2000 JUDSON C.

HICKEY SCIENTIFIC WRITING AWARD

Maxillofacial prosthetic rehabilitation of a midfacial defect complicated by

microstomia: A clinical report
Ansgar C. Cheng, BDS, MS,a Alvin G. Wee, BDS, MS,b and Li Tat-Keung, CDTc
Faculty of Dentistry, University of Toronto, and University Health Network-Princess Margaret Hospital,
Toronto, Ontario, Canada; College of Dentistry, The Ohio State University, Columbus, Ohio
Severe limitation in the oral opening, though an uncommon clinical presentation, makes gaining
access to the oral cavity difficult for any dental procedure. This article describes the maxillofacial
prosthetic management of a patient with a midfacial defect complicated by postsurgical microsto-
mia. Intraoral and extraoral prostheses restored the patient’s speech, dental articulation,
mastication, lip support, esthetics, and anterior oral seal. (J Prosthet Dent 2001;85:432-7.)

M icrostomia is defined as an abnormally small

oral orifice.1 A reduction in mobility of the mandible
record of appropriate anatomic landmarks.24-26 Accurate
preliminary impressions and diagnostic casts are
that results from tonic contracture of the masticatory essential for surveys, denture design, the development
muscles is known as mandibular trismus.1 It usually is of custom trays, and final impressions. Traditionally,
present as a prolonged, tetanic spasm of the jaw mus- stock trays are used for the fabrication of preliminary
cles by which the normal opening of the mouth is impressions. Even though stock impression trays
restricted.1 Patients with these defects may experience come in various sizes, materials, designs, and shapes,
a remarkable limitation of jaw opening and overall jaw the insertion of stock trays may be impossible if there
immobility. is a severe limitation in the oral opening. Generally,
It is well documented that trismus is a common the total height of a stock impression tray is approxi-
complication in patients who have had head and neck mately 1 to 1.5 cm. Laboratory modification of a
cancer treatment.2-5 In patients with oral malignancy, stock impression tray may further reduce its size and
posttreatment trismus is more commonly found in ease its insertion into the oral cavity. Theoretically, an
patients with mandibular tumors than those with max- impression can be made as long as the maximum ver-
illary tumors.6 tical opening can provide an interarch space that is
Limited oral opening can be caused by head and greater than the vertical height of an impression tray
neck radiation,3,7-11 reflex spasm,6 surgically treated and the lips can be stretched to a width that is equal
head and neck tumors,11 microinvasion of the mus- to or greater than the width of an impression tray. In
cles of mastication,6,12 connective tissue disease,13,14 traditional patients, successful removal and insertion
fibrosis of masticatory muscles,15 facial burns,16 and of impressions require a reasonable degree of flexibil-
reconstructive lip surgeries.17 Having a limited oral ity of facial soft tissue and lips. In situations where scar
opening can be a significant problem for patients tissue formation has decreased the flexibility of the
who need dental treatment.18,19 Clinical manage- lips significantly, insertion and removal of stock
ment of the problems associated with providing impression trays may be impossible.
dental prostheses for patients with trismus is not well Border molding materials such as modeling plastic
reported, 19 although the following management impression compound,25,27 vinyl polysiloxane,28,29
techniques have been described: surgery,6,20 the use and polyether30-32 impression materials have been
of dynamic opening devices,9,15,21 and modification accepted for clinical use in removable prosthodontics.
of denture designs.19,22,23 Polymeric border molding materials have several
The fabrication of removable partial denture prosthe- advantages over modeling plastic impression com-
ses requires a detailed impression of the tissue bed and a pound. The former allow: (1) accurate placement
onto the border, (2) ease of manipulation, (3) elimi-
aAssistant Professor, Department of Prosthodontics, University of nation of multiple insertions and removal of the
Toronto; Head, Maxillofacial Prosthetics, University Health border molding impression tray, (4) elimination of
Network-Princess Margaret Hospital.
bAssistant Professor, Section of Restorative Dentistry, Prosthodontics,
the water bath, and (5) superior accuracy.33
and Endodontics, Ohio State University. This article describes the prosthetic management
cAnaplastologist, University Health Network-Princess Margaret of a patient with a midfacial defect complicated by
Hospital. postsurgical microstomia. Intraoral and extraoral

