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CASE REPORT
Year : 2022  |  Volume : 18  |  Issue : 3  |  Page : 853-856

Prosthetic management of a midfacial defect


Department of Dental and Prosthetic Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Submission08-Sep-2020
Date of Decision18-Sep-2020
Date of Acceptance14-Jan-2021
Date of Web Publication25-Jul-2022

Correspondence Address:
Aishwarya Chatterjee
Department of Surgical Oncology, 48, 4th Floor, Dhanwantari OPD Block, SMS Hospital and Medical College, Jaipur 302 004, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1141_20

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 > Abstract 


Surgical ablation of a large tumor creates a defect which is technically difficult to reconstruct. Radiated tissue bed poses a challenge to reconstruction and is complicated in presence of osteoradionecrosis. This report describes a case of a 62 year old gentleman with oral cancer who underwent surgery and radiotherapy twice. He developed an orocutaneous defect (OCD) following surgery and radiotherapy. Prosthetic rehabilitation of OCD was done. Full facial impression with irreversible hydrocolloid was made and wax sculpture made on the model obtained. Standard laboratory steps were followed for mould fabrication and maxillofacial silicone was used to fabricate the prosthesis. It was retained to the spectacle with silicone adhesives. The silicone facial prosthesis provided to the patient was easy to use, covered the defect and improved the quality of life of the patient.

Keywords: Facial prosthesis, maxillofacial prosthesis, orocutaneous defect, silicone prosthesis


How to cite this article:
Dholam K P, Gurav S, Singh G, Chatterjee A. Prosthetic management of a midfacial defect. J Can Res Ther 2022;18:853-6

How to cite this URL:
Dholam K P, Gurav S, Singh G, Chatterjee A. Prosthetic management of a midfacial defect. J Can Res Ther [serial online] 2022 [cited 2022 Aug 10];18:853-6. Available from: https://www.cancerjournal.net/text.asp?2022/18/3/853/348227




 > Introduction Top


Reconstruction of the resulting large defect following tumor ablation is technically difficult. It is often complicated by hemorrhage, hematoma, wound infection, fistula formation, wound dehiscence, etc. Factors such as general condition of patient, tissue availability, and vascularity of radiated tissue bed decide on the possibility of surgical reconstruction. The risk of occurrence of these complications is increased if the patient is irradiated.[1],[2],[3] Late complication of radiation therapy is osteoradionecrosis (ORN).[4] The psychological perspective of the patient is important to consider as they are often distressed with such facial disfigurement.

When surgical reconstruction is unsuccessful, prosthetic rehabilitation is a challenging task. Prosthetic rehabilitation is governed by soft tissue conditions around the defect, available retentive options, acceptance, and material factors.[1],[3],[5],[6]

This clinical report describes the rehabilitation of a large facial defect caused by loss of a part of the maxilla superimposed with ORN.


 > Case Report Top


A 62-year-old male, operated for squamous cell carcinoma of the right mandibular alveolus, was referred for prosthetic rehabilitation of an orocutaneous defect (OCD). A detailed case history revealed that the patient was diagnosed with moderately differentiated squamous carcinoma (T4aN0M0) involving the right mandibular alveolus and gingivobuccal sulcus 14 years ago. Surgical resection was done followed by radiotherapy (RT) (60 Gray/30 fractions). He developed recurrence in the left buccal mucosa 5 years later and received 6 cycles of palliative chemotherapy followed by reradiation (re-RTh) (66 Gray/33 fractions). Percutaneous endoscopic gastrostomy tube was inserted owing to inability for per-oral intake secondary to severe trismus following reradiation. The patient was on metronomic chemotherapy and follow-up since 7 years. During follow-up, the patient presented with a slowly developing facial defect in the left cheek area. Computed tomography and positron emission tomography scans done in 2017 and 2018 revealed loss of trabeculations and multiple sites of cortical erosions, diffuse cortical irregularities, and destructions of the left hemimandible and maxillary bone, suggestive of ORN. He suffered from low self-esteem and depression owing to have to wear a face mask continuously with low social interaction.

The necrotic left maxillary bone sequestrated, leaving a defect and loss of facial contour. As no immediate surgical reconstruction was possible due to poor general condition of the patient and a tissue bed which was irradiated twice, prosthetic rehabilitation with a silicone maxillofacial prosthesis was planned.

