Prosthetic Rehabilitation for Head and Neck Cancer and Soft Tissue Injuries

Module details

Title

Prosthetic Rehabilitation for Head and Neck Cancer and Soft Tissue Injuries

Type

Specialist

Module code

SPE421

Credits

30

Requirement

Compulsory

Aim of this module

To create a reconstructive scientist capable of undertaking independent practice in the area of head and neck cancer, applying their knowledge of reconstructive science in patient evaluation, manufacturing and the review of outcomes. This module will enable trainees to perform a range of treatments, interact with patients, and demonstrate safe, patient-centred practice. Trainees will be expected to build on the competence gained during rotational training developing technical expertise in planning, interpreting and communicating the design and manufacture of dental and medical devices and surgical plans. They will consolidate skills in explaining procedures to patients and gaining informed consent, enhancing and extending practical skills in undertaking maxillofacial prosthetics, and it will give  the trainee the tools to undertake case-based learning in the workplace.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1, 3, 7	Competency Explain the procedure for the provision of treatment/a prosthesis to the patient, address any procedure-related questions they may have and provide information on how to manage their prosthesis.	Action View
# 2	Learning outcome 1, 3, 7	Competency Gain informed consent and plan the clinical examination of the patient in accordance with local/professional guidelines, adapting techniques as necessary to reflect possible outcomes and influencing	Action View
# 3	Learning outcome 1, 3, 7	Competency Treat patients in a way that respects their dignity, rights, privacy and confidentiality, and explain treatment options for patients requiring facial prostheses.	Action View
# 4	Learning outcome 1, 3, 7	Competency Minimise risks and hazards in compliance with health and safety policies performing effective cross contamination control and infection prevention.	Action View
# 5	Learning outcome 1	Competency Record a comprehensive and contemporaneous patient history, recognising the significance of changes in the patient’s reported health status and taking appropriate action.	Action View
# 6	Learning outcome 2	Competency Plan the treatment for (and with) patients with head and neck cancer, providing appropriate advice and support and referring patients for advice or alternative/adjunct treatment	Action View
# 7	Learning outcome 2	Competency Plan the treatment for (and with) patients with soft tissue injuries, providing appropriate advice and support and referring patients for advice or treatment where appropriate.	Action View
# 8	Learning outcome 2	Competency Discuss and agree treatment plans for a range of patients with head and neck cancer with clinical colleagues and the	Action View
# 9	Learning outcome 2	Competency Explain the procedure for the provision of a prosthesis to the patient, address any procedure- related questions they may have and provide information on how to manage their prosthesis.	Action View
# 10	Learning outcome 3	Competency Perform a systematic intra- and extra-oral clinical examination, recognising abnormalities of the oral cavity and discussing any areas of concern with colleagues where appropriate.	Action View
# 11	Learning outcome 4, 5, 6, 8	Competency Use patient scanning and rapid prototype techniques suitable for the creation of analogues and present case in the required setting.	Action View
# 12	Learning outcome 4, 5, 6, 8	Competency Manipulate 3D data for pre- operative planning for craniofacial patients.	Action View
# 13	Learning outcome 4, 5, 6, 8	Competency Convert 3D data to model analogues.	Action View
# 14	Learning outcome 4, 5, 6, 8	Competency Select and justify treatment plans for the prosthetic reconstruction.	Action View
# 15	Learning outcome 4, 5, 6, 8	Competency Select manufacturing techniques and materials requirements for prosthetic reconstruction.	Action View
# 16	Learning outcome 4, 5, 6, 8	Competency Prepare the patient and take impressions of patients to generate analogues for a range of defects.	Action View
# 17	Learning outcome 4	Competency Design, manufacture and evaluate a range of custom made peri- operative devices for the treatment of head and neck cancer.	