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CHENG, WEE, AND TAT-KEUNG THE JOURNAL OF PROSTHETIC DENTISTRY

prostheses restored the patient’s speech, dental articula-

tion, mastication, lip support, esthetics, and anterior
oral seal.
CLINICAL REPORT
A 68-year-old white man was referred to the
University Health Network-Princess Margaret
Hospital for prosthodontic assessment (Fig. 1). The
surgical procedure occurred approximately 1 month
before the assessment. No preoperative assessment
was performed. A squamous cell carcinoma was
resected from his premaxilla, maxillary lip, and the
inferior one third of his nose. The resulting maxillary
lip defect was immediately reconstructed with a full-
thickness flap harvested from the patient’s Fig. 1. Extraoral frontal view of defect. Premaxilla resection
mandibular lip. An immediate surgical obturator had resulted in deficient maxillary lip contour.
been placed in the maxillary defect. Preoperative
radiotherapy was completed approximately 3 months
before the ablative tumor surgery. The patient
received a total dosage of approximately 6000 cGy.
A clinical examination revealed a partially edentulous
maxilla and dentate mandible. There was remarkable
limitation in the oral opening with reduced perimeter of
the oral cavity (Fig. 2). Even though the immediate sur-
gical obturator could be removed for assessment of the
maxillary defect, removal and reinsertion of the pros-
thesis was exceptionally difficult. A preoperative
diagnostic cast was not available. Diagnostic impression
making with the use of standard stock trays was found
to be impossible. This presented an unusual challenge
for the fabrication of the definitive intraoral prosthesis.
The rehabilitation treatment plan included a definitive
obturator prosthesis and a nasal prosthesis. Fig. 2. Frontal view of opened oral cavity with regular den-
The defect was allowed to heal for 3 months after tal mirror (22 mm diameter) for comparison purposes.
surgery. Oral access was even more restricted as a result Estimated diameter of oral opening was less than 35 mm.
of healing, tissue resorption, and scar formation.
Fabrication of a detailed impression was needed to ful-
fill the retention, support, and stability requirements
of a definitive obturator prosthesis. An alternative
approach was used for definitive prosthesis fabrication.
Maxillary treatment
Surveying the maxillary teeth was impossible with-
out a maxillary diagnostic cast. An obturator design
was made based on the distribution of the patient’s
residual natural dentition. A preliminary survey of the
dentition was performed intraorally with a periodontal
probe, and tooth preparation was accomplished
according to the obturator design. Quadrant impres-
sion trays (Coe, Chicago, Ill.) for the left and right
residual maxillary dentition were selected to ensure
successful insertion and removal of the resulting Fig. 3. Final half maxillary casts. Midline was marked based
on intraoral visual observation.
impression. Modeling plastic impression compound
was used to modify the palatal extension of the impres-
sion trays. The midline of the palate was marked that the palatal extension of the impression trays
intraorally with an indelible pencil. It was important extended just beyond the midline to ensure sufficient