Treatment plan

Clinical examination of the defect revealed an irregular defect on the left side of the face. An OCD of size 15 mm in diameter at the widest section involved the left maxilla. There was loss of facial contour on the left angle of the mouth. The skin on the left hemimandible was inflamed and irritable [Figure 1]. The aim of the silicone prosthesis was to (i) restore the lost facial contour, (ii) obturate the OCD, and (iii) improve esthetics.
Figure 1: Preoperative (original)

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Treatment procedure

A facial moulage was made with irreversible hydrocolloid (Dentalgin; Prime Dental Products, Mumbai, Maharashtra, India) [Figure 2] and a cast was obtained (Kaldent Dental Stone Class III, Kalabhai Karson Pvt. Ltd.). On this cast, wax model was sculpted and wax trial carried out [Figure 3] and [Figure 4].
Figure 2: Facial moulage (original)

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Figure 3: Wax model on cast (original)

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Figure 4: Wax try in (original)

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At wax try-in stage, it was noticed that sufficient retention was lacking. The OCD did not provide enough anatomic undercut to provide retention. Hence, it was decided to attach the prosthesis to a spectacle to aid in retention. Thus, it precluded the need for adhesive or implants. A broad rimmed acrylic spectacle was selected and tried on the patient, borders of which were marked on the wax model. A light body polyvinyl siloxane (Aquasil LV, Dentsply Caulk, USA) wash impression of the OCD was made along with the wax sculpture to accurately record tissue undercuts and retrieved en masse.

Standard laboratory steps were followed for investing, dewaxing, and mold preparation. Room temperature vulcanizing silicone (A-2000-1, Factor II Inc., USA) was packed into the mold space after shade matching with patient's skin and intrinsic staining.

The silicone prosthesis was retrieved after curing cycle, trimmed, and finished before trying on the patient. The fit of the prosthesis and placement of the spectacle were checked. Intimate contact of the silicone prosthesis was checked. Primary impression by an irreversible hydrocolloid and a secondary impression by light body polyvinyl siloxane ensured that fine details of the defect and skin were recorded and close fit of the prosthesis could be achieved. The silicone prosthesis was attached to the spectacle using silicone primer [Figure 5] and [Figure 6].
Figure 5: Final prosthesis with spectacle frame (original)

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Figure 6: Postoperative final prosthesis (original)

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There was a dramatic change in the appearance of the patient and he was pleased with the effect. Instructions regarding positioning and maintenance of the prosthesis were given.


 > Discussion Top


Locoregional recurrence with prior history of RT can be salvaged with surgery and postoperative RT/systemic therapy or combination of systemic therapy and re-RTh.[6],[7],[8]

The patient had a history of the tissue beds irradiated twice, presence of ORN of the maxilla and left hemimandible, and fibrosis of the skin and tissues compounded with inflamed and irritated skin in the anterior chin region of the left hemimandible. It is documented that sequestrectomy and segmental osteotomy with flap reconstruction is the recommended treatment for advanced ORN in appropriate cases. However, it is still fraught with high complications.[9],[10],[11]

However the patient and his family had requested a more conservative mode of treatment because he was already depressed and did not want a surgical intervention. An alternative method was explored other than reconstructive surgery and after discussion with the involved parties a prosthetic mode of treatment was opted.

The main challenges in this case were (i) impression making, (ii) prosthesis retention, and (iii) patient acceptance.

The skin over the anterior chin area of the left hemimandible was inflamed; hence, an irreversible hydrocolloid impression material was chosen to make the impression as it does not compress the tissues when recording them.

The mode of retention for this prosthesis without adhesive and implant is unique. Retention in midfacial defects traditionally has been achieved by eye patches, spectacle frame, denture extensions, magnets, adhesives, precision attachments, and osseointegrated implants.[12],[13],[14],[15],[16] In this case, spectacle frame was the main source of retention and the tissue undercut provided by the OCD served as an auxiliary retentive area. The spectacle frames concealed part of the prosthesis margin.[15],[16] The irregular and unconventional nature of the prosthesis necessitated this mode of retention with spectacle. All other forms of retention were negated due to history of irradiation to the tissues twice and occurrence of ORN. The final prosthesis was passive on the skin and in the OCD. It did not cause irritation to the sensitized skin or mucosa. Movement was minimal as there was trismus.

Literature search revealed very few articles reporting such unconventional large prosthesis. Yojiro Ota et al. (1999) reported a large maxillofacial silicone prosthesis replacing the mandible. It was retained by the auricles and remaining maxillary anterior teeth with the help of retentive wires and magnet. No adhesive or implants were used.[17]

Another report by Nelson Fernandes et al. (2020) reported retention of large midfacial silicone prosthesis, with a customized, 3D printed titanium frame implant. This implant was surgically fixated and secured to the maxillary skeleton. A maxillary denture and silicone facial prosthesis was retained with the help of this framework.[18]

For an extraoral facial prosthesis to be successful, the key factors are good retention, being user-friendly, and restored esthetics and function.[13],[14] Implant placement in this patient with irradiated bone and ORN was ruled out at an initial stage of treatment planning. This facial prosthesis is an alternative method to reconstructive surgery. The silicone prosthesis was retentive and easy to use. Although skin shade matching was difficult, given that the skin in the region of the defect was irradiated, the best possible match was achieved.[19]

The main disadvantage of the prosthesis was when the patient removes the spectacle, the whole prosthesis also gets removed, thus uncovering the defect.


