosthesis may be difficult to fabricate because of
or necrosis of the soft tissue on the inferior velar surface. Improved
the palatal tissue under and behind which the prostl1esis must pass
functioning of the palatopharyngeal valve was noted in one patient
to b e effective. In such cases. a palatal lift has been found to be ef
after he had worn the palatal lilt for
fective (see chapter 15). Gibbons and Bloomer first reported the use
prosthetic
of such a prosthesis in an adult patient with flaccid velar paralysis resulting from bulbar poliomyelitis.'43 The lift elevated the velum and
palsy is the procedure of choice. Not only is there no surgical risk to
reduced the palatopha1yngeal space, resulting in improved speech.
with the prosthetic program compared with the surgica.l procedure.et.
In patients with weak or
paralyzed soft
management of palatal
a time. Based on
these results,
paresis in children with cerebral
the ch ild, but there appears to be a greater probability or success
Gonzalez and Aronson studied the use of palatal lifts in the treatment of 35 patients ranging in age from 4 to 72 years."' Of
311
i
19
Speech Pathology and Prosthodontic Applications
Table 19-5 Age of child 3to4 4 !05
5to6 6to 7 7 to 8
[1 Developmental sequence of speech1. Consonants correctly used in words
/mi. /p/, lbl. /wl, {hi In!. /V,Idl, lf}l.lkl, lgl,ljl Iff. M,lsl,lzJ /j/, ly, !II. !a/.101 /rl, lhwl, Is!, /zJ
production of the phonemes is again possible when the permanent dentition erupts. The developmental sequence of articulation is paralleled in the development o f skill in the use of other features of language. Children advance in orderly increments of language skills such as (1) length of utterance, (2) number of words they understand (recog nition vocabulary), (3) number of different words they use (vocabulary of use). (4) grammatic complexity of their sentence structures. (5) accuracy of syntax. (6) fluency and spontaneity of oral expression, and (7) social use of speech to influence listeners' opinions and actions.
Factors Related to the Development of Speech Skills
Intelligence The child's intelligence plays an important role in the rate of mastery
The ability of the child t o communicate depends on more than the
of speech and language skills. The intellectually disabled are typically
condition of the speech structures. Important internal and environ
delayed in their first use of words and sentences. They present more
mental variables profoundly influence a child's learning and use of
than the average number of articulation errors. most prominently
speech. One must appreciate the patient's social and family history
omissions of phonemes. Complete speechlessness can be attrib
in addition to medical history to visualize the dynamic relationships
uted to mental deficiency only in extreme cases152•153 (ie, 10 range
between these elements and plan a remedial program comprehen
of 10 to 25). Mutism is usually attributable to autism or, in an older
sive enough to meet the patient's needs.
child who once spoke but stopped speaking, to hysteria. Altl•ough the level of proficiency in speech and language ultimately attained by intellectually disabled children is below that of normal children. all
Developmental sequence of speech-sound mastery The child is not born able to produce the entire repertoire of pho
except those with extremely low intelligence demonstrate growth in these skills.
Hearing loss
nemes; the infant has a meager repertoire to which he or she gradually adds. The average child can produce 27 diffe rent phonemes by 2.5
Children who are deaf or profoundly hard of hearing display colos
years of age.'"" Mastery of the use of these phonemes in words takes
sal delays in acquisition of a symbol system and development of
longer. Cross-sectional studies of children generally a gree that the de
intelligible speech. Children whose loss of hearing is less severe
velopmental sequence is somewhat as shown in Table
develop a symbol system but miss ce1tain crucial features of the
19-5.1"'·1•1
The rate at which children master phonemes varies greatly. By 3
speech around them and display difficulty in reproducing it. Because
years of age, some children correctly articulate all of the consonants
children who are hard of hearing can monitor their performance to
and all of the vowels (vowels are typically mastered by all children
some degree, they produce voice and speech patterns less bizarre
early and without much difficulty). Other children do not master all of
than !hose of deaf children. Their communication may be lacking
the consonants until they attain the age of 8 years or perhaps even
in vocal melody. and they may demonstrate articulatory distortions,
later. Girls typically master phonemes in context somewhat earlier
particularly of phonemes with high-irequency components (ie. frica
than boys.
tives and affricates). Also. they may omit final phonemes and may
No single general principle appears to adequately account for
have trouble monitoring the intensity of their speech.
