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MINI SYMPOSIUM: HEAD NECK CANCER
Year : 2013  |  Volume : 50  |  Issue : 1  |  Page : 21-24
 

Rehabilitation of a mandibular segmental defect with magnet retained maxillofacial prosthesis


1 Department of Prosthodontics, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India
2 Department of Conservative Dentistry, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India

Date of Web Publication20-May-2013

Correspondence Address:
S S Mantri
Department of Prosthodontics, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.112282

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 » Abstract 

Resection or loss of a portion of the mandible can result in a variety of functional, cosmetic and psychological deficits that are dependent on the extent of the defect, the concomitant therapy and the timing of rehabilitative efforts. These impairments greatly affect the patient's Quality of life (QOL). The thrust in cancer care is not simply on survival but on rehabilitation, which aims to improve multiple impairments and QOL. This article describes a case of a 58-year-old female with segmental resection of the anterior mandible, extending to lower lip, resulting in a large intraoral as well extra oral defect. Prosthodontics rehabilitation was done using a two-piece intra oral and extra oral prosthesis oriented to each other using magnets. Use of magnets for retaining the extra oral prosthesis simplifies the clinical and laboratory phase enhancing patient's comfort and psychological morale.


Keywords: Acrylic resin, extra oral prosthesis, intra oral prosthesis, magnets, post surgical defect, quality of life


How to cite this article:
Mantri S S, Mantri S P, Rathod C J, Bhasin A. Rehabilitation of a mandibular segmental defect with magnet retained maxillofacial prosthesis. Indian J Cancer 2013;50:21-4

How to cite this URL:
Mantri S S, Mantri S P, Rathod C J, Bhasin A. Rehabilitation of a mandibular segmental defect with magnet retained maxillofacial prosthesis. Indian J Cancer [serial online] 2013 [cited 2020 May 29];50:21-4. Available from: http://www.indianjcancer.com/text.asp?2013/50/1/21/112282



 » Introduction Top


Cancer of the head and neck region can profoundly affect patients' quality of life, as they are constantly reminded of their affliction. Providing maxillofacial treatment for such patients should not only address physical and functional deficit but should also evaluate the possible psychological effects of these deformities.? [1] Prosthodontics rehabilitation of such patients is quite challenging and requires coordinated interaction between multidisciplinary team. [2],[3],[4] Tumors in and around the mandible usually require surgical removal of the lesion and extensive resection of the bone and soft tissues. Smaller lesions removed without discontinuity of the bone are relatively simple to restore with a prosthesis. Larger lesions that extend to the floor of the mouth may be more difficult to restore with a prosthesis even though the continuity of the mandible is maintained. [5] Such extensive defect requires surgical reconstruction to be done but patients are usually reluctant to undergo further surgical procedures due to psychological trauma or economic consideration. [6]

Prosthesis can be made from a variety of materials such as polymethyl methacrylate or urethane backed medical grade silicone. This prosthesis is retained with adhesives, tissue undercuts, magnets or in some cases osseo integrated implants. [7]

The use of magnets is one of the most efficient means of providing sectional prosthesis with adequate retention and stability in patients with deformities requiring complex rehabilitations. [8],[9] Magnets are attached to each section, when the sections are assembled properly; the magnets are attracted to each other and retain the sections. [9]

The aim of this article is to describe the prosthetic treatment for a head and neck cancer patient with a segmental mandibular and facial defect and the contribution of this prosthesis in improving the patients QOL.


 » Case Report Top


A 58-year-old female patient reported to the Department of Prosthodontics, with a discontinuity defect of the left mandibular segment involving lower lip, left commissure, and cheek, along with the teeth on the anterior and left quadrant. History revealed that the patient was diagnosed with squamous-cell carcinoma of lower left alveolus and had undergone surgical resection for the same. Clinical examination revealed segmental mandibular resection of left side of mandible involving anterior teeth, premolars and first molar on the defect side [Figure 1]. Facial defect involved lower lip and cheek mucosa on left side exposing the tongue to the exterior. The existing teeth were periodontally compromised. The defect in the inferior portion of the face was suggestive of Andy Gump deformity. [10] The mutilation left the patient with difficulty in speech and mastication with orofacial communication resulting in escape of food and fluids. Due to the extensive intra oral as well as extra oral defect, two-piece intra oral and extra oral acrylic resin magnet retained prosthesis was planned in two phases. Since the periodontal condition of the remaining teeth was compromised and chance of recurrence of the lesion was suspected a cast metal framework was not planned. An acrylic partial denture with a buccal flange, on the non-resected side engaging the remaining mandibular teeth was planned. The retained carious teeth were restored.
Figure1: Extra oral view of the defect

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Fabrication of Partial Denture

