Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Available online at www.ordoneardentistrylibrary.org
ISSN 2249-488X
Case – report
INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY
RECONSTRUCTION OF A MIDFACIAL DEFECT USING AN INTRAORAL-EXTRAORAL
COMBINATION
PROSTHESIS EMPLOYING MAGNETS: A CLINICAL REPORT
Dr. Arun Khalikar, Dr. Sattyam Wankhede , Dr. Bipin Muley, Dr. Nitesh Kumar Srivastava*
Dept. of Prosthodontics. Govt. Dental College and Hospital, Nagpur
Received: 2 Aug. 2015; Revised: 23 Sep. 2015; Accepted: 15 Oct. 2015; Available online: 5 Nov. 2015
ABSTRACT
Radical maxillectomy frequently leads to extended defects in hard and soft tissues that result in a connection between the oral
cavities and orbit. If the defect cannot be surgically reconstructed, a combination prosthesis may be necessary to remedy
dysfunction in patient function, comfort, esthetics. For minor defects, enlargement of the base of the intra oral prosthesis is
generally sufficient. Resections that affect more than one third of the maxilla usually require an intra oral and an extra oral
prosthesis that could be assembled and retained in the patient. This clinical
report describes a technique of prosthetic rehabilitation of midfacial defect with a silicone orbital prosthesis and intra oral
obturator that are retained by magnets.
Key words: Combination Prosthesis, Silicone Prosthesis, Magnets, obturators.
INTRODUCTION
Head and neck cancer treatment frequently leaves the patient with some facial deformity due to extensive
muscle and bone loss which, in turn, can cause the patient to become depressed and isolated 1. Surgical facial
reconstruction in suborbital, pre auricular, buccomandibular region are performed using skingrafts, local flaps,
regional myo cutaneous flaps and composite flaps.2 Post‑surgical
adjunct radiation therapy sometimes can compromise the successful regional myocutaneous flap and thus
resulting in unaesthetic facial defect or oro cutaneous fistulas.3Post‑surgical defects could be rehabilitated or
camouflaged
using polymethyl methacrylate, latexes, vinyl polymers, copolymers, polyurethane elastomers, silicone
elastomers and the various modes of retaining the facial prosthesis include straps, spectacle frames, extension
from the denture, magnets,
adhesives and implants material.4
This clinical report describes a technique of prosthetic rehabilitation of midfacial defect with a silicone orbital
prosthesis and intraoral obturator that are retained by magnets.
46
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Case report
A 34‑year‑old male patient was referred to the department of prosthodontics with an oro facial communication
defect. His medical records suggested that he was diagnosed with carcinoma cuniculatum‑squamous cell
carcinoma on the left maxillary alveolus extending to floor of orbit. The treatment involved extensive surgical
excision of carcinomatous tissues . Post surgically he underwent 60 CYG of radiation therapy for a period of 4
weeks.
The patient’s chief complaint was limited mouth opening and any solid or liquid food tends to flow out from the
oro facial communication.
His other major concern was his facial disfigurement and inability to socially present him to others.
On extra oral examination, the defect is seen on left side of face extending from roof of orbit to upper border of
zygomatic bone.
Intra oral examination revealed he had partially edentulous upper arch(missing teeth 21,22,23,24,25,260 and
partial edentulous lower arch(missing teeth 35,36,46).
Hemimaxillectomy of maxillary left alveolus showing non healing defect that comminucate orbital defect.
Procedure:
1-Diagnostic impression & fabrication DiagnosticCast & Surveying of castPreliminary impression of the maxillary arch along with the intraoral defect was made using irreversible
hydrocolloid (Dentalgin; Prime Dental Products, Mumbai, India). The impressions was poured in type III
gypsum material (Kalstone; Kalabhai Karson, Mumbai, India). (Fig.2)
Surveying of the diagnostic cast was done and necessary mouth preparation steps were undertaken. (Fig.3)
2- Mouth Prepration,final impression & master cast fabricationAfter surveying proper guiding planes and occlusal rest seats were prepared in mouth. Maxillary custom
impression tray was fabricated and adjusted for proper extensions,including the palatal defect. The impression
compound was relieved and a physiologic definitive impression was made using a medium viscosity polyvinylsiloxane impression material (AQUASIL).