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THE JOURNAL OF PROSTHETIC DENTISTRY CHENG, WEE, AND TAT-KEUNG

Final maxillary impressions were made for the left and

right half of the maxilla with the use of type II irre-
versible hydrocolloid (Jeltrate, Dentsply, Milford, Del.).
The 2 maxillary impressions then were poured in ADA
type V dental stone (Die Keen, Bayer Corp, South Bend,
Ind.). The midline of the palate was marked on the 2
maxillary cast halves, and the design of the maxillary den-
ture frameworks was drawn on the 2 half maxillary casts
(Fig. 3). Two framework segments made of chromium-
cobalt alloy (Vitallium, Neoloy Products Co, Posen, Ill.)
cast to 18-gauge wrought platinum-gold-palladium wire
(Ney Dental International, Bloomfield, Conn.) retainers
were prescribed.
The 2 maxillary obturator framework segments
Fig. 4. Evaluation of maxillary denture framework. Oral were evaluated intraorally to ensure proper fit. Dental
access was very limited. Two framework segments were floss was tied to the framework segments to facilitate
tied with dental floss to facilitate retrieval and prevent acci- retrieval and prevent accidental swallowing (Fig. 4).
dental swallowing. After the accuracy of the framework segments was ver-
ified, custom trays were made for each segment with
the use of an acrylic resin (GC pattern resin, GC
America Inc, Chicago, Ill.). The acrylic resin trays
were extended approximately 1 to 2 mm away from
the marked midline on their respective working casts.
The 2 impression tray/framework assemblies then
were reinserted intraorally and indexed together at the
midline with autopolymerizing acrylic resin (GC pat-
tern resin, GC America Inc) to form an altered cast
impression tray (Fig. 5).
Impression material adhesive (Tray adhesive,
Dentsply) was applied on the anterior border of the
impression trays. Tissue molding of the surgical defect
was accomplished by applying fast-setting occlusal
registration material (Regisil, Dentsply) onto the pre-
Fig. 5. Maxillary sectional altered cast impression trays maxilla area. The altered cast impression tray then was
indexed with autopolymerizing acrylic resin. inserted into the patient’s oral cavity. An air-water
syringe tip was used to retract the patient’s lip during
impression tray insertion. Muscle trimming was initi-
ated. On polymerization, the border molded
impression tray was withdrawn and inspected for
accuracy. Additional material was added to the defi-
cient areas until border molding of the tissue defect
was completed. Tray adhesive (Rubber based adhe-
sive, Kerr, Romulus, Mich.) was applied to the
intaglio surface of the impression trays. A wash
impression was made with low-viscosity polysulfide
material (Light-bodied Permlastic, Kerr) to complete
the altered cast impression (Fig. 6).
The 2 half maxillary master casts were sectioned,
repositioned in the altered cast impression, boxed in
dental wax, and poured in ADA type V dental stone to
form a full-arch maxillary master cast (Fig. 7).
Fig. 6. Completed maxillary altered cast impression made of
polysulfide material in acrylic custom tray after border molding. Mandibular impression
A quick-setting, rigid material was selected for
extension while allowing predictable insertion and intraoral custom tray fabrication. Occlusal registration
withdrawal of the impressions. material (Regisil, Dentsply) was dispensed intraorally