Preliminary impressions of the maxillary arch as well as remaining mandibular arch along with the intra oral defects were made using high viscosity irreversible hydrocolloid (Dentalgin, Prime Dental Products, Mumbai, India) The impressions were poured in type III gypsum material (Kalstone, Kalabhai Karson, Mumbai, India). Mandibular custom tray was fabricated with self-cure acrylic resin (DPI RR Cold Cure Bombay, Burma Trading Corp. Ltd.) and adjusted for proper extensions. Border molding was carried out with greenstick impression compound (Pinnacle, Dental Products of India, Mumbai) to record the functional anatomy of buccal and lingual tissues, including the defect area. Definitive impression was made using a medium viscosity polyvinyl siloxane impression material. (Reprosil; Dentsply DC Tray GmbH, Konstanz, Germany) and poured in type III gypsum material. Since the condyle on the defect side was intact and the second molar was in occlusion, maintaining the vertical relation, it was easy to carry out maxillomandibular relation. A face bow record was made, and the maxillary cast was articulated on a semi adjustable articulator (Hanau H 2 series, Waterpik, USA). Tentative centric relation record was used to articulate the mandibular cast into the articulators. Teeth arrangement and wax contouring was carried out and the wax prosthesis was tried in the patient's mouth. Monoplane occlusal scheme was used for mandibular posterior teeth to minimize occlusal loading. [11] Wrought wire clasps were used to encircle the molars on the opposite side for added retention of the prosthesis. Additionally, an acrylic buccal flange was provided on the non-defect side to act as a guide in directing the mandible to a position of maximum interdigitation with the opposing teeth, as well as for added retention and bracing effects. The denture was processed in heat cure resin (DPI Dental products of India). The partial denture restored the missing teeth as well as filled the defect improving mastication and phonetics. [Figure 2]
Figure 2: Acrylic partial denture restoring the defect

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Fabrication of Facial Prosthesis

An extra oral facial prosthesis for the lip and cheek defect was planned in the second phase of treatment. The patient was asked to wear the denture which had three pairs of cobalt samarium magnets, 20 mm in diameter and 2 mm in thickness (Jobmasters, Randallstown, MD, USA) embedded with self-cure resin on the polished surface of the denture [Figure 3]. After applying petrolatum around the adjacent facial tissues around the defect an impression of the defect area of face was made using irreversible hydrocolloid (Jeltrate Plus; Dentsply.com. Ltd., Petropolis, R.J. Brazil). A stone cast was made in type III dental stone for the laboratory phase of prosthesis fabrication. This model was used for preparing the wax contour of the facial prosthesis with the aid of the pre-surgical photographs of the patient. Before the wax prosthesis was tried on the patient for esthetics and marginal adaption, the counterpart of the magnets were fixed with wax inside the tissue surface of the facial prosthesis, in accordance to the magnets placed on the denture. After try in, the magnets were removed and the prosthesis was processed in heat polymerized polymethyl methacrylate (Trevalon, Dentsply, York, PA, USA). Basic color matching was achieved at packing stage in the presence of the patient. The prosthesis was tinted with acrylic paint suspension (Fevicryl, Pidilite Industries, Mumbai, India) for final characterization and shade. Patient was trained and instructed for proper placement and removal of the prosthesis, appropriate care and maintenance of both tissues, and prosthesis hygiene was emphasized. She was advised to avoid excessive exposure to sun to prevent discoloration of the extra oral facial prosthesis. It was observed that prosthesis retention was better due to magnets but even slight change in the placement of the prosthesis disturbed the symmetry of the lower lip with upper lip since the prosthesis was free to be placed and moved in any direction. For proper orientation of the prosthesis in the same position, two stainless steels non-braided bars were used (J.B.C. and Company, Las Vegas, U.S.) one anteriorly and one posteriorly. Two holes were drilled in the denture; the size depending upon the thickness of the bars. The two stainless steel bars were secured with self-cure resin at the indentations of holes. When the patient placed the extra oral prosthesis, the bars passed through the holes maintaining the orientation of the prosthesis and along with the magnets provided retention and prevented rotational movement of the prosthesis [Figure 4]. After the prosthesis was placed, the patient reported improvement in mastication and esthetic. Drooling of saliva and liquids were controlled drastically and helped her boost her morale, facilitating her live life near to normal [Figure 5].
Figure 3: Partial denture with magnets embedded on polished surface of the denture and two holes drilled for orientation rods

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Figure 4: Extraoral prosthesis with countermagnets fixed and intraoral prosthesis with magnets embedded on the polished surface

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Figure 5: Extraoral view of the patient wearing intraoral and extraoral prosthesis

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 » Discussion Top


Attempts to replace missing facial structures dates back as far as two thousand years ago based on anecdotal report, historical records and archeological findings. Adhesives or mechanically retained extra oral prosthesis was considered the standard of care. However, surveys of patients so treated showed a limited rate of acceptance of such treatment due to lack of retention. [12],[13] The application of craniofacial implants to retain facial prosthesis was widely applied and retrospective reviews of this effort was reported. [14],[15]