Conventional prosthodontic protocols of boxing and pouring the impression with type III gypsum material was
used to create a maxillary definitive cast.
(Fig.4)
3-Wax pattern fabrication & fabrication of metal frameworkA wax pattern for framework was fabricated and casting was contemplated. (Fig.5)
4-Try in of metal framework & impression of defectMetal frame work was tried in patient mouth and impression of defect was made with medium fusing
impression material (green stick) and light body impression material (AQUASIL). (Fig.6)
47
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
5-Altered cast fabricationAfter impression was made , an altered cast was fabricated (in dental stone) that contain both dentulous part and
impression of defect.( Fig.7)
6-Hollowing of defect to form intraoral obturatorTo reduce the weight of intra oral obturator defect part was hollowed by packing , a pouch of salt was used(
lost salt technique). Curing procedures were performed according to the manufacturer’s instructions. The cured
bulb was then retrieved after deflasking, and the salt was removed after drilling 2 mm holes in the lid portion.
Bulb was in two pieces that were attach together.5,6 (Fig.8.1,8.2,8.3,8.4,8.5,8.6)
7-Centric relation &teeth arrangementWith intra oral obturator was placed in mouth record centic relation teeth arrangement was done.
(Fig.9.1,9.2.9.3)
8-Attach magnet on superior aspect of obturatorA pair of commercially available closed-field magnets (Cobalt-Samarium), 5 mm in diameter and 2 mm in
thickness, was positioned with the help of autopolymerizing acrylic resin, and finishing and polishing was
carried out in the conventional manner.7Fig-10)
9-Flasking & finishing of obturatorAfter performing adjustments, the bulb was checked in patient’s mouth .Then the bulb was kept on the cast, and
a marking was done on the top portion of magnets with a copying pencil. The finished and polished prosthesis
was then tried to seat on the cast. The marks transferred on the tissue surface of the prosthesis determined the
position of the counter magnets. After attaching magnet flasking of obturator was done. (Fig.11.1,11.2,11.3)
10-Extraoral impression & Attachment of magnet on extra oral part of prosthesis –
An irreversible hydrocolloid facial-moulage was made to record the facial defect along with surrounding normal
extraoral structures and the extraorally exposed portion of the obturator with the second magnet placed over the
obturator-magnet. (Fig.12)
A definitive cast was formed from type III gypsum. (Fig.13)
A single thickness baseplate wax was adapted over the extraoral defect area of the definitive cast. The wax
sheet was flasked and processed in heat polymerized clear PMMA (Trevalon clear; Dentsply, York, PA, USA)
using conventional technique. The inner PMMA framework was tried over the patient’s extraoral defect by
placing obturator and second magnet in position.
An indentation for the second magnet was formed on the tissue surface of the framework. A cellophane paper
(DPI, Mumbai, India) was placed in between the obturator magnet and the second magnet to act as a separating
medium.
Auto-polymerizing clear PMMA was mixed and placed in the indentation of the second magnet formed inside
the tissue surface and the framework was seated over the defect area.8 (Fig.14)
48
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
11- Waxup the facial moulge
The position of the magnet was verified intra orally as well as extra orally .The other circular magnet
measuring the same diameter was mounted on the orifice of the cylindrical part of acrylic conformer.The final
portion of the facial prosthesis was sculpted with baseplate wax over the completed hollow PMMA
substructure. (Fig.15)
The wax sculpture was evaluated by positioning it on the patient’s face.( Fig.16)
The wax sculpture of the prosthesis was invested in type IV gypsum material (Ultrarock; Kalabhai Karson,
Mumbai, India) to form a mold for packing the silicone. Dewaxing was carried out in usual manner.9 (Fig.17)
After dewaxing, a uniform coat of mold separator was applied on the warm mold (both master cast and plaster
index) to facilitate separating the silicone from the mold.