Action View
# 18	Learning outcome 4	Competency Plan and manufacture a surgical dressing plate for an edentulous patient undergoing a hemi- maxillectomy for a maxillary tumour.	Action View
# 19	Learning outcome 4	Competency Plan and manufacture a surgical dressing plate for patients for a dentate patient undergoing a partial maxillectomy for a maxillary tumour.	Action View
# 20	Learning outcome 5	Competency Design, manufacture and evaluate a range of dentures, obturators and mandibular prostheses (following hemi/partial mandiblectomy) for postoperative oral rehabilitation following palatal resection.	Action View
# 21	Learning outcome 5	Competency Demonstrate effective compliance with regulatory requirements.	Action View
# 22	Learning outcome 5	Competency Plan and manufacture a maxillary denture with an acrylic hollow box obturator for an edentulous patient.	Action View
# 23	Learning outcome 6	Competency Design a range of radiation applicators and shields and other devices to support the radiotherapy treatment.	Action View
# 24	Learning outcome 6	Competency Manufacture and evaluate a range of radiation applicators and shields and other devices to support the radiotherapy treatment.	Action View
# 25	Learning outcome 3, 4, 5, 6	Competency Complete required records for manufactured devices.	Action View
# 26	Learning outcome 3, 4, 5, 6	Competency Evaluate the effectiveness of the prostheses you have manufactured and fitted with and patient satisfaction/quality of life	Action View
# 27	Learning outcome 3,6	Competency Monitor and support the patient through the longer-term rehabilitation process, adjusting and replacing prostheses as appropriate.	Action View
# 28	Learning outcome 7	Competency Advise patients with deformities requiring prosthetic rehabilitation.	Action View
# 29	Learning outcome 7	Competency Support, teach and familiarise the patient and/or carer in the use of the prosthesis, including the development of user instructions and advice.	Action View
# 30	Learning outcome 7	Competency Where appropriate, provide patient counselling support as required and identify and communicate need for referral for further support as required.	Action View
# 31	Learning outcome 10	Competency Lead a patient assessment, identify and define individual requirements for dynamic splint therapy and discuss with the patient.	Action View
# 32	Learning outcome 9	Competency Assist in the design and manufacture of splints for the treatment of hypertrophic and keloid scars in a range of patients and demonstrate effective compliance with MHRA procedures.	Action View
# 33	Learning outcome 4, 5, 6, 9	Competency Assist in the evaluation of manufactured devices suitable for patient use.	Action View
# 34	Learning outcome 1, 2, 8	Competency Plan and manufacture an auricular prosthesis.	Action View
# 35	Learning outcome 1, 2, 8	Competency Plan and manufacture a nasal prosthesis.	Action View
# 36	Learning outcome 1, 2, 8	Competency Assist in the planning and manufacture an indwelling ocular prosthesis.	Action View
# 37	Learning outcome 10	Competency Lead a patient assessment, identify and define individual requirements for facial prosthetic reconstruction and discuss with the patient.	Action View
# 38	Learning outcome 10	Competency Lead a patient assessment, identify and define individual requirements for nipple areola complex prosthesis and discuss with the patient.	Action View
# 39	Learning outcome 10	Competency Lead a patient assessment, identify and define individual requirements for contour or digit prostheses and discuss with the patient.	Action View
# 40	Learning outcome 10	Competency Lead a patient assessment, identify and define individual requirements for ocular prosthetic reconstruction and discuss with the patient.	Action View
# 41	Learning outcome 11	Competency Identify a topic area, gain the appropriate permissions and perform a clinical audit with associated medical device-related risk assessments.	Action View
# 42	Learning outcome 11	Competency Analyse the results and develop recommendations to consolidate good practice and rectify any issues identified.	Action View
# 43	Learning outcome 11	Competency Present your clinical audit as a written report and discuss the recommendations with colleagues.	Action View

