JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 144-147

Rehabilitation of facial defect on a unique case of disfigurement


1 Department of Prosthodontics, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India
2 Department of Prosthodontics, SRM Dental College, Chennai, Tamil Nadu, India

Date of Submission13-Apr-2021
Date of Acceptance03-Jul-2021
Date of Web Publication17-Jan-2022

Correspondence Address:
Dr. Chithambaradhas Sivakala Arunkumar
Assistant Professor, Department of Prosthodontics, Meeankshi Ammal Dental College, Chennai 600095, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_17_21

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   Abstract 


Rehabilitation of facial disfigurement after a surgery or trauma is difficult to address as it involves individuality of the patient. Face being the visual pro forma, rehabilitating it is always a challenging task. This is predominantly due to the presence of soft tissue, lack of anatomic undercut, and increased muscle activity. The use of osseointegrated implants provides the most reliable retention, however, placing it on an intact facial defect further complicates rehabilitation. This case report is about rehabilitation of lost facial feature after tumor resection surgery.

Keywords: Facial defect, facial disfiguration, facial prosthesis, silicone prosthesis


How to cite this article:
Arunkumar CS, Jei J B, Krishnan M, Muthukumar B. Rehabilitation of facial defect on a unique case of disfigurement. J Int Clin Dent Res Organ 2021;13:144-7

How to cite this URL:
Arunkumar CS, Jei J B, Krishnan M, Muthukumar B. Rehabilitation of facial defect on a unique case of disfigurement. J Int Clin Dent Res Organ [serial online] 2021 [cited 2022 May 28];13:144-7. Available from: https://www.jicdro.org/text.asp?2021/13/2/144/335869




   Introduction Top


Face is not only an organ of identity but also the individual's belief about himself or herself.[1] It represents the index of emotions oneself perceives. Hence, any facial disfigurement causes a profound psychosocial implication affecting the quality of life of the individual. Most facial disfigurements (disfigurements) are either congenital or acquired, of which disfigurement after a trauma or surgery is the most debilitating as it leads to cocooning of any active individual in the society.[2] Hence, rehabilitation of the patient must be done not only to improve the facial esthetics but also to build the active confidence in the individual. This case report describes a simple, effective, and noninvasive method of rehabilitation of a facial defect.


   Case Report Top


A 56-year-old female patient reported to the Department of Prosthodontics in SRM Dental College with a chief complaint of unesthetic facial appearance [Figure 1]. The patient gave a history of surgery done 6 months back to remove a tumorous grown on her cheek. On extraoral examination, the skin was taut with normal perspiration. However, there was ipsilateral loss of facial expression on the right side. Facial EMG activation was performed where loss of muscle tone in zygomaticus major, zygomaticus minor, and risorius was evident. The labial commissure on the right side was raised during smile indicating the loss of facial expression [Figure 2]. There was no evidence of pain on palpation. On intraoral examination, there was segmental resection of the maxilla (Brown's Class I) with loss of buccal frenal attachment and no signs of inflammation or infection. The buccal mucosa had a thick fibrous band of scar tissue and so the option of a cheek plumber was ruled out. The patient had no history of previous facial prosthesis. Hence, a treatment of conventional silicone exoprosthesis was proposed to mask the facial defect.
Figure 1: preoperative photograph

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Figure 2: preoperative photograph during smilez

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   Method of Fabrication Top


Impression making

The patient was prepared for impression of facial moulage. The facial margins were boxed using modeling wax, and petroleum jelly was applied to the face. The nostrils were blocked using cotton plugs, and plastic straw was used to maintain the airway. The impression of the face was made using irreversible hydrocolloid (Zelgan plus, Dentsply, USA), and models were poured using dental stone (Gemstone, India) [Figure 3].
Figure 3: facial moulage

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Wax pattern fabrication

Wax pattern was fabricated on a tin foil base using modeling wax (GC Asia Dental Pte Ltd, Singapore) on the stone mold [Figure 4], and the trial was done for the patient. A separate impression of the defect site was made using heavy body elastomer (Virtual, Dentsply Pvt Ltd, Germany) and picked up with light body elastomeric impression material (Reprosil, Dentsply Pvt Ltd, Germany), and a master cast was obtained in die stone [Figure 5] (Ultrarock, Kalabhai, India). With the dimensions of the opposing side as a reference, the wax pattern was checked for adaptation on the die stone master cast and tried on the patient [Figure 6]. After trial, the wax pattern was placed in a refrigerator to prevent wax distortion.
Figure 4: primary cast in die stone