The prosthesis was packed with a silicone and colored using intrinsic stains selected according to the patient’s
skin color. The silicone was heated for 2 hours at 90℃, deflasked, trimmed and cleaned. A conditioner was also
applied onto the acrylic conformer to obtain a good bonding between the conformer and silicones.
(Fig.18)
The gypsum-mold was preserved for future re-packing in case of discoloration or damage of the overlying
silicone layer.
14-Finishing of prosthesisWhen the mold temperature had cooled down the final RTV silicone base and catalyst were mixed in 10: 1
proportion and the thixotropic material, intrinsic colors were added similar to the trial silicone preparation.10
Once a uniform homogenous mix was obtained the silicone base shade was reverified against the patient’s skin
tone and using a brush the RTV silicone was painted uniformly on the mold surface.
This uniform brush application will help in eliminating any void formation. After the complete application, the
plaster index was reoriented back onto the master cast and complete seating of the same was verified with the
help of notches created on the land of the cast.
The master cast and plaster index were secured with elastics and left for overnight curing of the RTV silicone.11
The completely cured RTV silicone’s facial prosthesis was retrieved from the mold the following day and
subjected to finishing and polishing. Extrinsic stains were added to mimic the keratinized appearance and to
achieve a darker lip tone.
Instruction to patient-
49
•
Insert and remove the prosthesis gently
•
Clean underline facial surface properly
•
Follow up regularly
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Post Prosthesis evaluationPost prosthesis delivery periodic recall and check-ups were scheduled at 1st month, 3rd month and 6th month to
make any necessary adjustments. Patient was satisfied in terms of facial appearance, color matching,
swallowing activity and prosthesis preventing escape of food and fluids from the mouth. There was no
noticeable complication at the orocutaneous communication site due to the use of prosthesis;
alternatively patient’s psychological morale was improved with the use of silicone prosthesis.
Discussion
Large orofacial defects result in serious functional (impairment of speech, mastication, and deglutition) as well
as cosmetic deformity. The cosmetic deformity often has a significant psychological impact upon the patient.
Acceptable cosmetic results usually can be obtained with a facial prosthesis. However, retention of a large
prosthesis can be challenging. With ingenuity and an understanding of the remaining anatomic structures,
intraoral and extraoral prostheses that mutually retain one another can be constructed. Various methods of
auxiliary retention for facial prostheses have been described in the literature; they include eyeglasses,12
extensions from the denture that engage tissue undercuts,12,13 magnets,12,14 adhesives,12 combinations of the
above,12,13-15 and osseointegrated implants.12,13,16,17 Although osseointegrated implants may provide the most
reliable prosthesis retention; additional surgeries, expenses, inadequate bone, and prior radiation to the area may
contraindicate this type of treatment.18,19 The prosthetic rehabilitation of a patient with a combined intraoralextraoral defect has been presented in this article. A 2-piece (intraoral obturator and facial) combination
prosthesis was fabricated. Magnets provided mutual retention of the prosthesis. This was an esthetic option as
there was sufficient space to utilize magnets without hindering the external appearance of the prosthesis.
Several authors have reported different problems that compromise the serviceability of facial prostheses made
of a combination of PMMA and silicone.4,20 These include degradation of the silicone properties, delamination
of silicone from the PMMA base, reduced marginal integrity of the facial prosthesis, resulting in open margins,
and poor simulation of facial expressions due to the rigidity and heavy-weight of the PMMA base.4,20 Increased
bulk of the PMMA framework was always a worry for the prosthodontists. There has been increased interest in
using a fiber-reinforced composite as a dental and medical biomaterial for the fabrication of a facial prosthesis
framework which would be light-in-weight.3 This requires more sophisticated techniques and expensive
materials than PMMA. This article describes a technique to make a light-weight PMMA substructure by making
it hollow. The light-weight facial prosthesis facilitates better retention with magnets. The problems of
delamination of silicone from PMMA base can be easily overcome by bonding the processed silicone to an
underlying substructure with medical adhesive type A under vacuum as described by Lemon et al.
