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| CASE REPORT |
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| Year : 2022 | Volume
: 22
| Issue : 3 | Page : 294-299 |
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Rehabilitation of a mid-facial defect using maxillary obturator with a maxillary expansion device and orbital prosthesis
B Devi Parameswari, Annesha Koinyaki Konwar, Annapoorni Hariharan
Department of Prosthodontics and Implantology, Meenakshi Academy of Higher Education and Research, Chennai, Tamil Nadu, India
| Date of Submission | 01-Dec-2021 |
| Date of Decision | 11-May-2022 |
| Date of Acceptance | 12-May-2022 |
| Date of Web Publication | 18-Jul-2022 |
Correspondence Address:
B Devi Parameswari
Meenakshi Ammal Dental College, Alapakkam, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jips.jips_527_21
Midfacial defects are defined as congenital or acquired defects in the horizontal plane at the middle third of the face and communicate with intraoral maxillary defects. These defects lead to speaking difficulty, difficulty in saliva control and deglutition, mastication, and esthetics. Prosthetic rehabilitation of such defects with maxillofacial prosthesis is a challenging task. Maxillary defects with bilateral undercuts present are common. This case report explains to achieve retention by engaging the bilateral undercuts with the desired path of insertion and obtaining adequate retention of these prostheses. This clinical case report presents prosthetic rehabilitation of a mid-facial defect involving one orbit and the premaxilla region with the help of silicone orbital prostheses and magnets along with an expansion device. This dramatically improved the patient's speech, mastication, deglutition, esthetics, and self-confidence.
Keywords: Maxillary expansion screw, maxillary obturator, orbital prostheses, rehabilitation
How to cite this article:
Parameswari B D, Konwar AK, Hariharan A. Rehabilitation of a mid-facial defect using maxillary obturator with a maxillary expansion device and orbital prosthesis. J Indian Prosthodont Soc 2022;22:294-9 |
How to cite this URL:
Parameswari B D, Konwar AK, Hariharan A. Rehabilitation of a mid-facial defect using maxillary obturator with a maxillary expansion device and orbital prosthesis. J Indian Prosthodont Soc [serial online] 2022 [cited 2022 Aug 12];22:294-9. Available from: https://www.j-ips.org/text.asp?2022/22/3/294/351285 |
| Introduction | |  |
Middle face defects are either congenital or acquired in the horizontal plane at the middle third of the face and communicate with intraoral maxillary defects. Acquired midfacial defects not only affect patients' speech, deglutition, and mastication but also alter the quality of life and well-being.[1],[2],[3],[4] Based on the location of the defect, they are broadly divided into the midline and lateral midline defects. Midline defects include complete or partial nose or upper lip defects in communication with an intraoral maxillary defect. Lateral midfacial defects are complete or partial defects of cheek and orbital contents with an intraoral maxillary defect.[5]
Surgical reconstruction alone rarely rehabilitates such large midfacial defects. A well-fitting, removable maxillofacial prosthesis gives successful results in such cases of prosthodontic rehabilitation to restore function and esthetics.[6] This removable obturator prosthesis restores the lost intraoral and extraoral structures and acts as a barrier between the oral and nasal cavities. Maxillary complete denture along with a modified obturator restores oral functions and esthetics in patients with palatal defects.[7]
This clinical case report explains in detail the prosthodontic rehabilitation of a midfacial defect and restored esthetics and improving the quality of life.
| Case Report | | |
A 57-year-old male reported to the clinical department of maxillofacial prosthodontics for replacement of his missing facial and intraoral structures. Intraoral examination presented a postsurgical defect due to rhino-orbital mucormycosis in the premaxilla region in continuation with the nasal cavity and an orbital defect following enucleation of his left eye [Figure 1]. The defect margins were normal and healthy. The maxillary defect was under the classification of Aramany's Class VI type of maxillectomy defect (anterior resection). The patient had a completely edentulous maxillary arch with hypermobile tissue in the anterior region [Figure 2].