Assessments

You must complete:

• 5 case-based discussion(s)
• 5 of the following DOPS/ OCEs:

Produce mould for orbitofacial prosthesis.	DOPS
Prepare and pour up an impression taken from a maxillary defect case.	DOPS
Select and paint a pupil iris unit.	DOPS
Fit an orbitofacial or nasal prosthesis and instruct patient in use of fixation system.	OCE
Examine patient with an oroantral, oronasal or orofacial defect.	OCE
Take an ocular impression.	OCE
Fit a postburn or keloid splint.	OCE

Learning outcomes

1. Observe informed consent and assist in planning the treatment of the patient who has experienced maxillofacial trauma in accordance with local/professional guidelines, adapting techniques as necessary to reflect possible outcomes and influencing factors.
2. Observe informed consent and assist in clinical assessment of a patient who has a craniofacial deformity in accordance with local/professional guidelines, adapting techniques as necessary to reflect possible outcomes and influencing factors.
3. Record a comprehensive and contemporaneous patient history, recognising the significance of changes in the patient’s reported health status and taking appropriate action.
4. Write a treatment plan for patients who have experienced maxillofacial trauma or have a craniofacial deformities in partnership with the patient, supporting the patient to manage their fear and anxiety, and referring to other support services for advice or alternative/adjunct treatment where appropriate.
5. Discuss and agree treatment plans for a range of patients referred to the unit with maxillofacial trauma or craniofacial deformities with clinical colleagues, the patient and, if appropriate, relatives or carers.
6. Plan, design, manufacture and evaluate dental devices for patients with fractures involving the mandible, maxilla and middle third of the facial skeleton.
7. Discuss treatment options, design, plan, manufacture, fit and evaluate a range of auricular (ear) prostheses for patients with congenital absence of pinna (external part of the ear) prosthesis with the patient, their carers or relatives, and colleagues as appropriate.
8. Discuss treatment options and plans with patients, their carers or relatives, and colleagues for bimaxillary orthognathic (jaw) surgery and generate a pre- surgical plan.
9. Manipulate, analyse and interpret 3D digital imaging data of the head and neck, for patients requiring orthognathic surgery.
10. Manufacture medical implants for patients requiring surgical repair.
11. Assist in the routine maintenance, calibration and quality assurance procedures on the equipment used to plan and make medical devices.

Learning outcomes

1. Apply theoretical principles of materials’ properties and performance in the design and manufacture of medical devices for head and neck cancer and soft tissue injuries.
2. Evaluate the underlying risk, including the legal and ethical requirements in the manufacture of medical devices, including those used in the prosthetic rehabilitation for head and neck cancer and soft tissue injuries.
3. Critically analyse new developments and scientific advances in biomedical materials, manufacturing techniques and clinical performance, and discuss their application for new and innovative treatments.
4. Explain the use of quality of life measures/outcomes in the treatment and rehabilitation of head and neck cancer, including the underpinning evidence base.
5. Explain the potential routes of transmission of infectious agents in clinical practice, mechanisms for the prevention of infection, the scientific principles of decontamination and disinfection and their relevance to health and safety in a clinical setting.
6. Compare and contrast the range of physical and psychological responses to illness exhibited by patients with head and neck cancer and soft tissue injuries, and the treatments and support mechanisms available.
7. Discuss and evaluate the role of members of the multidisciplinary team involved in the treatment and rehabilitation of patients with head and neck cancer and soft tissue injuries, including speech therapy, dentistry, clinical psychology and self-help/charities, etc.
8. Explain the epidemiology, pathogenesis and prevention of head and neck cancer.
9. Explain the structure, behaviour, diagnostic investigations and management of swellings in the head and neck.
10. Describe the surgical procedures relevant to the excision of neoplasms and the provision of prostheses (i.e. resection skin grafts, bone grafts, tissue expansion and flaps).
11. Describe the use, design principles and constructional techniques of obturators and appliances used in the peri-operative, intermediate and definitive rehabilitation stages of treatment.
12. Discuss and evaluate the use of radiotherapy in the treatment of head and neck cancer and the effects of radiotherapy on patients, including the patient perspective.
13. Discuss the principles underpinning the manufacture of radiation applicators and shields and other devices used in radiotherapy treatment.
14. Analyse and manipulate digital data associated with the design and manufacture of facial prostheses.
15. Select and apply appropriate materials and techniques to create anatomical models.
16. Select and justify treatment plans for the provision of ocular, facial and other external prostheses for patients with head and neck cancer, based on the patient assessment and diagnosis.
17. Discuss the process of scar formation, including hypertrophic and keloid scars following chemical and thermal injuries.
18. Discuss the incidence and aetiology, appearance and classification of chemical and thermal injuries of the skin.
19. Discuss and evaluate the evidence-based underpinning the clinical treatment of burn and other thermal skin injuries.
20. Discuss and critically evaluate the treatment of hypertrophic and keloid scars and the effect of pressure on scar formation.
21. Discuss the range of devices and materials that can be used in the treatment of hypertrophic and keloid scars.

