Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2018; 63: 124–128

doi: 10.1111/adj.12563

Prosthodontic management of maxillofacial cases:

a case series
J Dudley,* F Mughal,* E Hotinski,* M Mahmud*
*Adelaide Dental School, The University of Adelaide, Adelaide, South Australia, Australia.

ABSTRACT
Maxillofacial prosthetics is an important and recognized sub-discipline of prosthodontics that forms a key component of
postgraduate training programmes. General dentists have a role to play in the management of maxillofacial defect
patients even though treatment usually requires a multidisciplinary approach in an institutional environment. Maxillofa-
cial prosthetic cases frequently present with complex histories but simple patient goals. The conservatively managed
implant-retained auricular prosthesis, speech aid prosthesis and orbital prosthesis cases described in this report were
completed in a postgraduate clinical residency program and highlight the intrinsic complexities, challenges and ultimately
satisfaction related to cases of this nature.
Keywords: Auricular prosthesis, maxillofacial prosthetics, multidisciplinary, orbital prosthesis, speech aid prosthesis.
(Accepted for publication 23 August 2017.)

INTRODUCTION CASE REPORT

Maxillofacial prosthetics is the branch of prosthodon-
Case 1: Implant-retained auricular prosthesis
tics concerned with the restoration and/or replacement
of stomatognathic and craniofacial structures with Auricular defects may present due to trauma, congeni-
prostheses that may or may not be removed on a reg- tal abnormalities and malignancies.6 Auricular defor-
ular or elective basis.1 While not routinely taught in mities range from a grossly normal but small ear to
undergraduate Australian dental curricula, the sub-dis- the absence of the entire external ear and account for
cipline represents a required competency within post- three in every 10 000 births, with bilaterally missing
graduate specialist training programmes in Australia.2 ears seen in fewer than 10% of all cases.7 While tradi-
Maxillofacial prosthetic treatment often requires a tional methods of management include the use of
multidisciplinary approach and is usually conducted medical-grade skin adhesives, spectacles and tissue
in teaching or hospital institutions. However, general undercuts, there are associated difficulties related to
dentists have long had an important assisting role to retention reliability, stability, adverse tissue reactions,
play in the management of patients through having accelerated discoloration and prosthesis deterioration
familiarity with the essential treatment concepts and resulting in reduced patient acceptance.8 The use of
prostheses that patients may present with for repair, implants has created a viable treatment alternative
maintenance or appropriate referral.3 that provides more predictable aesthetics, improved
Maxillofacial prosthetics has several advantages retention and stability of prostheses in comparison
over surgical intervention and generally involves with other retention methods.9,10
restoring elements of normal speech, mastication, deg- A 24 year old healthy male patient presented with
lutition functions and aesthetics.4,5 The following con- left microtia and two 4-mm implants in the mastoid
servatively managed cases were completed in a bone with Hader bar attachments. The previously
postgraduate clinical residency programme by collabo- constructed auricular prosthesis had been lost and the
ration between The University of Adelaide and Mahi- implants demonstrated grade II peri-implantitis
dol University, Bangkok. The complexity of the cases (Fig. 1). Following curettage in the peri-implant
was underpinned by challenges in prosthesis retention, region, the prosthesis extensions were outlined and
patient acceptance, maintenance regimes and artistic impression copings were attached to implant abut-
flair required for successful outcomes. ments. A wash impression was taken with thixotropic
124 © 2017 Australian Dental Association
 Prosthodontic management of maxillofacial cases

Fig. 1 Initial presentation of mastoid implants. Fig. 2 Wash impression of the tissue and implants.

soft and hard form silicone material (Multisil Epi-

thetik soft and hard form; Bredent, Senden, Germany)
(Fig. 2). The laboratory analogues were attached to
the impression copings and the impression was then
boxed and poured in type IV dental stone (Vel-Mix
Stone; Kerr, Orange, CA, USA).
The existing Hader bar and nylon clips (ERA;
Sterngold Dental, Attleboro, MA, USA) were attached
on the cast and an acrylic housing with retentive ele-
ments constructed. A wax pattern was fabricated and
tried-in then a three-piece wax-pattern mould was
fabricated to allow for staged wax elimination. Final
processing of the three-piece mould was completed
with an intrinsically coloured bulk-filled silicone elas-
tomer (Mulitisil-Epithetic Country; Bredent). The
prostheses was again tried-in, adapted to the defect
area and coloured extrinsically (Dry pigment; Factor
II, Lakeside, AZ, USA) then inserted with appropriate Fig. 3 Final auricular prosthesis.
care instructions (Fig. 3). On review, the patient was
pleased with the result and the prosthesis demon-
strated well-adapted margins with noticeably velopharyngeal insufficiency. This can initially lead to
improved peri-implant tissue health. difficulties in feeding, sucking and swallowing, and
later the production of excessive nasal resonance (hy-
pernasal speech). A speech aid prosthesis creates an
Case 2: Speech aid prosthesis for unrepaired cleft
artificial seal between the oral and nasal cavities and
palate
facilitates changes in oral air pressure to prevent these
The management of cleft lip and palate defects usually problems.11 Prosthetic management of patients with a
commences soon after birth with patients often com- soft palate defect is challenging, particularly when
pletely rehabilitated by the time they reach adult life. edentulous, as retention of the prosthesis is often com-
However, when left untreated, the dynamic closure of promised due to the inability to obtain an adequate
the soft palate, which separates the nasopharynx and border seal, lack of palatal surface area for support
oropharynx during function, cannot occur resulting in and increased weight of the prosthesis.12
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J Dudley et al.

