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#22645 03-20-2007 05:14 AM
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Hello all,

My name is Dai Phan and I am a maxillofacial prosthodontist ( a dentist specialises in prosthetic reconstruction). I have given numerous CE courses to dentists on numerous dental topics. If you have any questions about dentistry as well as oral cancer related topics, I will be happy to offer my opinion. Please note that my opinion is not a substitute for seeking care with your practitioners as nothing can be diagnosed over the Net. To introduce myself to a more personal level, please see this link below. Thank you and have an enjoyable day! DP

http://abqtrib.com/news/2007/feb/15/erik-siemers-doctor-enjoys-healthy-doses-laughter/

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Dear Dr. Phan,

My husband served a year in Vietnam--1968-69--so I can relate a bit to your history. What a saga for you and your family.

I very much appreciate your writing to this site. There are not many of us who use prosthodontic devices, but there are a few, and I am one of them.

I am 15 months post surgery for a hemi maxillectomy and partial palatectomy. I have been fitted for an obturator, which is surprisingly satisfactory, though, or course, still imperfect.

I will write my questions here, since someone else might be interested, or might need the same information.

In my surgery, all teeth on the right side were removed; the first remaining tooth is the lateral incisor on that side. I lost 5 teeth (the wisdom tooth had already been removed years ago,) along with the bone and about 2/3 of the hard palate on that side.

I have received my "definitive" obturator....a "cadillac" made of metal and acrylic. We are still trying to improve the fit of the appliance, as there is some leakage and some movement.

Here is my most specific question: My prosthodontist has suggested that, since I do not have rear teeth on the surgery side, I would improve the retention of the appliance if I would have my front teeth crowned, so that a special clip could be installed on the rear side of the lateral incisor and the right central incisor. I would have to crown at least four, and possibly five teeth for a satisfactory appearance.

I hesitate to cut down good teeth, especially after having lost five good teeth already. The crowns would, of course, have to be made of porcelain over metal, and not the newer all=porcelain type.

The other option would be to get zygomatic implants. I do not have the pterygoid bone process remaining. I have consulted a specialist at Baylor Dental School in Dallas about the zygomatic implants. They sound interesting, but I haven't seriously considered them.

Do you have suggestions? My surgeon feels that I am cancer-free, and he is actually encouraging me to consider reconstructive surgery.

I am feeling a bit overwhelmed by so many options. What would your advice be?

I am so glad that you came along with your offer of advice, since I am to go to my prosthodontist on Thursday of this week.


Colleen--T-2N0M0 SCC dx'd 12/28/05...Hemi-maxillectomy, partial palatectomy, neck dissection 1/4/06....clear margins, neg. nodes....no radiation, no chemo....Cancer-free at 4 years!
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Hello Dai Phan

I was interested in your story. Congratulations on what you have achieved in your adopted country. It is heartwarming that you are now able to offer support to the communities that gave you that opportunity.

The laughter struck a chord with me. I found it to be a great help during my treatment even though I sounded very peculiar! It seemed to be a release for everyone.

Best wishes and love from Helen


RHTonsil SCC Stage IV tx completed May 03
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Hello Colleen,

First let me say "Thank you" from the bottom of my heart to your husband for serving my country so many years ago. I work at the VA and it is such an honor to serve those who give us now the freedom we are enjoying. Regarding the obturator, one of the challenges of the obturator is getting adequate retention of the prosthesis. Lack of retention will cause air leakage that affects speech as well as causing problems with function such as fluids coming out of nose while drinking water. Therefore the remaining teeth must be ultilized to the maximum to provide needed stability. What you described sounded to me like attachments that are incorporate in to the crowns where the obturator is attached through male and female attachments. These kinds of retention devices are for cases where the tooth contour is inadequate for conventional clasp (round wire)design or a stronger form of retention is needed. It is also for cases where clasps would present an esthetic concern especially in the front area. I see no problems with having the teeth crowned for this purpose. Another way to help the obturator to stay in place better is by using hollow bulb rather than using a solid one. Ask your prosthodontist to consider a hollow bulb if yours is a solid one. If I recall right, a study done indicated that 33% of weight can be reduced with the hollow bulb approach. Regarding the implants, I would consider this as a second option since why go through surgery again if a simpler approach can be ultilized such as the first option?

If you feel that your speech is not clear or you having problems with the appliance during function, perhaps the bulb portion (the obturator part) needs to be adjusted or relined to account for tissue changes. It is not common to have the prosthesis adjusted even years after insertion. DP

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Dr Phan

Quite an amazing story , Although your journey was different then the one we face it was definitley a trying one and one of uncertainty , and just keeping the faith to get through. Thank you for sharing and for joining the group and being able to give answers to those who may need them. I am not aware of exaclty what your specialty does , so Am I safe in assuming I dont need them ? LOL ( I KNOW I KNOW never ASSUME anything). But I am glad you are hear for those who do and lord forbid If I ever do , it is nice to know you are offering services ( answering questions) to those in their time of need .