Indicative content

Methods of obtaining 3D data

• Methodology of the different modalities of obtaining digital data (CT, MRI, surface data acquisition) and new developments in imaging
• 3D volumetric and 3D surface data acquisition and methods of obtaining 3D data
• Identification of principle anatomical structures on X-rays, CT, MRI and surface data scans

Dimensional data

• Dicom data, conversion to a 3D data and 3D images
• Anatomical landmarks and artefacts for the different methods of data collection
• Accuracy of 3D reconstructed images
• 3D software programs for pre-operative planning, image manipulation and assessment in pre/postoperative outcomes
• 3D software systems to predict ideal implant locations (i.e. Simplant)
• New developments in digital analysis

Anatomical models

• Anatomical models from 3D data (i.e. CNC milling, rapid prototyping techniques)
• Manufacture and accuracy of 3D models used to create facial prostheses and templates

Dynamic splint therapies

• Anatomy and pathology in relation to the skin and thermal injury
• Patient protocols, management of the burns patient, scar review and scar indexing
• Keloid scar formation
• Keloid treatment strategies
• Post-burn trauma therapy aetiology and assessment of condition
• Histopathology in relation to pressure splinting
• Impression techniques with and without anaesthetics
• Cranio/Maxillofacial appliances, neck splints, microstomia appliances and hand splints
• Keloid splinting

Surgical procedures and devices

• Theatre protocols
• Information required for different surgical procedures (CT scans, models, etc.)
• Different surgical procedures relevant to the provision of prostheses (i.e. skin grafts, bone grafts, tissue expansion, flaps and resection)
• Principles of soft tissue surgery and plastic surgery
• Principles of tissue transfer and graft support appliances
• Design principles and service requirements of surgical splints for dentate and edentulous patients
• Evaluation of laboratory-constructed surgical splints
• Comparative treatments, evaluation of splint appliances
• Design principles of appliances used in tissue transfer
• Intermediate obturator prostheses

Effects of irradiation on tissues

• Mechanisms and effects of irradiation damage of tissues, with emphasis on the head and neck
• Types of malignant lesions for which radiotherapy is likely to be effective
• Lesions for which radiotherapy is indicated and those for which it is inappropriate
• Effects of irradiation of relevance to the craniofacial team
• Radiation applicators and shields

Dentures and obturation

• Surgical splint design principles
• Intermediate obturator prostheses
• Legal, ethical, professional and technical issues associated with the provision of dentures and obturators
• Classification of post-surgical defects, effect of defect on prosthodontic design principles
• Managing restricted opening
• Materials and techniques used in obturator construction
• Design features of obturator prostheses
• Open box, hollow box, glove obturators, obturator retention and soft palate obturation
• Surface finish of prostheses and microbial colonisation and degradation of silicone elastomers
• Intermediate obturator prostheses
• Definitive obturator prostheses for partially dentate patients
• Occlusion in relation to complete and partial prosthodontics for maxillary defects
• Alternative denture retention units
• Two-part bolt, split post and tube, hinged sectional and swing lock designs
• Use of implants and precision attachments
• Criteria for clinical presentation and patient use
• Occlusal schemes for patient requiring:
• complete dentures and obturators
• neutrocentric
• monoplane
• lingualised occlusion
• balancing ramps
• Gerber based
• Two part dentures, design criteria for patients with microstomia

Ocular prosthetics

• The ocular prosthetic patient: aetiology and assessment of condition
• Intra-orbital implant consideration assessment
• Ocular socket microbiology
• Recognition and pathology of diseases of the ocular socket and globe
• Surgical techniques associated with indwelling ocular prostheses
• Impression materials selection
• Ocular impression techniques
• Impression techniques for haptic lenses
• Interpretation of the ocular impression
• Modification of the ocular impression
• Modification of prosthesis patterns
• Ocular colouration, iris structure
• Colour assessment and matching, iris painting techniques
• Ocular reaction to materials
• Patient review
• Recognition of conditions and diseases associated with indwelling ocular prostheses
• Cleaning and surface analysis of prostheses

