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CLINICAL REPORT
aAssociate Pr
bPredoctoral
cAdjunct Pro
dAdjunct Pro
THE JOURNA
The challenge of managing oral maxillofacial rehabilitation
with quality and cost-benefit
Wagner Araujo de Negreiros, DDS, MSc, PhD,a Raiza Ricarte Teixeira,b
Raniel Fernandes Peixoto, DDS, MSc, PhD,c and Rômulo Rocha Regis, DDS, MSc, PhDd
ABSTRACT
Although orofacial cancer leads to substantial functional, esthetic, and psychosocial deficits for
patients, reconstructive plastic surgeries may not be indicated for large facial defects. The high
costs of prosthetic oral maxillofacial rehabilitation may hamper such treatment, which
commonly involves virtual planning, craniofacial implants, and computer-aided design and
computer-aided manufactured prostheses. This report shows the treatment of 2 patients with
large facial defects from surgical resection of cancerous tissue who were rehabilitated with
implant-supported bar-clip overdentures and facial prostheses fabricated by using low-cost
straightforward methods. (J Prosthet Dent 2020;-:---)
Oral maxillofacial defects
result from trauma, congen-
ital disorders, or surgical
resection of cancerous tissue.1
Loss of facial continuity cau-
ses substantial functional
(speech, mastication, and
swallowing), esthetic, psy-
chological, and social deficits
for the patients.2 Reconstructive surgery may be the
preferred method in most patients, but it can be
limited by age, comorbidities, insufficient residual
tissue, inadequate donor sites, and vascular impair-
ment after radiation. Therefore, prosthetic rehabilita-
tion may be an excellent choice, as it offers self-
confidence and satisfactory quality and esthetics,
without compromising wound healing and the
monitoring of tumor recurrence.3,4 Rehabilitation
protocols are available which allow virtual planning,
guided implant surgery, and 3D printing of facial
prostheses with precision.5 However, for patients with
unfavorable socioeconomic conditions, the use of
conventional methods for fabricating maxillofacial
prostheses may be necessary, which may challenge
many healthcare teams worldwide. Thus, 2 clinical
reports are provided to illustrate how clinicians can
meet these challenges with lower costs and satisfac-
tory outcomes through the creative use of dental
implants, customized components, and oral maxillo-
facial prostheses.
ofessor, Department of Restorative Dentistry, Faculty of Pharmacy, Dentis
student, Faculty of Pharmacy, Dentistry and Nursing, Federal University o
fessor, Department of Restorative Dentistry, Faculty of Pharmacy, Dentistry
fessor, Department of Restorative Dentistry, Faculty of Pharmacy, Dentistry
L OF PROSTHETIC DENTISTRY
CLINICAL REPORT
Patient 1
A 49-year-old man was diagnosed with an invasive
squamous cell carcinoma of the maxilla, base of the nose,
upper lip, and right cheek (Fig. 1). Oncologic therapy
involved surgery to remove the entire lesion followed by
36 sessions of radiotherapy. Grafts and reconstructive
plastic surgery were the first treatments analyzed, but
they were contraindicated because of the extent of the
defect. The use of a conventional or implant-supported
complete denture was contraindicated because the only
remnant bone in the maxilla was the right tuber. An
implant-supported bar-clip overdenture and a facial
prosthesis retained by magnets were the prosthetic so-
lution for the patient because a cone bean computed
tomography (CBCT) scan showed the presence of
favorable bone structure in the right maxillary tuber and
left zygomatic bone. These areas had received a reduced
dose of radiation as per the intensity-modulated radia-
tion therapy technique used.
try and Nursing, Federal University of Ceará (UFC), Fortaleza, CE, Brazil.
f Ceará (UFC), Fortaleza, CE, Brazil.
and Nursing, Federal University of Ceará (UFC), Fortaleza, CE, Brazil.
and Nursing, Federal University of Ceará (UFC), Fortaleza, CE, Brazil.
1
Figure 1. Clinical appearance of oral maxillofacial defect at initial presentation. A, Frontal view. B, Lateral view.
Figure 2. Clinical appearance of implants installed in both right maxillary
tuber and left zygoma.
