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

432 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 85 NUMBER 5

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
Fig. 4. Evaluation of maxillary denture framework. Oral
access was very limited. Two framework segments were
tied with dental floss to facilitate retrieval and prevent acci-
dental swallowing.
Fig. 5. Maxillary sectional altered cast impression trays
indexed with autopolymerizing acrylic resin.
Fig. 6. Completed maxillary altered cast impression made of
polysulfide material in acrylic custom tray after border molding.
extension while allowing predictable insertion and
withdrawal of the impressions.
434
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
were evaluated intraorally to ensure proper fit. Dental
floss was tied to the framework segments to facilitate
retrieval and prevent accidental swallowing (Fig. 4).
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-
maxilla area. The altered cast impression tray then was
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).
Mandibular impression
A quick-setting, rigid material was selected for
intraoral custom tray fabrication. Occlusal registration
material (Regisil, Dentsply) was dispensed intraorally
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

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THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 10. Definitive nasal prosthesis made of silicone elas-
tomer.
Fig. 11. Lateral view of patient with intraoral and extraoral
definitive prostheses in situ.
reconstruction, and scleroderma may severely limit or
even preclude convenient access to the patient’s oral
cavity. Making an impression for patients with such a
clinical presentation is always a challenge.
In the treatment described, a semirigid material was
436
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
further enhanced by a vinyl polysiloxane wash impres-
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
retainer adjustment and to reduce the overall size of
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
using the surveyed full-arch master cast. The rest of
the laboratory procedures for the obturator fabrication
follow traditional denture fabrication.
Proper maxillary lip support and lip competency are
essential for the establishment of a natural facial profile
VOLUME 85 NUMBER 5
CHENG, WEE, AND TAT-KEUNG
and proper fit of the resulting nasal prosthesis. Scar tis-
sue formation, tightness of the reconstructed area,
paresthesia, and anesthesia may change lip functions.
In addition, excessive lip support may introduce a
destabilizing force on the obturator prosthesis. In gen-
eral, the fabrication of facial prostheses should always
follow the completion of intraoral prosthetic rehabili-
tation.
SUMMARY
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 described the maxillofacial prosthetic manage-
ment of a patient with a midfacial defect complicated by
postsurgical microstomia. Intraoral and extraoral pros-
theses restored the patient’s speech, dental articulation,
mastication, lip support, esthetics, and anterior oral seal.
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Reprint requests to:
DR ANSGAR C. CHENG
DEPARTMENT OF DENTISTRY
ONTARIO CANCER INSTITUTE-PRINCESS MARGARET HOSPITAL
610 UNIVERSITY AVE
TORONTO, ONTARIO M5G 2M9
CANADA
FAX: (416)292-4340
E-MAIL: ansgar_cheng@hotmail.com
Copyright © 2001 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2001/$35.00 + 0. 10/1/115030
doi:10.1067/mpr.2001.115030
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