Sharlee


Sharlee
35 year old Female Non smoker, very occasional alcohol ..Scc T1N0M0,partial glossectomy and left neck disection ,2/9/07 No rad deemed ness. 4/16 tonsillectomy ..Trimengenial Neuralga due to surgery
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Hi Dai,

Great to have a prosthodontist here to help field questions. You apparently have experience caring for post cancer treatment patients, something that I lack in my practice.

Your expertise will be greatly appreciated by many. Thank you for taking the time to answer questions and I was very impressed with your story.

Jerry


Jerry

Retired Dentist, 59 years old at diagnosis. SCC of the left lateral border of the tongue (Stage I). Partial glossectomy and 30 nodes removed, 4/6/05. Nodes all clear. No chemo no radiation 18 year survivor.

"Whatever doesn't kill me, makes me stronger"
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Dr. Phan -
Yours truly is an amazing story - we welcome you! I don't know how many of us could have survived what you went through. We hope your parents are still with you and enjoying their freedom and life in general now. Thanks for your offer of advice for our members who need it.
Warmly, JaneP


Husband: 3 SCC gum and cheek cancers 2002, 2005, 2006: surgery only. Scans clear after removal of small, well differentiated, non-invasive cancers. No radiation. 4th SCC lip diagnosed 4/13/07 - in situ, removed in biopsy. More lip removed 2/8/08 - dysplasia. 2 Biopsies 3/17/09 no cancer (lichenoids)
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Dear Dr. Phan,

Many thanks for your response, and for your generous comments about my husband's service in Vietnam. FYI....He was stationed at Long Binh, and served at first at Fire Support Base Rita, in the Fish Hook area near the Cambodian border. While at Rita, his encampment was over-run by the Vietcong, and his unit lost 12 killed and had 25 wounded, and my husband was the only medical officer there....fresh out of medical school. His colonel was wounded that night (and my husband received a medal for valor that night) and the colonel's saga was later featured on A & E. It showed a documentary film of the night of the attack, and I ordered it and have it here. It does not show my husband, but it shows the incoming artillery, and it shows the colonel being treated behind a barn. It doesn't show the young doctor treating him.

My prosthodontist feels that the curved wire attatchment around the final tooth will eventually put too much stress on that tooth, since it is the lateral incisor and is not considered to be a strong tooth. I currently have several clasps on the molars on the non-surgery side, and a very small curved wire clasp on the incisor. It does not go around to the front and is hardly visible.

My problem is that I have no assurance that crowning the teeth and having the male/female clip on the back side will improve the stability of the obturator. My speech is actually excellent, even though there is a slight bit of movement in the appliance. I sing also, and occasionally I feel/hear some vibration in the appliance as it shifts slightly.

There is slight movement which makes my tissues sore by day's end.

There is some leakage of liquids that we are attempting to remedy. There is leakage even when I clench my teeth to hold the appliance securely in place.

I want the best speech and singing that I can get, and of course my prosthodontist can not guarantee that I will have a better result than I have now.

Nor can you, of course.

But I do want to look and feel as normal as possible.

Thanks for listening.


Colleen--T-2N0M0 SCC dx'd 12/28/05...Hemi-maxillectomy, partial palatectomy, neck dissection 1/4/06....clear margins, neg. nodes....no radiation, no chemo....Cancer-free at 4 years!
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another question......about hollow bulbs....I know that he spoke of using a hollow bulbed obturator, but I do not think that this one has a hollow bulb. We did decide that we did not want to use one without a top on the bulb, but I thought that the bulb could be hollow and still be covered and sealed. Is this so?

This is my "definitive" obturator, made of metal and acrylic, and costing plenty ($2500) so I expect it to be a significant improvement over what I have had in the past. We haven't gotten what I consider to be a good fit yet, but it does not feel as lightweight as I had expected. I will ask him about that.


Colleen--T-2N0M0 SCC dx'd 12/28/05...Hemi-maxillectomy, partial palatectomy, neck dissection 1/4/06....clear margins, neg. nodes....no radiation, no chemo....Cancer-free at 4 years!
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Hi Colleen,

Amazing story and the valor of your husband! Please send my sincere appreciation to him for what he did for my country. From what I gathered, it seems that you are doing very well with your appliance. Attachments would no doubt will increase the retention of the prosthesis but they also can be a "double edged sword". Too much retention will put stress on the abutment teeth (holding teeth) and that will cause movement or mobility and that you do not want. This is especially on a lateral incisor where the root is small and has weaker bony support than say a molar. Your prosthodontist will be the best person to evaluate your case precisely. Regarding getting the obturator to be perfect as possible can be almost impossible in some cases. The appliance is surrounded by movable tissues so therefore you will always have some minor movements. Most of my patients have learned to deal with this nusience well. Sometimes trying to make something to be as perfect as possible may end up as a "wild goose chase". I can tell this from personal experience. On the hollow bulb, yes it can be made either without the top or the top with hollow space inside. DP

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Dr. Phan, you have a wonderfully perceptive nature, and you are able to cut to the heart of matters in a way that I have not experienced before. I have had excellent care, but I would have benefitted from your concise explanations and realistic approach. I wish that NM were closer to Louisiana!

