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The Other Side of VA Dentistry

A dentist holds up a mold of a face next to his patient

“Facial Moulage” procedure was done to produce the master cast of the face. Photo by Kenneth Holt, William Jennings Bryan Dorn VAMC

by Dr. Dai C. Phan, Maxillofacial Prosthodontist, William Jennings Bryan Dorn VA Medical Center
Monday, July 28, 2014

Restoring Oral and Facial Defects

In our patient population, it’s not uncommon for some Veterans to lose part of the oral cavity or have facial defects due to trauma, cancer, or both. Left with these disfiguring injuries, the reconstructions via artificial substitutes are normally rendered by the dental specialist in the dental service line.

Maxillofacial prosthodontics is a sub-specialty of the prosthodontics specialty that deals with the restoration of the defects in the maxillofacial region through the use of prostheses. A typical request is to provide oral prostheses to address the missing parts of the hard and soft palate, tongue or part of the jaw so that the patients can more easily eat, drink and speak. In cases where extra oral parts need to be restored – such as a nose, ear, eyes or part of the face — maxillofacial prosthodontist will also be called on to provide this kind of restoration.

Louis “Lou” Matarangolo had part of his maxillary palate and nose removed many years ago due to a facial tumor. Louis’s reconstruction called for an oral device called an obturator to close the palatal defect and a nasal prosthesis made out of medical-grade silicone to restore the missing nose.

Teamwork was vital to the success of this rehabilitation. It involved a dental specialist as well as dental technicians at Dobbs Labs, Inc. in Hoover, Ala., and a maxillofacial prosthetics technician at the James J. Peters VA Medical Center in Bronx, N.Y.

My job was to provide an accurate reproduction of the defect areas and their surrounding anatomical structures, as well as the measurements, so that both the dental and the nasal prostheses could be fabricated. A master cast of the entire face was sent to the prosthetics technician, along with current and past photos of the patient, so that the artificial nose would accurately reflect the patient’s pre-surgery appearance.

Gloved hands adjust a prosthetic nose on the face of a man

Evaluation of the nasal prosthesis for color, complexion matching and adaptation of the margins. Photo by Kenneth Holt, William Jennings Bryan Dorn VAMC

Prosthesis Matches Skin Tone and Complexion

The dental laboratory technician created the oral prostheses from the measurements provided on the laboratory prescription. The nasal prosthesis was then waxed up and processed to match the patient’s skin tone and complexion from the references provided.

At the “try in” visit, I fitted the prostheses to determine how well they performed during function. This involved the assessment of how stable or retentive the nasal prosthesis was during talking, breathing, chewing as well as the quality of speech when the obturator is in place.

I took that feedback and gave it to the technicians with my recommendations, and they changed the prostheses to fit his needs.

Sometimes at the delivery visit, pigments have to be applied to ensure the seamless transition between the natural and artificial skin tones. The most important factor in prosthetic reconstruction’s success is to make the artificial substitutes virtually indistinguishable from the real anatomical structures when viewed by a casual observer. And due to the seasonal changes that affect skin color – tan in the summer, paler skin in the winter and anything in between — I provided different nasal prostheses for him so they can be customized at any time as needed.

Two views of a man’s face with prosthetics of different skin ones

Two different prostheses were provided to accommodate seasonal changes to the skin color. Photos by Kenneth Holt, William Jennings Bryan Dorn VAMC

Every single patient presents a wealth of challenges due to the uniqueness of the maxillofacial defects and I find my field of work highly rewarding when I know that my service has such an impact on someone’s quality of life. Practicing maxillofacial prosthodontics allows me to combine medicine, dentistry and art into one. It gives me even more satisfaction when I am able to provide valuable service to those who gave us the freedom we have today. For our returning troops who may have maxillofacial defects sustained by wartime injuries, prosthetic reconstruction provided by VA dental services fills a gap in cases where surgical reconstruction may not be feasible.

My special thanks to the technicians at Dobbs Labs, Inc. for construction of the oral prostheses and to Sarah Wisniewski (maxillofacial prosthetic technician in training) at the James J. Peters VAMC — in Bronx, N.Y., for fabrication of the nasal prostheses.

Dr. Phan and his older brother and parents escaped from Vietnam in 1978. He is an avid mentor for students seeking a career in dentistry and frequently lectures on a variety of dental topics. Read Dr. Phan’s story on page 18 of this issue of VA’s Vanguard magazine.

 While we focus on patient safety as an everyday responsibility, Patient Safety Awareness Week allows us time to highlight some of the exciting ways people all over the VA are working to achieve high quality and safe care for their patients. 
— Robin R. Hemphill, Chief Safety and Risk Awareness Officer, Director National Center for Patient Safety