CLINICAL REPORT

aAssistant PrbAnaplastologcAssociate PrdProfessor, D

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Implant-supported and magnet-retained oral-nasalcombination prosthesis in a patient with a total rhinectomyand partial maxillectomy due to cancer: A clinical report

Alexander M. Won, DDS,a Patti Montgomery,b Ruth Aponte-Wesson, DDS MS,c and Mark Chambers, DMD, MSd

ABSTRACTThis clinical report describes the fabrication of an implant-supported and magnet-retained com-bination oral-nasal prosthesis for a patient with a midline midfacial defect. The patient had un-dergone a total rhinectomy and partial maxillectomy as part of his cancer treatment. The nasalprosthesis was retained on the face by a magnet attached to the implant-supported maxillarydenture, resulting in improved appearance and the recovery of speech, mastication, and swallowingfunctions. (J Prosthet Dent 2017;117:315-320)

Since the introduction ofmicrovascular free flaps, mostfacial defects are now rehabil-itated surgically. However, notevery patient is a candidate fora surgical reconstruction. Forexample, squamous cell can-cers have metastatic potential,

so periodic visual inspection of the oncologic defect isimportant. Teichgraeber and Goepfert1 recommended a2-year wait before any surgical reconstruction becausethe cancer recurred in 45 of 147 patients (30.6%), andtwo-thirds of all recurrences were seen within 2 years.Also, the complexity of the nose makes surgical recon-struction difficult, especially after a total rhinectomy.2

Multiple surgical reconstructive procedures are neededto achieve an acceptable looking nose, and postoperativeradiation therapy can delay wound healing and increasethe risk of flap complications.3-5

Prosthetic rehabilitation can be an attractive alterna-tive to the surgical reconstruction of the nose. Since theadvent of endosseous dental implants, patients haveshown great acceptance of oral-nasal prostheses, withexcellent recovery of oral and nasal function; the pros-thodontics community has also shown satisfaction withsuch prostheses.6

This clinical report describes the prosthetic rehabili-tation of a patient who initially presented with squamouscell carcinoma of the nasal septum, floor, lateral wall,vestibule, and maxilla. He underwent a total rhinectomy,

ofessor, Department of Head and Neck Surgery, University of Texas MD Aist, Department of Head and Neck Surgery, University of Texas MD Andeofessor, Department of Head and Neck Surgery, University of Texas MD Aepartment of Head and Neck Surgery, University of Texas MD Anderson C

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partial maxillectomy, wide local excision of the upper lip,split thickness graft, and full-mouth extraction, and 4implants were placed in the maxilla. He was then treatedwith concurrent radiation and chemotherapy.

CLINICAL REPORT

A 57-year-old man presented for prosthetic rehabilitationafter a total rhinectomy and partial maxillectomy as partof his cancer treatment. The patient needed a nasal andobturator prosthesis because of the surgical defect.

Denture design and placementPreliminary impressions were made with irreversiblehydrocolloid for the fabrication of custom trays. Thehealing abutments were removed, and the tissue depthswere measured for future locator abutment heights(Fig. 1).

At the patient’s next appointment, 4 locator abut-ments (Locators; Zest Anchors Inc) were inserted andtightened according to the manufacturer’s recommendedtorque values. Next, the maxillary and mandibularcustom trays were evaluated clinically, and the functional

nderson Cancer Center, Houston, Texas.rson Cancer Center, Houston, Texas.nderson Cancer Center, Houston, Texas.ancer Center, Houston, Texas.

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Figure 1. Initial presentation. A, B, Extraoral views. C, Intraoral view. D, Panoramic radiograph.

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borders of the vestibule were recorded with greenmodeling plastic impression compound (Kerr ImpressionCompound; Kerr Corp). The locator abutment levelimpression copings were then placed onto the locatorabutments, and a closed-tray impression was made withlight body polyvinyl siloxane impression material (Take IAdvanced; Kerr Corp) (Fig. 2).