Due to his financial constraints, the option of rehabilitation with an implant-retained prosthesis was opted out. The treatment plan included rehabilitation of the orbital defect with Silicone eye prosthesis, an esthetic flexible material, with a modified two-piece obturator, which closed the intraoral defect and thus separated the oral cavity from the nasal cavity and facilitated swallowing and phonetics. The obturator prosthesis was fabricated in two pieces. The first piece engaged the bilateral undercut of the defect, consisting of an acrylic plate sectioned at the middle and unified using expansion screws. The second piece was the acrylic complete denture. Two pieces were retained together with the help of opposite poles of magnets.
| Treatment Procedure | | |
The primary impression of the palate along with the defect was recorded with an impression compound (DPI, Pinnacle,) [Figure 3] and the mandibular impression was made with irreversible hydrocolloid (Zhermack, India). The defect was recorded to its permissible extent. Primary casts were made with dental plaster and the special impression tray was fabricated by relieving the anterior flabby tissue region. Border molding was done with a green stick impression compound (DPI, Mumbai, India.). The palatal defect was recorded with a green stick impression compound to record permissible depth, extent, and all possible undercuts of the defect followed by a secondary impression using light body polyvinyl siloxane material (Dentsply Aquasil Impression material) [Figure 4]. The final cast was made with dental stone (Type III gypsum) and an acrylic record base was fabricated.
Acrylic plates with additional palatal extensions into the lateral undercut were fabricated on the master cast sectioned at the center and unified by a maxillary expansion screw (Dentaurum Hyrex Expansion Screw) with a keyhole and a separate key for activation. Due to inadequate usable undercuts, this maxillary expansion device was used, to ensure maximum retention by engaging the laterally extended acrylic plates and locking onto the palatal undercuts on activation of the device. The activation of this device is done by engaging the key onto the keyhole and making 45° turns upward till the palatal extensions of the device were engaged adequately onto the undercuts [Figure 5]a, [Figure 5]b, [Figure 5]c. Two pairs of 5 mm × 1.5 mm diameter cobalt samarium magnets (Milestone, India) were attached on each side of the expanding acrylic plate using autopolymerizing resin (DPI). After positioning the acrylic plates intraorally and the activated maxillary expansion screw, a pickup impression was made with the prefabricated acrylic denture base [Figure 6]a and [Figure 6]b onto which a cast was cast poured, and used for new denture base fabrication [Figure 7]. Zinc oxide eugenol (DPI) paste was painted onto each magnet of the screw assembly as an indicating material for proper positioning of opposite poles of another two pairs of magnets and was fixed on the tissue surface of the new maxillary denture base. Jaw relation, wax trial, and final denture processing on the denture base were carried out conventionally. The maxillary denture was then inserted and properly positioned and the denture was attracted by the opposite pole of magnets toward the inner expansion plate [Figure 8]. | Figure 5: (a) Expansion device, (b) wax up of expansion device, (c) acrylised expansion device with the prosthesis
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 | Figure 6: (a) Intraoral positioning of first part of prosthesis, (b) pickup impression – to fabricate second part of prosthesis
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Orbital prostheses fabrication
An orbital defect impression was made using an irreversible hydrocolloid. Boxing wax was used to outline the margins onto which the impression material was poured after greasing the area with petroleum jelly. A moist gauze pack was kept in the defect to avoid the flow of impression material into the undesired region according to the required impression. Fast-setting dental plaster (about 0.25-inches thick) was used as a base for the impression material to provide support and to avoid tearing and distortion of the impression during removal [Figure 9]. The impression was then boxed and poured with dental stone to get the working cast.