2 Volume - Issue -
Two external hexagon dental implants (Titamax Ex;
Neodent) were installed in the right maxillary tuber
(4.1×10 mm) and 2 in the left zygomatic bone (3.5×8
mm) (Fig. 2) with assistance from a custom acrylic resin
surgical guide. After 3 months of osseointegration, a rigid
framework was planned from the right maxillary tuber to
the left zygomatic bone (Fig. 3A). The unusual design of
this framework (from inside the mouth to the face) was a
relevant aspect for the outcome of this treatment, offering
support and retention to the overdenture and retaining
the facial prosthesis (Fig. 3B). Procedures for intraoral
maxillary impression, reestablishment of the vertical
dimension of occlusion, buccal corridor, smile line re-
cords, and artificial tooth selection were performed to
fabricate a bar-clip overdenture (Fig. 3C). A gold-plated
magnet (Neodymium; Magnetos Gerais) was attached
to the overdenture buccal flange, parallel to the magnet
of the metal framework (Fig. 3D). The overdenture was
delivered and an acrylic resin bar infrastructure (Jet;
Clássico Artigos Odontológicos) was made containing 2
additional magnets connected to the others to retain the
facial prosthesis.
THE JOURNAL OF PROSTHETIC DENTISTRY
A facial impression (Elite; Zhermack SpA) was made
involving the frontal surface of the overdenture and
adjacent soft structures, capturing the resin bar. The right
nostril, upper lip, and left cheek were sculptured. The
base skin color was selected from a mixture of pigments
Negreiros et al
Figure 3. A, Custom bar in acrylic resin; implants connected from left side to right side. B, Metal bar containing 2 segments for overdenture bar-clip
retention and magnet holder to retain facial prosthesis. C, Overdenture retained to bar-clip system. D, Clinical appearance after overdenture delivery.
Magnet placed on buccal flange for facial prosthesis retention.
- 2020 3
(FI-SK; Factor II Inc), followed by intrinsic (A 2200; Factor
II Inc) and extrinsic (FE-1999; Factor II Inc)
characterization and sealing (564-KIT; Factor II Inc)
(Fig. 4). After continuous use of the prostheses, his
speech, mastication, self-esteem, and self-confidence
were improved. Follow-up has been carried out every 6
months. After 2 years, the overdenture remained satis-
factory, but the facial prosthesis was replaced for esthetic
reasons.
Patient 2
A 65-year-old woman had a highly invasive basal cell
carcinoma involving the premaxilla, upper lip, and nasal
pavilion (Fig. 5). Adjuvant radiotherapy was not neces-
sary. Bucconasal communication was present because of
the absence of the premaxilla, with considerably impaired
mastication, swallowing, phonetics, and esthetics.
Reconstructive plastic surgery was contraindicated
because of the extent of the defect. A conventional
obturator complete denture would not have had
adequate support or retention. A cone bean computed
tomography scan showed adequate bone height and
Negreiros et al
width but low density in both maxillary tubers. Thus,
rehabilitation with an implant-supported bar-clip over-
denture and a magnet-retained nasolabial prosthesis was
proposed.
Two external hexagon dental implants (4.1×10 mm)
(Titamax Ex; Neodent) were installed in each maxillary
tuber with assistance from a custom acrylic resin surgical
guide. One implant on each side was lost because of poor
bone quality. An intraoral impression (Elite; Zhermack
SpA) of the maxillary arch involving implants, bucconasal
communication, and palate was made after 4 months of
osseointegration (Fig. 6). The presence of remaining skin
in the lip region complicated this step because it reduced
the mouth opening. A wax evaluation prosthesis made
on the gypsum cast (Herostone; Vigodent SA Ind Com)
was used to record the vertical dimension of occlusion
and centric relation and to attach the artificial teeth
(Fig. 7A). A nasolabial prosthesis waxing (Plastiline;
Redelease)was necessary to place the anterior teeth
correctly (Fig. 7B). The trial denture allowed adequate
space to wax and cast a bar from the right to the left side
of the palate (Pattern; GC America Inc) with 2 locations
THE JOURNAL OF PROSTHETIC DENTISTRY
Figure 4. Clinical appearance after rehabilitation with oral maxillofacial prostheses. A, Frontal view. B, Lateral view.
4 Volume - Issue -
for clip attachments (Fig. 7C). Finally, a gold-plated
magnet (Neodymium; Magnetos Gerais) was attached
in the anterior flange to retain the facial prosthesis
(Fig. 7D). This denture acted as retention for the facial
prosthesis and a palatal obturator, restoring the masti-
cation, speech, and swallowing functions.
An acrylic resin bar infrastructure (Jet; Clássico Artigos
Odontológicos) was fabricated containing one additional
magnet connected to the other one previously attached.