I am thankful that you discovered this site and offered your services. There are not many persons on this forum who use obturators, but with more specific support available, I'll bet that there will be more before long.

Thanks.

I go to my prosthodontist tomorrow.....2 hours out of town, but not as far away as NM....and I will go better armed to make my final decision about the attatchments.

For my information: Do you often recommend pterygoid or zygomatic implants for securing obturators?

And.....do you see much reconstructive surgery of palatal and maxillary surgical defects? or do most such patients find satisfactory results with the obturator and opt not to undergo the reconstruction?


Colleen--T-2N0M0 SCC dx'd 12/28/05...Hemi-maxillectomy, partial palatectomy, neck dissection 1/4/06....clear margins, neg. nodes....no radiation, no chemo....Cancer-free at 4 years!
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I think that my prosthodontist intends to place a bar behind the lateral incisor and the central incisor on that side, for double support of the appliance, so that the lateral incisor doesn't take the entire force.

I am concerned that it will take perhaps more force with the clip behind it than it does now, with the small wire hugging the side of the tooth.

Also....I am beginning to think that the lateral incisor...the one closest to the surgical excision site.....is becoming slightly discolored, though the periodontist says that roots look healthy. I don't know what that might mean.


Colleen--T-2N0M0 SCC dx'd 12/28/05...Hemi-maxillectomy, partial palatectomy, neck dissection 1/4/06....clear margins, neg. nodes....no radiation, no chemo....Cancer-free at 4 years!
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Hello Colleen,

Although I have worked on obturators with zygomatic implants, I have yet to recommend this type of treatment to one of my patients. Thankfully, most of the patients that I have treated only had partial maxillectomy where the remaining teeth on the other side provide satisfactory retention of the obturator. The implants retained prostheses are reserved for cases where the patient is edentulous (no teeth remaining), has recieved total maxillectomy or the remaining teeth are not suitable for clasps or attachments.

Regarding the surgical repair of the palatal defects, I cannot comment on it much because it is outside of my expertise. I have seen a case with excellent surgical repair where the defect is small however. On large maxillary defects that have multiple teeth missing, prosthetic repair makes more sense since you can use the appliance as a foundation to restore missing teeth. By the time the patients are referred to me for prosthetic reconstruction, the surgical approach is no longer a high end option.

I can tell you that it is very rare to have a surgical reconstruction of extra-oral defects such as the ear or nose that are satisfactory. All surgical recontructions I have seen in my short career so far leave lots to be desired. An implant retained prostheses I believe is the best treatment in this particular case.

Discoloration of the lateral incisor can be caused by many factors. If you have decreased saliva output, the "washing" action by the saliva is decreased thus plaque or food particles tend to accumulate and thus changing the color of the tooth. Very common in people who drink lots of coffee or tea with decreased saliva output. Medications also play a role. Peridex (oral rinse) is known to cause moderate stain on the teeth. Another cause is necrosis of the pulpal tissue inside the tooth (nerve tissues dying). Your dentist can check for the tooth vitality with some simple tests. There are more causes of tooth darkening but those mentioned are more common causes. Let me know how your visit with your dentist goes. DP

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Dear Dr. Phan,

I hope that you do not regret offering to advise us online!! I do not mean to take advantage of you, but I am very, very glad to have your input. Thanks very much for your generosity!

My visit with the prosthodontist today went well enough...I have decide to delay any decision to have my teeth crowned. Your advice about avoiding too firm an attatchment coincided with that of a cousin who is a retired dentist, with whom I conferred this morning. My prosthodontist was ok with this decision.

We will continue to work with fine-tuning this appliance with re-lining material, and when we feel that we have it finalized, he will re-bake it for permanence. (This is my definitive obturator, made on a metal framework.)

I will undoubtedly have more questions for you, but for now, I am feeling more secure in my decision about the crowns, thanks to your advice. The crowns will always be an option down the line.

As for reconstruction, my current surgical recovery has been so perfect that I hesitate to interfere with that. Also, the surgery is quite drastic, in my opinion, with no guarantee of success, and I simply can not consider that experience at this time.


Colleen--T-2N0M0 SCC dx'd 12/28/05...Hemi-maxillectomy, partial palatectomy, neck dissection 1/4/06....clear margins, neg. nodes....no radiation, no chemo....Cancer-free at 4 years!
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Hello Colleen,

I am glad you are doing well. I am here to offer my opinion and perhaps people may find it useful. It is my pleasure to be at your service. DP

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