434 VOLUME 85 NUMBER 5

CHENG, WEE, AND TAT-KEUNG THE JOURNAL OF PROSTHETIC DENTISTRY

on the mandibular occlusal surfaces. After the materi-

al set, it was carefully retrieved. Excess material was
removed, and what remained was a rigid but semiflex-
ible custom impression tray. This tray was repositioned
intraorally to verify proper extension. A wash impres-
sion was made in a medium-body impression material
(Reprosil, Dentsply) (Fig. 8).
Obturator and nasal prosthesis fabrication
The maxillary cast was resurveyed on a dental sur-
veyor; a path of insertion was determined, and
retentive undercuts were marked. The wrought wire
retainers were adjusted to engage the appropriate
amount of undercuts according to the obturator
design and path of insertion. A maxillary record base Fig. 7. Completed 1-piece maxillary cast.
was made of acrylic resin (Formatray, Kerr) and dental
wax. The patient was seen for maxillomandibular
records and a trial insertion appointment.
During the esthetic try-in, sufficient lip support was
obtained without violating the patient’s neutral zone
and lip competency. The maxillary obturator then was
processed in heat-polymerizing acrylic resin in the tra-
ditional manner (Fig. 9). At the delivery appointment,
the patient was instructed in the insertion and removal
of the prostheses.
When the maxillary lip support and lip competency
were found satisfactory, an adhesive-retained silicone
elastomer nasal prosthesis was fabricated according to
the standard protocol34 (Figs. 10 and 11).
DISCUSSION
Fig. 8. Completed mandibular impression made of vinyl
When maxillary lip defects are reconstructed with polysiloxane impression material.
the use of tissue from the mandibular lip, the conti-
nuity of the oral aperture is effectively restored.
However, because the net loss of soft tissue from the
maxillary lip is not replenished in such a procedure,
microstomia is inevitable. Such clinical situations
introduce significant challenges for future dental
treatment and regular oral hygiene maintenance. The
placement of standard full-arch stock impression trays
may be impossible, and this fact may suggest that suc-
cessful dental prosthesis fabrication and usage also are
not feasible. In general, as long as the insertion and
removal of an immediate obturator are manageable by
the patient and an impression can be made to cover
the required anatomy, a successful definitive obturator
prosthesis can be fabricated.
One of the most technique-sensitive and demand-
ing steps in denture fabrication is border molding. Fig. 9. Intaglio of completed maxillary denture prosthesis.
Border molding helps establish optimal extension of
the denture base while preventing functional interfer- starting point for denture design and denture fabrica-
ence with oral musculatures. An accurate custom tray tion. Even though stock impression trays are made in
is important for the fabrication of a predictable final various sizes, there are times when individual anatom-
impression. A diagnostic impression commonly is ic variation may prevent the use of full-arch stock
made with a stock tray and irreversible hydrocolloid. impression trays. A previous history of radiation thera-
The accuracy of a full-arch diagnostic cast is a crucial py, surgical excision of a head and neck tumor, surgical

MAY 2001 435

THE JOURNAL OF PROSTHETIC DENTISTRY CHENG, WEE, AND TAT-KEUNG

used as an impression tray for the mandibular diagnos-

tic impression. Vinyl polysiloxane occlusal registration
material mixed in an automix dispenser was used
because of its excellent flow, ease of mixing, handy dis-
pensary, rigidity, and rapid setting properties, all of
which allowed it to be used in the mandibular arch
successfully as a custom diagnostic impression tray.
Because the material was dispensed intraorally, the
problem of inserting a full-arch stock impression tray
with limited oral access was eliminated. Moreover,
because the material provides a reasonable amount of
elasticity, it can be removed even though it may be
slightly oversized with respect to the microstomia. The
accuracy of this diagnostic mandibular impression was
Fig. 10. Definitive nasal prosthesis made of silicone elas- further enhanced by a vinyl polysiloxane wash impres-
tomer. sion technique.
Final maxillary impressions were made with the use
of stock quadrant trays. Compared with full-arch
stock trays, quadrant trays are more agile for inser-
tion/removal in situations of limited oral access. To
ensure proper tissue coverage, modeling plastic
impression compound was used for tray extension.
Irreversible hydrocolloid was used for final impression
of the obturator framework segments. If the impres-
sion material had engaged excessive tissue undercuts
or locked in because of excessive bulkiness, it could
have been easily broken down into smaller pieces for
retrieval.
A full-arch diagnostic cast ideally should be sur-
veyed before removable partial denture design and
tooth preparation. In this patient treatment, a full-arch
maxillary cast was not available for survey at the treat-
ment-planning stage because of difficulties in gaining
oral access for full-arch impression making. A prelimi-
nary intraoral survey that used a periodontal probe was
performed before tooth preparation.
Although chromium-cobalt alloys have been wide-
ly used as a denture framework material, component
breakage is not uncommon after repeated adjustment.
Wrought wire retainers were prescribed to permit
flexibility for adjustment, engagement, and disen-
gagement of retainers into the appropriate dental
undercut, with respect to the selected path of inser-
tion. This ensured sufficient retention without a
preoperative diagnostic cast survey. Infrabulge retain-
ers should be avoided in this situation to simplify
Fig. 11. Lateral view of patient with intraoral and extraoral retainer adjustment and to reduce the overall size of
definitive prostheses in situ. the retainer. In the event that any major discrepancy is
found between the functional configuration of individ-
ual components and the selected path of insertion, a
new removable partial denture framework can be made
reconstruction, and scleroderma may severely limit or using the surveyed full-arch master cast. The rest of
even preclude convenient access to the patient’s oral the laboratory procedures for the obturator fabrication
cavity. Making an impression for patients with such a follow traditional denture fabrication.
clinical presentation is always a challenge. Proper maxillary lip support and lip competency are
In the treatment described, a semirigid material was essential for the establishment of a natural facial profile

