**6. Management**

*Management of maxillofacial defects is a multidisciplinary, well planned execution of procedures starting pre-surgery and extending long after rehabilitation is complete. It includes patient awareness, early diagnosis & prompt treatment, role of Healthcare specialist/worker, role of a psychological counselor, family and support groups.*

#### **6.1 Patient awareness, early diagnosis & prompt treatment**

Awareness, early diagnosis and prompt treatment can help minimize the spread of habit related orofacial cancers, involvement of normal anatomical structures and the extent and size of defect requiring rehabilitation.

**Various awareness programs and statutory warnings like increased chances of cancers due to cigarette or tobacco consumption are displayed on television, radio and alongside streets in many Asian countries for awareness of patients about the harmful effects and the dreaded consequences.** Also advertisements about treatment options available and life post-rehabilitation are propagated to spread awareness and reduce anxiety among patients.

### **6.2 Role of Healthcare specialist / worker**

Management of patients with maxillofacial defect is a multidisciplinary approach and involves specialists from various branches. Prosthodontic rehabilitation allows replacement of lost structures with artificial substitutes to near normal appearance as possible. For extraoral defects, esthetics is the main concern. Various measures are taken to ensure correct anatomical alignment of the artificial prosthesis, well adaptation, proper retention using retentive aids including anatomical, mechanical or physical means and shade matching. Advancements in technology and introduction of three dimensional scanning techniques using extraoral scanners, reconstructions using DICOM image files, rapid prototyping, and spectrophotometer have enhanced the precision that can be achieved in maxillofacial prosthetics**. For intraoral defect, advancements in material like PEEK and modifications in designs allows to achieve more esthetic results by concealing the metal display and enhancing appearance with function** [9].

To allow patient to accept the treatment and comply with the instructions, it is important that the patient is in psychological state of mind to accept the loss and cope up with the grief. Active listening and empathy are the qualities that the clinician must possess to look past patient's defect and understand the deep seated distress.

Psychotherapeutic techniques help in recognition of the feelings that patient is trying to express and allowing them to express to do so in elaborate form for better understanding and management.

Evaluation of psychological status of patient can be done in form of interviews, rating scales, tests or questionnaires which may be self-administered or by clinician. Some scales to aid in psychological evaluation Becks Depression inventory, Hospital Anxiety and Depression scale, General Health Questionnaire-12/28, ICP, ICF, MMPI and others.

**Preoperative care** includes understanding that **the diagnosis and breaking the news like cancers puts** the patient into a progressive cycle of loss and grief where they start questioning themselves and their destiny. It is an emotional turmoil for the patient and the family. Letting the patient vent out and come to terms with the reality helps them cope up with the therapy. Patient should be introduced to various survivors groups, AV aids can help in making them understand the progression of the disease and various rehabilitation options available.

The patient and family should be made aware of the emotional reactions and fluctuations they can expect during the postoperative and extended-care phases of treatment. Giving advance warning helps the patient realize that his or her emotional reactions during treatment are normal.

### **6.3 Postoperative care**

Post operatively, the patient is in a vulnerable state as the trauma of surgery added up with the actual loss of part of 'self'. Alteration of facial symmetry, alteration in speech, difficult mastication and esthetic compromise pushes patient into a deep psychological distress. Good communication skills, motivation, psychodynamic therapy, support groups, active listening, empathy can help to improve the mental make-up of the patient and family.

#### **6.4 Extended care & Team work**

A rehabilitation specialist, maxillofacial Prosthodontist, reconstructive surgeon are a ray of hope for the patients. A well fitted prosthesis or reconstructive surgical modalities improves patient's condition and enable them to restore form, function and esthetics. Team work including role of psychological counsellor, administration of anti-depressants, nutrition counselling and diet modification to combat the side effects of radiation therapy or dysfunctioning of certain organs like xerostomia, alternate medicine specialists like naturopathy, yoga, mind body exercises can help patient develop a positive mental attitude and improve prognosis of the treatment.

#### **6.5 Case summary**

A 42 yrs old male patient reported with a chief complaint of a non-healing ulcer in the palate since 04 months with no facial disfigurement. Patient gave a history of smoking and tobacco chewing since past 08 years. On examination and histopathological investigations, a diagnosis of verrucous carcinoma was arrived at. Treatment plan formulated was surgical resection followed by prosthodontic rehabilitation. On interviewing the patient and history taking, it was felt that the patient was very anxious and concerned about his facial appearance. To check his current state of anxiety, a self administered questionnaire (DASS) was provided and based on the results it was observed that he had moderate-severe anxiety state [10]. His family was addressed and prepared so that they could provide the patient with necessary support needed. When the patient was told about the diagnosis, he was unable to accept it and had bouts of crying. He was counselled and was introduced to a support group with patients who had undergone similar procedure earlier. AV aids were used to motivate the patient and introduce the prosthetic options and their

#### *Beauty - Cosmetic Science, Cultural Issues and Creative Developments*

impact on lifestyle. On active listening, it was observed that patient had a financial crunch due to loss of job and that was another reason for his hysteria. He was introduced to local Non-profitable institution who were ready to share the expense for the surgery. Pre-surgery a mock procedure was shown to the patient. During surgery, maxillectomy was performed using Weber-Fergusson incision that resulted in a large intra oral defect and a visible facial scar. His speech, mastication and nutrition was affected. Depressive state was prevalent as observed in his behavior, response, loss of apatite and unwillingness to meet or talk to others. He was kept of psychological counselling sessions for 03 months on weekly basis and a well fitted definitive prosthesis was fabricated. Post 06 months, he was able to adjust to the condition and volunteered to be a member of support group to help others in similar hardships. His psychological state changed from normal to highly anxious and depressive post-surgery and eventually improved to mild-moderate anxious state post rehabilitation.