10
This
technique is advantageous as there is no need to fabricate the whole prosthesis again in case of discoloration or
damage of the silicone layer because the outer silicone layer can be removed and re-packed with the new
silicone on the PMMA substructure if the mold is preserved.. The cast-metal framework improves retention,
50
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
stability, support and bracing of the prosthesis and thus increases the longevity of both prosthesis as well as
supporting tissues. Major disadvantage of 2-piece prosthesis is that the mobility of intraoral obturator can make
facial prosthesis mobile especially during functions. We did not find clinically significant vertical mobility or
sinking down of the prosthesis during functional movements due to light weight of the prosthesis and good
extraoral bony support of the remaining orbital roof and zygoma. Durability of surface-coatings of the longterm magnets is a major concern; hence it is advised to use the magnets with strong surface coatings. Periodic
recall appointments at the interval of 6 months are advisable for assessment of the prosthesis (retention, stability
and support) and the supporting tissues.
Conclusion
The oro facial communication can be successfully rehabilitated close to patient’s normal skin tone using RTV
silicone facial prosthesis. The magnetically retained
maxillofacial prosthesis provides an esthetically acceptable facial contour, functionally prevents food spill over
from the oral cavity and boosts patient’s psychology to present themselves socially.
References
1. De Sousa A. Psychological issues in acquired facial trauma. Indian J Plast Surg 2010;43:200‑5.
2. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of concomitant lip and cheek
through‑and‑through defects with combined free flap and an advancement flap from the remaining lip. Plast
Reconstr Surg 2004;113:491‑8.
3. Balakrishnan C, Narasimhan K, Gursel T, Jackson O, Schaffner A. Closure of orocutanous fistula using a
pedicled expanded deltopectoral flap. Can J Plast Surg 2008;16:178‑80.
4. Kumar TP, Azhagarasan NS, Shankar KC, Rajan M. Prosthetic rehabilitation of orofacial donor site fistula
following surgical reconstruction: A clinical report. J Prosthodont 2008;17:336‑9.
5. Guttal SS, Patil NP, Nadiger RK, Kulkarni R. A study on reproducing silicone shade guide for maxillofacial
prostheses matching Indian skin color. Indian J Dent Res 2008;19:191‑5.
6. Javid N. The use of magnets in a maxillofacial prosthesis. J Prosthet Dent 1971;25:334‑41.
7. Nagaraj E, Shetty M, Krishna PD. Definitive magnetic nasal prosthesis for partial nasal defect. Indian J Dent
Res 2011;22:597‑9.
8. Soganci G, Yalug S, Kocacikli M. An alternative approach to combine orbital prosthesis and obturator: A
case report. Eur J Dent 2011;5:459‑64.
9. Morrow RM, Rudd KD, Rhoads JE. Dental laboratory procedures complete dentures. 2nd ed. St. Louis;
Mosby; 1986. p. 312-38.
51
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
10. Lemon JC, Martin JW, King GE. Modified technique for preparing a polyurethane lining for facial
prostheses. J Prosthet Dent 1992;67:228-9.
11. Udagama A. Urethane-lined silicone facial prostheses. J Prosthet Dent 1987;58:351-4.
12. Thomas K. Prosthetic rehabilitation. London; Quintessence Publishing; 1994. p. 93-103.
13. Beumer J III, Curtis TA, Marunick MT. Maxillofacial rehabilitation: prosthodontic and surgical
considerations. St Louis; IshiyakuEuroAmerica Inc; 1996. p. 408-16.