436 VOLUME 85 NUMBER 5

CHENG, WEE, AND TAT-KEUNG THE JOURNAL OF PROSTHETIC DENTISTRY

and proper fit of the resulting nasal prosthesis. Scar tis- 17. Smith PG, Muntz HR, Thawley SE. Local myocutaneous advancement
flaps. Alternatives to cross-lip and distant flaps in the reconstruction of
sue formation, tightness of the reconstructed area, ablative lip defects. Arch Otolaryngol 1982;108:714-8.
paresthesia, and anesthesia may change lip functions. 18. Meraw SJ, Reeve CM. Dental considerations and treatment of the
In addition, excessive lip support may introduce a oncology patient receiving radiation therapy. J Am Dent Assoc
1998;129:201-5.
destabilizing force on the obturator prosthesis. In gen- 19. Heasman PA, Thomason JM, Robinson JG. The provision of prostheses
eral, the fabrication of facial prostheses should always for patients with severe limitation in opening of the mouth. Br Dent J
follow the completion of intraoral prosthetic rehabili- 1994;176:171-4.
20. Werner R. Treatment of trismus following radiotherapy in nasopharyn-
tation. geal cancer (N.P.C.). Singapore Med J 1974;15:64-8.
21. Dijkstra PU, Kropmans TJ, Tamminga RY. Modified use of a dynamic bite
SUMMARY opener—treatment and prevention of trismus in a child with head and
neck cancer: a case report. Cranio 1992;10:327-9.
Severe limitation in the oral opening, though an 22. Naylor WP, Manor RC. Fabrication of a flexible prosthesis for the
uncommon clinical presentation, makes gaining access edentulous scleroderma patient with microstomia. J Prosthet Dent
to the oral cavity difficult for any dental procedure. This 1983;50:536-8.
23. Suzuki Y, Abe M, Hosoi T, Kurtz KS. Sectional collapsed denture for a
article described the maxillofacial prosthetic manage- partially edentulous patient with microstomia: a clinical report. J
ment of a patient with a midfacial defect complicated by Prosthet Dent 2000;84:256-9.
postsurgical microstomia. Intraoral and extraoral pros- 24. Felton DA, Cooper LF, Scurria MS. Predictable impression procedures for
complete denture. Dent Clin North Am 1996;40:39-51.
theses restored the patient’s speech, dental articulation, 25. Halperin AR, Graser GN, Rogoff GS, et al. Mastering the art of complete
mastication, lip support, esthetics, and anterior oral seal. dentures. Chicago: Quintessence Publishing; 1988. p. 31-80.
26. McGivney GP, Carr AB. McCracken’s removable partial prosthodontics.
10th ed. St. Louis, MO: Mosby; 1999. p. 337-45.
REFERENCES 27. Allen P, Worrollo S. Border molding with composition heated in a
1. Academy of Prosthodontics. The glossary of prosthodontic terms. 7th ed. microwave oven. J Prosthet Dent 1991;65:325.
J Prosthet Dent 1999;81:39-110. 28. Chaffee NR, Cooper LF, Felton DA. A technique for border molding
2. McClure D, Barker G, Barker B, Feil P. Oral management of the cancer edentulous impressions using vinyl polysiloxane material. J Prosthodont
patient, part II: oral complications of radiation therapy. Compendium 1999;8:129-34.
1987;8:88, 90-2. 29. Colaizzi FA, Farah JW. Simplified border molding using silicone materi-
3. Sakai S, Kubo T, Mori N, Itoh M, Miyaguchi M, Kitaoku S, et al. A study al. Fla Dent J 1981;52:20-1.
of the late effects radiotherapy and operation on patients with maxillary 30. Zarb GA, Bolender CL, Hickey JC, Carlsson GE. Maxillary impression