Anaplastology

• Principles of the clinical management of facial prostheses, pre-treatment assessment, treatment planning, pre-prosthetic surgery
• Principles of facial prosthesis design
• Impression techniques for facial and body prostheses, impression materials
• Patient management during impression procedures
• Surface scanning, rapid prototyping of analogues and prostheses, new developments in surface scanning, analysis and 3D printing
• Facial prosthetic materials, properties, biocompatibility, colouration
• Methods of skin tone simulation
• Retention and methods of support of facial prostheses
• Introduction to multipart prostheses
• Anatomical accuracy, topography and surface effects
• Colour technology, material and colour stability in prosthetic materials
• Relevant polymeric and silicone chemistry, lamination, tissue adhesives and relevant skin preparations
• Nipple prostheses, digit prostheses

Bonding of silicone to acrylic

• Primers and rationale for use and selection
• Substrate/primer/silicone interface, mechanical and chemical factors

Medical legal aspects

• Medical legal aspects of treating patients, patients’ complaints procedures, and carers
• Medical Devices Directive
• Personal Protective Equipment regulations
• Medical history and records, patient and professional communication
• Medical ethics, informed choice/consent/negligence and maxillofacial prosthetics practice

Risk management and governance

• Compliance with the requirements of the Medical Devices Directive (MDD)
• Clinical Governance framework
• Current standards and compliance in the healthcare environment, including Standards for Better Health, NHS Litigation Authority
• Management of innovation and prototype devices and treatment

Management of patient

• Patient evaluation and referrals
• Management of patient’s fears/anxiety and ability to empathise with patients in stressful situations, and the manifestations of anxiety/pain and the range of methods available in their management and control
• Personal and professional interaction with terminally ill patients, including counselling skills
• Theories and evidence base underpinning health-related behaviour
• The effects of drugs, allergies and lifestyle factors on patient health and rehabilitation
• Risks and benefits of care/management for the patient and their family/partners/carers
• Common psychosocial disorders (abnormal psychology, anxiety, depression, psychoses, eating disorders, alcoholism and drug addiction)
• Recognition and appropriate care of patients with tissue conditions (psoriasis, eczema, contact dermatitis, dry mouth, sore mouth/mouth burning syndromes)
• Dementia, Alzheimer’s, Parkinson’s disease
• Process of grief and loss
• Body image and effect of altered body image
• Patient-centred counselling skills, including the importance of appropriate location and the amount of time devoted to the task
• Role of support groups (physical and internet)
• Principles of patient education and supporting patients to be actively involved in their care
• Quality of life outcome measurement and analysis
• Care pathways and referral for social and psychological support

Activities

• Experience a range of clinical services and in each setting identify how each service contributes to holistic approach to patient care and discuss potential improvements to enhance patient safety, dignity and care. These experiences should take place across the two specialist modules and should usually include:
  • oral and maxillofacial head and neck clinics, including observation of diagnostic procedures and a range of imaging techniques
  • diagnostic services (radiography, CT, MRI and pathology)
  • operating theatres, including observing surgery for the head and neck cancer interventions. A range of surgical procedures to include soft tissue dissection for salivary gland, parotid and neck node removal, composite hard and soft tissue dissection to remove larger maxillary and sinus tumours
  • attend inpatient areas to observe preoperative admission and postoperative care
  • postoperative review clinics
  • facial prosthetic clinics
  • reconstructive clinics for the primary and secondary management of postoperative deformities and subsequent surgical reconstruction options
  • assessment tools for secondary surgical and prosthetic planning (X-ray, CT, cone beam computed tomography (CBCT), 3D imaging, medical photography).
• Critically review the institution’s incident reporting mechanism and identify key learning for yourself and the reconstructive science department and discuss with your training officer.
• From our clinical experience identify a patient who has been referred to the psychological support services and discuss the management strategies to support the patient, with the healthcare professional and patient reflecting on how this experience will impact on your future practice.
• Attend multidisciplinary team meetings and discuss the advantages and disadvantages of integrated care pathways from the perspective of the healthcare professional.