14. Dumbrigue HB, Fyler A. Minimizing prosthesis movement in a midfacial defect: a clinical report. J
Prosthet Dent 1997;78:341- 5.
15. Verdonck HW, Peters R, Vish LL. Retention and stability problems in a patient with a large combined
intra- and extraoral defect: a case report. J Facial Somato Prosthet 1998;4:123-7.
16. Menneking H, Klein M, Hell B, Bier J. Prosthetic restoration of nasal defects: Indications for two different
osseointegrated implant systems. J Facial Somato Prosthet 1998;4:29-33.
17. Worthington P. Branemark PI. Advanced osseointegration surgery: Applications in the maxillofacial region.
Carol Stream, Ill; Quintessence; 1992. p. 307-26.
18. Arcuri MR, LaVelle WE, Fyler E, Jons R. Prosthetic complications of extraoral implants. J Prosthet Dent
1993;69:289-92.
19. Roumanas E, Nishimura R, Beumer J III, Moy P, Weinlander M, Lorant J. Craniofacial defects and
osseointegrated implants: Six-year follow-up report on the success rates of craniofacial implants at UCLA. Int J
Oral Maxillofac implants 1994;9:579-85.
20. Taft RM, Cameron SM, Knudson RC, Runyan DA. The effect of primers and surface characteristics on the
adhesion-in-peel force of silicone elastomers bonded to resin materials. J Prosthet Dent 1996;76:515-8.
ACKNOWLEDGEMENTS- I would like to thanks Dr.Arun Khalikar (HOD & GUIDE), Dr.Sattyam
Wankhede & Dr.Bipin Muley for success of the case.
52
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
LIST OF FIGURES
FIGURE 1: Preoperative photos
fig.1.1
fig.1.2
fig.1.3
FIGURE 2: Diagnostic impression
Fig.2
FIGURE 3: Surveying of cast
Fig.3
53
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
FIGURE 4: Mouth Prepration,final impression & master cast fabrication
3-
Fig.4
FIGURE 5: Wax pattern fabrication & fabrication of metal framework
4-
Fig.5
FIGURE 6: Try in of metal framework & impression of defect
Fig.6
54
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
FIGURE 7: Altered cast fabrication
Ho
Fig.7
FIGURE 8: Hollowing of defect to form intraoral obturator
Fig.8.1 Adaptation of a layer of wax and Sealed wax lid.
Fig.8.2 Flasking of waxed-up bulb.
Fig.8.3 Dewaxing of waxed-up bulb.
55
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Fig.8.4 Packing with heat-cured PMMA.
Fig.8.5 A pouch of packed salt
Fig.8.6 Defect side view of bulb.
FIGURE 9: Centric relation &teeth arrangement
Fig.9.1
Fig.9.2
Fig.9.3
FIGURE 10: Attach magnet on superior aspect of obturator
Fig-10
56
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
FIGURE 11: Flasking & finishing of obturator
E
E
Fig.11.1
Fig.11.2
Fig.11.3
FIGURE 12: Extraoral impression
Fig.12
.
FIGURE 13: Definitive cast of extra oral prosthesis
Fig.13
FIGURE 14: Magnet attached onextra oral prosthesis
Fig.14
57
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
FIGURE 15: Wax pattern fabrication of facial sculpture
Fig.15
FIGURE 16: Trial of wax sculpture
Fig.16
FIGURE 17: Dewaxing
Fig.17
58
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
Dr. Nitesh Kumar Srivastava et al . / IJRID Volume 5 Issue 5 Sep.-Oct. 2015
FIGURE 18: Packing of silicone material
Fig.18
FIGURE 19: Pre operative &Post operative
Fig.19
59
Dr. Nitesh Kumar Srivastava et al / IJRID Volume 5 Issue 5 Sep.-Oct. 2015