cancer. A survey more than 10 years after initial treatment. Cancer procedure. In: Zarb GA, Bolender CL, Hickey JC, Carlsson GE, editors.
1998;62:2114-7. Boucher’s prosthodontic treatment for edentulous patients. 10th ed. St.
4. Rahn AO, Drone JB. Dental aspects of the problems, care, and treatment Louis, MO: Mosby–Year Book; 1990. p. 179-93.
of the irradiated oral cancer patient. J Am Dent Assoc 1967;74:957-66. 31. Tan HK, Hooper PM, Baergen CG. Variability in the shape of maxillary
5. Jansma J, Vissink A, Bouma J, Vermey A, Panders AK, Gravenmade EJ. A vestibular impression recorded with modeling plastic and a polyether
survey of prevention and treatment regimens for oral sequelae resulting impression material. Int J Prosthodont 1996;9:282-9.
from head and neck radiotherapy used in Dutch radiotherapy institutes. 32. Smith DE, Toolson LB, Bolender CL, Lord JL. One-step border molding of
Int J Radiat Oncol Biol Phys 1992;24:359-67. complete denture impressions using a polyether impression material. J
6. Ichimura K, Tanaka T. Trismus in patients with malignant tumours in the Prosthet Dent 1979;41:347-51.
head and neck. J Laryngol Otol 1993;107:1017-20. 33. Groh CL, O’Brien WJ. Impression materials. In: O’Brien WJ, editor.
7. Dreizen S. Oral complications of cancer therapies. Description and inci- Dental materials properties and selection. Chicago, IL: Quintessence
dence of oral complications. NCI Monogr 1990;9:11-5. Publishing; 1989. p. 177-202.
8. Engelmeier RL, King GE. Complications of head and neck radiation ther- 34. Beumer J, Curtis T, Marunick M. Maxillofacial rehabilitation: prostho-
apy and their management. J Prosthet Dent 1983;49:514-22. dontic and surgical considerations. Tokyo: Ishiyaku EuroAmerica, Inc;
9. Brunello DL, Mandikos MN. The use of a dynamic opening device in the 1996. p. 404-6.
treatment of radiation induced trismus. Aust Prosthodont J 1995;9:45-8.
10. Beumer J 3rd, Curtis T, Harrison RE. Radiation therapy of the oral cavity: Reprint requests to:
sequelae and management, part 1. Head Neck Surg 1979;1:301-12. DR ANSGAR C. CHENG
11. Horst RW. Trismus: its causes, effects and treatment. ORL Head Neck DEPARTMENT OF DENTISTRY
Nurs 1994;12:11-2. ONTARIO CANCER INSTITUTE-PRINCESS MARGARET HOSPITAL
12. Cohen SG, Quinn PD. Facial trismus and myofascial pain associated 610 UNIVERSITY AVE
with infections and malignant disease. Report of five cases. Oral Surg TORONTO, ONTARIO M5G 2M9
Oral Med Oral Pathol 1998;65:538-44. CANADA
13. Jablonski S. Jablonski’s dictionary of dentistry. 1st ed. Melbourne, FL: FAX: (416)292-4340
Krieger Publishing Co; 1992. p. 700-1. E-MAIL: ansgar_cheng@hotmail.com
14. al-Hadi LA. A simplified technique for prosthetic treatment of microsto-
mia in a patient with scleroderma: a case report. Quintessence Int Copyright © 2001 by The Editorial Council of The Journal of Prosthetic
1994;25:531-3. Dentistry.
15. Nakajima T, Sasakura H, Kato N. Screw-type mouth gag for prevention 0022-3913/2001/$35.00 + 0. 10/1/115030
and treatment of postoperative jaw limitation by fibrous tissue. J Oral
Surg 1980;38:46-50.
16. Maragakis GM, Garcia-Tempone M. Microstomia following facial burns.
J Clin Pediatr Dent 1998;23:69-74. doi:10.1067/mpr.2001.115030

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