A 67 year old completely edentulous man presented perforated mesh framework cast with acrylic resin
with an unrepaired cleft palate and a unilateral cleft bases and wax rims incorporated for the jaw relations
lip repaired as an infant (Figs. 4 and 5). The patient and tooth set-up stages. Final processing with heat-
had previously worn conventional maxillary and polymerizing acrylic resin incorporated a hollow-bulb
mandibular acrylic removable partial dentures with design to reduce the overall weight of the prosthesis
the maxillary partial denture including obturation of and assist in retention. Conventional complete denture
the hard palate only, without soft palate involvement. stages were followed for the mandibular complete
Medical history established a previous successful heart denture. The maxillary complete denture incorporat-
valve repair. Recent final natural tooth extractions ing a speech aid prosthesis and conventional mandibu-
rendered the current partial dentures redundant but lar complete denture were delivered to the patient
the patient related not wearing any prosthesis for with immediate and considerable phonetic and aes-
approximately 10 years. Preoperative speech analysis thetic improvement (Fig. 6).
revealed a distinct hypernasality during phonation.
In the maxillary arch, treatment commenced by tak-
Case 3: Orbital prosthesis
ing an alginate impression in a modified stock tray to
facilitate construction of a custom acrylic impression Prosthetic rehabilitation after surgical removal of the
tray. The extent of the palatal defect was initially eye can be divided into ocular and orbital prosthe-
recorded using CoeComfort (GC, Tokyo, Japan) while ses.13 Ocular prostheses contain an acrylic shell to
the patient performed functional movements, then a cosmetically restore tissue loss following eye enucle-
final wash impression was taken using Variotime ation while orbital prostheses replace additional loss
Monophase silicone (Hereaus Kultzer, Hanau, Ger- of tissue such as eyelids, eyelashes and eyebrows, and
many). Master models were poured and a cobalt- are routinely retained by mechanical, adhesives or
chrome alloy (Vitalliumâ; Dentsply, York, PA, USA) craniofacial implants.14 Orbital defects may result
from surgical ablation of benign or malignant
tumours, congenital malformations or traumatic aeti-
ologies, all of which influence patient appearance,
function and psychology.15 Following orbital enucle-
ation, the remaining musculature has a great influence
on the possible types of the prostheses.16
A 20 year old female patient presented with a his-
tory of right eye enucleation from a retinoblastoma as
a 1-year-old. Further history established two fornix
surgeries over the past 10 years with follow-up radio-
therapy and chemotherapy (Fig. 7). An ocular prosthe-
sis had been provided but was poorly tolerated and
not accepted due to poor retention and unsatisfactory
aesthetics. The defect area demonstrated scar contrac-
tures, insufficient lower fornix depth and lacrimal duct
Fig. 4 Unrepaired cleft palate with residual soft palate at rest.

Fig. 6 Maxillary speech aid prosthesis with hollow-bulb obturator

Fig. 5 Unrepaired cleft palate with residual soft palate during phonation. design.
126 © 2017 Australian Dental Association
 Prosthodontic management of maxillofacial cases

Fig. 7 Initial patient presentation with orbital defect.

Fig. 9 Final orbital prosthesis.

fluid secretion. The construction of the orbital prosthe-

sis commenced with impressions of the defect using
thixotropic soft and hard form silicone material (Mul- treatment, the presented cases illustrated the complexi-
tisil-Epithetik; Bredent) stabilized with wooden sticks ties encountered in maxillofacial prosthetics that
(Dalian Goodwood; Medical Care, Dalian, China) required the use of highly specific techniques and
(Fig. 8). An impression of contralateral eye was taken materials. The cases included in this report focused on
and models poured using type IV stone (Vel-Mix the technical aspects of management, however the psy-
Stone; Kerr). A wax pattern was fabricated to permit a chological aspects were of critical importance under-
diagnostic try-in and sclera and iris shade selection. A pinned by patient acceptance of their prosthesis.
further try-in ensued to confirm the shade. Processing Patients frequently presented with complex histories
commenced by mixing medical-grade silicone (MDX but a simple request, that being to achieve a reason-
4-4210; Dow Corning, Auburn, MI, USA) with intrin- able aesthetic and functional result to facilitate accep-
sic coloration and coloured rayon flock (Factor II) tance in normal functions of society. Of greatest
until the patient’s skin colour was achieved. satisfaction in the management of the cases were the
At the insertion appointment, excess silicone was patient responses to their treatment outcomes.
trimmed and extrinsic staining was completed using
dry earth pigments (Dow Corning, Factor II, Midland, ACKNOWLEDGEMENTS
MI, USA) (Fig. 9). Due to unfavourable soft and hard
tissue defects, history of fornix surgeries, minimal The authors would like to thank the registrars and
undercut from superior orbital rim and obliteration of staff of the Department of Maxillofacial Prosthetics at
the inferior fornix, the prosthesis required the use of Mahidol University.
adhesive to assist in retention. The prosthesis resulted
in a satisfactory aesthetic and retentive outcome DISCLOSURE
restoring the soft and hard tissue defect.
The authors declare no conflict of interest regarding
the publication of this paper.
DISCUSSION
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