This arrangement was captured in a new facial impression
of the frontal surface of the overdenture, nasal defect, and
adjacent soft structures. Base skin color, characterization,
and sealing were selected as described in clinical report 1
(Fig. 8). The patient was able to eat, swallow, and speak
with quality. After 2.5-year follow-up, the overdenture
was still functional. However, the silicone nasolabial
prosthesis was remade because of esthetic changes.
DISCUSSION
Head and neck tumors often lead to large facial de-
formities, with great functional, psychosocial, and
THE JOURNAL OF PROSTHETIC DENTISTRY
esthetic deficits.6,7 Challenges in the treatments for
the patients described included the esthetic and
functional rehabilitation under economic restraints.
The only affordable treatment was an oral maxillofa-
cial rehabilitation with prostheses fabricated by using
low-cost straightforward methods. The importance of
clinical creativity and resourcefulness in providing
successful prosthetic results, including restoring
function, esthetics, and quality of life, is emphasized.
In addition, the result was satisfactory because of the
use of dental implants and magnets for prosthetic
retention.
A multidisciplinary approach to the treatment of
maxillofacial cancer provides an improved response
to the treatment, health, well-being, and social in-
clusion of patients.8 Anaplastologists then have great
challenges regarding intraoral and extraoral rehabili-
tation, especially when they do not participate in the
initial therapy planning with the medical team.8 In
clinical report 2, the surgeon left some skin in the
upper lip region that did not restore the lip and
made rehabilitation difficult, limiting the mouth
Negreiros et al
Figure 5. Clinical appearance of oral maxillofacial defect at initial presentation. A, Frontal view. B, Lateral view.
Figure 6. Modified impression technique involving implants, bucconasal
communication, and palate.
- 2020 5
opening. These aspects demonstrate the need for
comprehensive treatment teams to be more con-
cerned with both tumor removal and maxillofacial
rehabilitation.
The lack of support for the overdenture in clinical
report 1 required a restrictive diet regarding solid food,
control of parafunctional habits, and prostheses
removal during sleep to avoid overloading the im-
plants.9,10 In addition, replacing natural lips is a great
esthetic challenge because this structure has great
mobility especially during speech and smiling; how-
ever, the prosthetic lip remains immobile.11 Another
challenge was the need to replace the silicone pros-
theses in both patients. Although good-quality medical
silicones, intrinsic and extrinsic pigments, and paint
sealants are available,12,13 extrinsic factors such as
sunlight, temperature, humidity, wind, dust, and pol-
lutants cause the silicone and pigment to degrade.13
Thus, facial prostheses inevitably need to be replaced
periodically, and periodic monitoring of patients is
Negreiros et al
essential. New studies aiming at developing new ma-
terials with better chemical, physical, and
biologic properties are needed.
THE JOURNAL OF PROSTHETIC DENTISTRY
Figure 7. A, Orientation plane adjustment for artificial teeth. B, Nasolabial prosthesis sculpture; esthetic and phonetic tests. C, Metal bar containing 2
segments for overdenture bar-clip retention. D, Nasolabial prosthesis retained to overdenture by magnets.
Figure 8. Clinical appearance after rehabilitation with oral maxillofacial prostheses. A, Frontal view. B, Lateral view.
6 Volume - Issue -
THE JOURNAL OF PROSTHETIC DENTISTRY Negreiros et al
- 2020 7
SUMMARY
In spite of the technical and material limitations of both
treatments, the outcomes demonstrate that properly
rehabilitating patients presenting with extensive facial
defects is possible.
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Corresponding author:
Dr Raniel Fernandes Peixoto
Department of Restorative Dentistry
Faculty of Pharmacy, Dentistry and Nursing
Federal University of Ceará
Alexandre Baraúna St, 949, Rodolfo Teófilo, Fortaleza 60430-160, CE
BRAZIL
Email: raniel.peixoto@ufc.br
Acknowledgments
The authors thank Mr Francisco Assis Sousa da Silva Filho (sculptor of maxillo-
facial prostheses) and the other volunteer members of the Face Defects Center
(From Portuguese “Núcleo de Defeitos da FaceeNUFACE”) at the Federal University
of Ceará, Brazil, for the technical support in the execution of the treatment.
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.07.038
THE JOURNAL OF PROSTHETIC DENTISTRY
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mailto:raniel.peixoto@ufc.br
https://doi.org/10.1016/j.prosdent.2020.07.038
	The challenge of managing oral maxillofacial rehabilitation with quality and cost-benefit
	Clinical report
	Patient 1
	Patient 2
	Discussion
	Summary
	References