 > Conclusion Top


A patient, who received RT following resection of tumor of the mandible followed by ORN and facial defect, was rehabilitated with spectacle-retained silicone prosthesis. We advocate the use of facial prosthesis in conjunction with surgical reconstruction as an armamentarium for improving esthetics, confidence, and quality of life even in severely mutilated facial defects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Beumer J 3rd, Marunick MT, Esposito SJ. Maxillofacial Rehabilitation. 3rd ed. USA: Quintessence Publishing Co.; 2011.  Back to cited text no. 1
    
2.
Deepak K, Paul TS. Atlas of Oral and Maxillofacial Surgery. 1st ed. St. Louis, Missouri: Elsvier Publishing; 2016.  Back to cited text no. 2
    
3.
Dhanda J, Pasquier D, Newman L, Shaw R. Current concepts in osteoradionecrosis after head and neck radiotherapy. Clin Oncol 2016;28:459-66.  Back to cited text no. 3
    
4.
Sykes LM. An interim extraoral prosthesis used for the rehabilitation of a patient treated for osteoradionecrosis of the mandible: A clinical report. J Prosthet Dent 2001;86:130-4.  Back to cited text no. 4
    
5.
Robb GL, Marunick MT, Martin JW, Zlotolow IM. Midface reconstruction: Surgical reconstruction versus prosthesis. Head Neck 2001;23:48-58.  Back to cited text no. 5
    
6.
Kapetanakos M, Wisniewski S, Golden M, Randazzo J. Restoration of facial form and lip competence in a patient with a midfacial defect. J Prosthodont 2018;27:496-500.  Back to cited text no. 6
    
7.
Nabil S, Samman N. Risk factors for osteoradionecrosis after head and neck radiation: A systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:54-69.  Back to cited text no. 7
    
8.
National Comprehensive Cancer Network, Inc. USA, Clinical Practice Guidelines in Oncology, Head and Neck Cancers: Very Advanced Head and Neck Cancers. Ver. 2. 2018. Available from: https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck_blocks.pdf. [Last accessed on 2018 Jun 20].  Back to cited text no. 8
    
9.
Dai T, Tian Z, Wang Z, Qiu W, Zhang Z, He Y. Surgical management of osteoradionecrosis of the jaws. J Craniofac Surg 2015;26:e175-9.  Back to cited text no. 9
    
10.
Li Z, Liu S, Xie S, Shan X, Zhang L, Cai Z. Advanced osteoradionecrosis of the maxilla: A 15-year, single-institution experience of surgical management. Acta Otolaryngol 2020;140:1049-55.  Back to cited text no. 10
    
11.
Shen Y, Li J, Ow A, Wang L, Lv MM, Sun J. Acceptable clinical outcomes and recommended reconstructive strategies for secondary maxillary reconstruction with vascularized fibula osteomyocutaneous flap: A retrospective analysis. J Plast Reconstr Aesthet Surg 2017;70:341-51.  Back to cited text no. 11
    
12.
Moreno JF, Terán JF, Cardín VG. Prosthetic hybrid rehabilitation in orofacial defect. Case presentation. Rev Odontol Mex 2017;21:119-24.  Back to cited text no. 12
    
13.
Guttal SS, Akash NR, Prithviraj DR, Lekha K. A unique method of retaining orbital prosthesis with attachment systems – A clinical report. Con Lens Anterior Eye 2014;37:230-33.  Back to cited text no. 13
    
14.
Buzayan MM. Prosthetic management of mid-facial defect with magnet-retained silicone prosthesis. Prosthet Orthot Int 2014;38:62-7.  Back to cited text no. 14
    
15.
Kiat-amnuay S, Gettleman L, Khan Z, Goldsmith LJ. Effect of adhesive retention on maxillofacial prostheses. Part I: Skin dressings and solvent removers. J Prosthet Dent 2000;84:335-40.  Back to cited text no. 15
    
16.
Karakoca S, Ersu B. Attaching a midfacial prosthesis to eye glass frames using a precision attachment. J Prosthet Dent 2009;102:264-5.  Back to cited text no. 16
    
17.
Ota Y, Ebihara S, Ooyama W, Kishimoto S, Asai M, Saikawa M, et al. A large maxillofacial prosthesis for total mandibular defect: A case report. Jpn J Clin Oncol 1999;29:256-60.  Back to cited text no. 17
    
18.
Fernandes N, van den Heever J, Hoogendijk C, Botha S, Booysen G, Els J. Reconstruction of an extensive midfacial defect using additive manufacturing techniques. J Prosthodont 2016;25:589-94.  Back to cited text no. 18
    
19.
van Oort RP, Vermey J, Ten Bosch JJ. Skin response to cobalt 60 irradiation and the consequences for matching the color of facial prostheses. J Prosthet Dent 1984;52:704-10.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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