The processed record bases were placed in the mouthand adjusted to accommodate the patient’s anatomy. Theocclusal rims were adjusted according to the patient’s ver-tical dimension of occlusion, esthetics, and phonetics and toensure adequate lip support. The maxillomandibular

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relation was recorded in an upright position with polyvinylsiloxane occlusal registration material. A mold guide(BlueLine; Ivoclar Vivadent Inc) was then used to select theappropriate denture teeth and arrange them in lingualizedocclusion.

Once the wax trial dentures were approved, the den-tures were processed using heat-polymerized poly(methylmethacrylate) (Lucitone 199; Dentsply Intl) (Fig. 3). At thepatient’s next appointment, the maxillary overdenture andmandibular denture were delivered (Fig. 4). Once thepatient was comfortable with the new prostheses, thedesign and fabrication of the nasal prosthesis began.

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Figure 2. Definitive impression of maxillary arch.Figure 3. Processed maxillary and mandibular prostheses.

Figure 4. Dental prostheses restored patient’s vertical dimension and profile. A, Frontal view. B, Profile view.

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Nasal prosthesis fabrication and combinationprocedureA multipurpose magnet with lip (MPMS; Factor II, Inc)was attached to the superior extension of the maxillarydenture for the future retention of the nasal prosthesis(Fig. 5). Before the definitive impression of the nasaldefect and surrounding tissues was obtained, undesirabletissue undercuts were blocked out with wet gauze. Thepatient was instructed to breathe through his mouththroughout the definitive impression procedure. A

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customized impression coping for the magnet wasplaced, and polyvinyl siloxane adhesive was added to theimpression coping. Next, the patient’s facial midline wasmarked with an indelible marker (Dr. Thompson’s sani-tary color transfer applicators; Great Plains DentalProducts Co). The definitive impression of the nasaldefect along with the surrounding face was made withlight body polyvinyl siloxane material, and heavy bodypolyvinyl siloxane was placed over the light bodyimpression material for rigidity (Fig. 6).

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Figure 5. Intaglio surface and multipurpose magnet were chemically polymerized into superior extension of maxillary denture. A, Intaglio view.B, Oblique view.

Figure 6. Definitive impression of nasal defect with surrounding tissues. A, Light-body polyvinyl siloxane impression material. B, Heavy-bodypolyvinyl siloxane placed over light-body impression material for rigidity.

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An acrylic resin keeper was fabricated with a magnetover the definitive cast, and the nasal prosthesis wassculpted with specially formulated wax in the usualmanner and adapted to the patient’s defect during thenext visit. Once the fit and esthetics had been optimizedand confirmed, oil paint was mixed with MDX 4-4210silicone and Georgia kaolin to create a sample color thatmatched the patient’s facial base color. The remaining

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nasal sculpture was then invested in the usual manner.Once the wax was eliminated, the definitive cast wasduplicated with irreversible hydrocolloid to make aperforated cast for the polyurethane lined prosthesis asdescribed by Udagama.7

Next, MDX 4-4210 silicone was mixed with oil paintand Georgia kaolin to match the previous base color ofthe patient’s skin and mixed with medical adhesive type

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Figure 7. Definitive oral-nasal combination prosthesis. A, Oblique superior view. B, Posterior view.

Figure 8. Delivery of definitive implant-supported and magnet-retained oral-nasal prosthesis. A, Frontal view. B, Superior view.

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A. The silicone mixture was inserted into a syringe,injected into the mold, and processed as described byUdagama and Drane.8 Finally, the mold was placed into aspring press and allowed to polymerize overnight.

On the day of insertion, the excess silicone wastrimmed, and extrinsic color was painted on the nasalprosthesis in several layers with the prosthesis on thepatient. The prosthesis was then oven polymerized (Fig. 7).

On the day of delivery, the nasal prosthesis wasretained on the face by a magnet attached to the implant-supported maxillary denture and water-based adhesive(Daro Adhesive Extra Strength; Factor II Inc) for edge

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retention (Fig. 8). Three months after delivery of theprosthesis, the patient reported improved mastication,speech, and deglutition, and he was satisfied with theoverall appearance.