the developmental sequence of speech. Among the factors that
The incidence of hearing loss is higher in children with cleft palate
probably play a role in determining this sequence are (1) frequency of
compared to the general population.154 Incidence of pathologic
occurrence of the phonemes in the child's environment, (2) visibility
conditions of the middle ear also i s higher than in the general
of the phonemes, (3) their auditory distinctiveness, (4) their phonetic
population. 1*1$7 Hearing loss occurs more frequently in children
power. (5) the distinctive tac1ile and proprioceptive characteristics of
with cleft palate only than in cl1itdren with clefts of both lip and
their production. (6) the complexity of muscular adjustment required
palate. 1011 One cannot make a general statement about the incidence
for their production, and (7) the child's changing dental status. With regard to the last factor, although children typically master lsi and
of hearing toss within the cleft palate population because research data indicate that it varies widely with the age of the group tested.
lzl between the ages of 5 and 6 years. these sounds often become
Spriestersbach et al reported that the hearing acuity of children with
distorted when maxillary anterior primary teeth are lost. Correct
cleft palate varies a s a function of age.158 Children who were 6 years
3121
J
Factors Related to the Development of Speech Skills
or older when they were tested had Significantly smaller incidence
severe picture of communication disturbance. Their motor difficulties
and magnnude of toss than did children tested before 6 years of
are often complicated by hearing loss.
age. The research of Goetzinger et at suggested that adults with
Some patients who do not show the weakness, slowness. or
cleft palate do not display more hearing problems than the general
incoordination that causes dysarthria nevertheless may demonstrate
adult population. •so
unusually poor motor-speech performance. Such difficulty in per
Some clinicians believe that t11e manner in which cleft palate is
fomling skilled motor acts voluntarily is termed apraxia. 162 A patient
managed bears an important relationship to the incidence of hearing
with oral apraxia is unable to follow instructions to wiggle or pro
toss. Masters et at studied a group of 172 patients."'" They reported
trude and retract the tongue, to whistle, to blow. to click the teeth,
that patients wnh prosthetically repaired clefts had the highest
t o click the tongue, or to cough. Associated with this, or sometimes
incidence of hearing toss, and they attributed this hearing toss to the
occurring independently, is apraxia of speech, demonstrated by
prosthodontist's inability to fabricate
adequate prosthesis prior
difficulty in producing phonemic units of speech. The patient cannot
to 2 years of age and the failure of the prosthesis to restore palatal
understand where to place the tongue to produce a given phoneme
musculature function.
or how to execute a sequence of movements to produce a word.
an
They considered the preservation of nom1al physiology of the eustachian tube and middle ear to be essential. However, their data did not take into account the age of the children at the time
Specific language disability
they were tested. Spriestersbacll et al also found that the incidence
of hearing loss was greater in children treated prosthetically than
Some children display difficulty in understanding and using language
in children with surgically repaired clefts, but the degree of loss
even though testing reveals no hearing loss. motor defect, intellec
between the two groups was not significantly different. 1"' Because
tual impairment, or emotional disturbance. Such difficulty in handling
of these findings, they doubted that the higher incidence of hearing
the symbol system is designated specific language disability (devel
loss in subjects wearing obturators could be explained on the basis
opmental aphasia or congenital aphasia). It is presumed that such
of poorly functioning palatal musculature.
cllildren have tl1is difficulty because of bilateral cerebral lesions or
In another study by Graham et al,161 54 patients were examined
defective crucial neural substrate for language. Such children may
before and after placement of an obturator: no ear infections
express themselves with gestures and indicate considerable under
developed after initial placement of the obturator. and no patients
standing of their environment, but they are unable to understand the
showed an increase in hearing toss after obturator use. It was
significance of what is said to them or. in milder cases. give the ap
concluded that an obturator can b e wom with no adverse effect
pearance of mishearing words in a way similar to the hard of hearing.
on the otologic condition of the palatal cleft patient Patients in this
Less severe degrees or specific language disability may account for
study had received otologic care from infancy, and obturators were
some of the persistent articulation and syntactic problems displayed
not fabricated before these children were 4 years of age.
by some children. Examination with the Illinois Test o f Psycholinguistic Abilities may indicate that a child has particular difficulty in the
Impairment of motor control
sequencing and recall of series of auditory units. '60 Although the child may be able to discriminate between and produce individual sounds. he or she may be unable to blend sequences of sounds
Children with cerebral palsy and patients with neuromuscular impair
and recognize what words they compose. Sentences generated are
ment may display, as a part of their motor difficulties. i mpairment of
often syntactically primitive and reveal a disability in incorporation
control of the speech apparatus with resulting dysarthria. •e. Motor
of implicit syntactic rules from the surrounding auditory language
impairment may range from minimal weakness or incoordination to
environment. The specific reading disability known as dyslexia falls
complete paralysis or severe incoordination: consequently, speech
within the general category of specific language disability.•G