In this case acrylic, partial denture was given. One of the significant problems encountered when fabricating this prosthesis is lack of retention. In addition, the edges of the facial prosthesis do not adapt perfectly to the patients face because of the movement of border tissues. Retention elements apart from conventional adhesives are required. The use of magnets in multiple/sectional maxillofacial prosthesis is an excellent means to retain them together. [16] To ensure proper retention and efficient stability the stainless steel rods were used to orient the facial prosthesis. The prosthesis was extended sufficiently, and magnets positioned properly. Thus, an economic, noninvasive and simple method was used to rehabilitate the patient. There exist a significant and important opportunity to deliver an enhanced service in facial prosthetics through technology implementations, three- dimensional data acquisition, 3D modeling and computerized color formation. Evidenced based studies pertaining to the value of facial prosthetics will have to be added to better understand the economic, functional and psychological burden of having a facial ablation procedure involving the orofacial, ocular, auricular and nasal tissues. [17]


 » Conclusion Top


Prosthetic rehabilitation of patients after extensive procedures for the removal of neoplasms in the maxillofacial region requires multidisciplinary treatment approach. Treatment procedures should be aimed to preserve and initialize the existing remaining supporting structures to improve retention of the prosthesis and satisfactory function. Certain basic principles of conventional methods have to be modified for mandibular resection patients because of restrictive physical factors. The prognosis of treatment depends on taking full advantage of the remaining structures. Free flap reconstruction would have been the ideal treatment plan for this patient. Due to her economic constraints, she was not willing to undergo reconstructive surgery. An attempt to provide a cost effective, simple and cosmetically acceptable sectional prosthesis for a female patient with extensive intra oral extra oral defect is made.

 
 » References Top

1.Hickey JA, Salter M. Prosthodontic and psychological factors in treating patients with congenital and craniofacial defects. J Prosthet Dent 2006;95:392-6.  Back to cited text no. 1
    
2.Davenport J. Managing the prosthetic rehabilitation of patients with Head and Neck Cancer. Dent News (Lond) 1996;3:7-11.  Back to cited text no. 2
    
3.Clarke LK. Rehabilitation for the head and neck cancer patient. Oncology (Williston Park) 1998;12:81-9.  Back to cited text no. 3
    
4.Hubalkowa H, Holakovsky J, Bradza F, Diblik P, Mazanek J. Team Approach in the treatment of extreme maxillofacial defects - Five case report series. Prague Med Rep 2010;3:148-57.  Back to cited text no. 4
    
5.Adisman IK. Prosthesis serviceability for acquired jaw defects. Dent Clin North Am 1990;34:265-84.  Back to cited text no. 5
    
6.Martin JW, Lemon JC, King GE. Maxillofacial reconstruction after tumor ablation. Clin Plast Surg 1994;21:87-96.  Back to cited text no. 6
    
7.Beumer J, MaT, Marunick M,Roumanas E,Nishimura R. Restoration of facial defects: Etiology, disability and rehabilitation. In: Beumer J, Curtis TA, Marunick MT, editors. Maxillofacial rehabilitation: Prosthodontic and surgical considerations. St. Louis: Shiyaku. Euro America; 1996. p. 377-453.  Back to cited text no. 7
    
8.Barron JB, Rubinstein JE, Archibald D, Manor RE. Two piece orbital prosthesis. J Prosthet Dent 1983;49:386-8.  Back to cited text no. 8
    
9.Sasaki H, Kinouchi Y, Tsutsui H, Yoshida Y, Karv M, Ushita T. Sectional prostheses connected by samarium-cobalt magnets. J Prosthet Dent 1984;52:556-8.  Back to cited text no. 9
    
10.Cantor R, Curtis TA. Prosthetic management of edentulous mandibulectomy patients. Part 1 Anatomic, physiologic and psychologic consideration. J Prosthet Dent 1971;25:446-57.  Back to cited text no. 10
    
11.Desjardins RP. Occlusal considerations for the partial mandibulectomy patients. J Prosthet Dent 1979;41:308-15.  Back to cited text no. 11
    
12.Jani RM, Schaaf NG. An evaluation of facial prosthesis. J Prosthet Dent 1978;39:546-50.  Back to cited text no. 12
    
13.Chen MS, Udagma A, Drane JB. Evaluation of facial prosthesis for head and neck cancer patient. J Prosthet Dent 1981;46:538-44.  Back to cited text no. 13
    
14.Parel SM, Tjellstrom A. The United States and Swedish experience with osseo integration and facial prosthesis. Int J Oral Maxillofac Implants 1991;6:75-9.  Back to cited text no. 14
    
15.Wolthaardth JF, Wilkes GH, Parel SM, Tjellestrom A. Craniofacial integration, the Canadian experience. Int J Oral Maxillofac Implants 1993;8:197-204.  Back to cited text no. 15
    
16.Goiato MC, Fernandes AU, dos Santos DM, Barao VA. Positioning magnets on a multiple/sectional maxillofacial prosthesis. J Contemp Dent Pract 2007;8:101-7.  Back to cited text no. 16
    
17.Lemon JC, Kiat-amnuay S, Gettleman L, Martin JW, Chambers MS. Facial prosthetic rehabilitation: Pre-prosthetic surgical techniques and biomaterials. Curr Opin Otolaryngol Head Neck Surg 2005;13:255-62.  Back to cited text no. 17
    


    Figures

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

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