DISCUSSION

For the rehabilitation of midline midfacial defects,Nadeau9 described an intraoral-extraoral combinationprosthesis with magnets. Later, such combinationprostheses were discouraged because the connection ofthe prostheses often resulted in movement of the facial

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prosthesis during mastication.9,10 However, in these casereports, the combination prostheses were mainlyretained by medical adhesives or tissue undercuts.Retention of a large prosthesis is one of many limitationsof prosthetic rehabilitation; others include the propertyof materials, the psychological effect, and the mobility oftissues.11 This clinical report describes how these chal-lenges were addressed in the fabrication of an implant-supported and magnet-retained combination oral-nasalprosthesis for a patient with a midline midfacial defect.In the patient described, 4 implants were placed in themaxillary ridge, with good anterior-posterior spread forbetter support and retention; this improved the likeli-hood of the patient accepting the prosthesis. By havingendosseous dental implants, not only was the over-denture retained but also the nasal prosthesis could bemagnetically attached and supported by a stable baseinstead of movable tissues. Because of its magneticsupport, the patient was able to orient the nasal pros-thesis easily and without discomfort. Also, the patientneeded only minimum medical adhesive, which trans-lates to better patient acceptance and ease of care andthe extended life of the prosthesis. Overall, the additionof implants and a large magnet with a flange increasedthe acceptance of the intraoral-extraoral prosthesis tothe great satisfaction of both the patient and treatingteam.

SUMMARY

Prosthetic rehabilitation can be a good alternative tosurgical reconstruction for patients who have undergonea total rhinectomy. Prosthetic rehabilitation can lessenthe number of surgical procedures and result in betterappearance and a natural-looking nose. The value ofdental implants in the rehabilitation of maxillofacial pa-tients is indisputable, as the implants increase stability,

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support, and retention, thus improving the overalloutcome and patient satisfaction with the restoration. Forthe patient in this report, the implant-supported oral-nasal combination prosthesis represented a majorimprovement in quality of life. His masticatory, speech,and deglutition functions and his facial estheticsimproved so that he could return to normal life. Withoutthe implants, his current level of comfort would not havebeen achieved.

REFERENCES

1. Teichgraeber JF, Goepfert H. Rhinectomy: timing and reconstruction. Oto-laryngol Head Neck Surg 1990;102:362-9.

2. Stanley RJ, Olsen KD. Rhinectomy for malignant disease. A 20-year expe-rience. Arch Otolaryngol Head Neck Surg 1988;114:1307-11.

3. Bourget A, Chang JT, Wu DB, Chang CJ, Wei FC. Free flap reconstructionin the head and neck region following radiotherapy: a cohort studyidentifying negative outcome predictors. Plast Reconstr Surg 2011;127:1901-8.

4. Thankappan K. Microvascular free tissue transfer after prior radiotherapy inhead and neck reconstructionda review. Surg Oncol 2010;19:227-34.

5. Klug C, Berzaczy D, Reinbacher H, Voracek M, Rath T, Millesi W, et al. In-fluence of previous radiotherapy on free tissue transfer in the head and neckregion: evaluation of 455 cases. Laryngoscope 2006;116:1162-7.

6. Flood TR, Russell K. Reconstruction of nasal defects with implant-retainednasal prostheses. Br J Oral Maxillofac Surg 1998;36:341-5.

7. Udagama A. Urethane-lined silicone facial prostheses. J Prosthet Dent1987;58:351-4.

8. Udagama A, Drane JB. Use of medical-grade methyl triacetoxy silanecrosslinked silicone for facial prostheses. J Prosthet Dent 1982;48:86-8.

9. Nadeau J. Maxillofacial prosthesis with magnetic stabilizers. J Prosthet Dent1956;6:114-9.

10. Nadeau J. Special prostheses. J Prosthet Dent 1968;20:62-76.11. Birnbach S, Herman GL. Coordinated intraoral and extraoral prostheses in

the rehabilitation of the orofacial cancer patient. J Prosthet Dent 1987;58:343-8.

Corresponding author:Dr Alexander M. WonDepartment of Head and Neck SurgeryThe University of Texas MD Anderson Cancer Center1400 Pressler St, Unit 1445Houston, TX 77030Email: amwon@mdanderson.org

Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

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