Wax-up was done using modeling wax and a ready-made stock eye shell button matching the patient's previous photograph and right side-eye in color, shape, and size. The patient was called for try-in and an evaluation of the fit of the eye wax pattern, pupil orientation, size, and amount of scleral visibility, when compared to the contralateral eye was done using the paper iris disk technique when the patient was directly looking at a point at eye level at 6 feet away [Figure 10]. Once the mock trial was done on the patient, the final surface contour and skin texture of the wax pattern were carved on the working cast, and wrinkles and lines were obtained by dabbing a wet gauze piece into softened wax [Figure 11]. Investment, flasking, and dewaxing of the pattern were done conventionally. After dewaxing, color matching was done in natural light to achieve the desired color using medical-grade silicone (Technovent Ltd., UK) mixed with the intrinsic colors and was packed following the manufacturer's instructions. It was allowed to set for 24 h under room temperature. The flash from the final prosthesis was trimmed off using a sharp blade. External characterization was done guided by the patient's skin color [Figure 12]. The patient was instructed to use an adhesive (Daro Hydro Bond adhesive) for better retention of the orbital prosthesis. The patient was then trained properly on how to wear the prosthesis by engaging in the available undercuts [Figure 13] and was instructed to maintain proper hygiene of both the prostheses.
| Discussion | | |
Acquired defect of the maxilla results in communication between the oral and nasal cavity causing difficulty in swallowing, speech, nasal leak, and an unpleasant appearance. Rehabilitation of such defects can either be done by surgical correction or by prosthesis or by using a combination of both methods.[5] Prosthetic rehabilitation of maxillofacial defects has several advantages over surgical reconstruction such as:
(1) It is inexpensive, (2) It facilitates regular clinical examination, (3) Maintenance of oral hygiene, (4) Acceptable esthetic results.
However, retaining a maxillofacial prosthesis is a challenging task, due to the constant downward gravitational pull. Many methods of improving the retention of the maxillofacial prosthesis were carried out by Jean Nadeau in 1955, Boucher and Heupel in 1966, Javid in 1971, and Federick using magnets.[8] Magnets of smaller dimensions are made using rare earth alloy Sm–Co (Samarium–cobalt) and Nd–Fe–B (Neodymium–Iron–Boron).[9] The reduction of tarnish and corrosion of magnets is achieved by using nickel, gold, and titanium coating of these magnets.[10] The major challenge, in this case, was less retentive prosthesis, as the defect was in the premaxilla region and is completely edentulous with inadequate ridge support. In this case, the only reliable undercut is the bilateral lateral undercut. A single path of insertion is not possible to engage bilateral undercuts. Hence, an acrylic plate is inserted inside the defect with inactivated expansion screws. After the acrylic, the plate is positioned, by activating the expansion screws, both sections of the acrylic plate move and engage bilateral undercut, and retention is achieved.
Magnets were used to keep both the plate and the denture in place thus facilitating retention and easy placement and removal. The orbital prostheses fabricated with medical-grade silicone and pigments improved postoperative esthetics by filling the orbital volume and adhesive facilitated further retention. Though implant-retained prosthesis is the best treatment option, due to economic constraints and inadequate available bone density, magnet retained prosthesis was done as the possible treatment option for this patient.
| Conclusion | | |
The difficulty that a prosthodontist has to deal with while treating patients with maxillofacial defects is the multiple undercuts, with different paths of insertion. This novel method of engaging the lateral undercuts using expansion screws opens a new arena to engage bilateral undercuts, thus reducing the bulk of the prosthesis as it decreases the vertical extension of the prosthesis inside the defect. Satisfactory functional and aesthetic results for a patient with a maxillofacial defect can be achieved with proper planning and adequate retention is obtained using magnets and other selected retentive aids.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 8. | Javid N. The use of magnets in a maxillofacial prosthesis. J Prosthet Dent 1971;25:334-41. |
| 9. | Pattanaik S, Wadkar AP. Rehabilitation of a patient with an intra oral prosthesis and an extra oral orbital prosthesis retained with magnets. J Indian Prosthodont Soc 2012;12:45-50. |
| 10. | Drago CJ. Tarnish and corrosion with the use of intraoral magnets. J Prosthet Dent 1991;66:536-40. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
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