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Figure 5: master cast

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Figure 6: wax trial

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Mold preparation

Grooves were made on the master cast for orientation. For preparation of a two-part mold, separating media (DPI Cold Mould Seal, DPI India) was applied on the master cast which is the first counter. The first counter is then boxed with modeling wax (Hindustan Modelling Wax, The Hindustan Dental Products, India), and dental stone was poured into the prepared first counter. After the final set of the two-part mold, dewaxing was done [Figure 7]. Following dewaxing, the mold was coated with a layer of silicone releasing spray (Miracle Aerosol Industries, India) before silicone packing.
Figure 7: two-part molds

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Silicone exoprosthesis

The manipulation of silicone (Technovent, MaxFacIndia, India) was carried out on a neutral white tile. Gradual addition of intrinsic stains was performed for an evenly stained silicone mass. Once the desired shade was achieved, silicone was packed in increments on the counters. Incremental addition of silicone was carried out to eliminate the entrapment of air bubbles. Then, the counters were reoriented and clamped for overnight curing. Following the overnight curing, the prosthesis was removed from the counter [Figure 8], and finishing and polishing were done using silicone trimmers. The prosthesis was tried on the patient, and final extrinsic shade matching was performed [Figure 9]. Retention for silicone exoprosthesis was obtained by using water-based silicone adhesives (Probond Adhesive, Technovent, MaxFacIndia, India). The patient was reviewed after 1 week. The patient had no signs of irritation, inflammation, or infection.
Figure 8: silicone exoprosthesis

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Figure 9: postoperative photograph

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   Discussion Top


The word “self” is the ability to appreciate oneself from others. Self concept is the perception of the individual about themselves. It is necessary to have self-belief and confidence in oneself to survive in the society.[3] Although appreciation of self in terms of esthetics or face value is a faded memory, it adds to abled social function. Hence, any disfigurement in the face not only produced a physical disability but also deranges the psychological makeup. The individual thus turns incognito to society. Convincing the individual to accept and accustom to the facial backlash is injustice. And also nurturing the individual back with able confidence becomes a task.[4] Hence, reconstruction or rehabilitation of any facial defect must be done in time to maintain the psychological balance.

Although reconstruction is fairly effective in management of disfigurement, management of both functional and esthetic deficits is arduous to address. Hence, rehabilitation is better off. The present case report is a rehabilitation of a facial defect after excision of intraoral malignancy maxillofacial silicones with water-based adhesive retention. The reason for the use of adhesive retention was the absence of muscle activity in the area of defect. Most of the muscles of the cheek with exception to the buccinator and masseter participate in facial expression. This serves as an advantage, as in the present case, there was loss of activity on the zygomaticus major, zygomaticus minor, and risorius which voids the chances of muscle movement in the cheek.

Over the years, the approach of retention for silicone facial prosthesis from pressure-sensitive adhesives has emerged to have an edge in the retention of maxillofacial silicones. Hatamlesh et al. studied the use of adhesives on 1193 maxillofacial prosthesis patients and found, adhesives retained 48% of orbital prosthetics and 45% of nasal prosthetics in the UK. However, the prognosis thereof was influenced by chemical constituent of the adhesive. Between water-based and resin-based adhesives, Sánchez et al. found that water-based adhesives were most effective for patients with severe facial damage as the degree of skin irritation was comparatively lesser.[5] Nevertheless, with respect to patient satisfaction and quality of life, adhesive retention of facial prosthesis has a negative impact, due to difficulties of removal.[6] Yet, the demanding cost of maxillofacial implants makes adhesive retention viable under suited scenarios.


   Conclusion Top


Silicone facial prosthesis is advantageous in terms of lightweight, inexpensive, noninvasive, biocompatible, and esthetic nature. Hence, a simple adhesive retained silicone exoprosthesis in such unique scenarios would successfully serve the purpose without aggressive side effects which will be enthusiastically accepted by the patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Baumeister RF, Smart L, Boden JM. Relation of threatened egotism to violence and aggression: The dark side of high self-esteem. Psychol Rev 1996;103:5-33.  Back to cited text no. 1
    
2.
Costa EF, Nogueira TE, de Souza Lima NC, Mendonça EF, Leles CR. A qualitative study of the dimensions of patients' perceptions of facial disfigurement after head and neck cancer surgery. Spec Care Dentist 2014;34:114-21.  Back to cited text no. 2
    
3.
Zahavi D, Roepstorff A. Faces and ascriptions: Mapping measures of the self. Conscious Cogn 2011;20:141-8.  Back to cited text no. 3
    
4.
Zebrowitz LA, Montepare JM. Social psychological face perception: Why appearance matters. Soc Personal Psychol Compass 2008;2:1497.  Back to cited text no. 4
    
5.
Sánchez-García JA, Ortega A, Barceló-Santana FH, Palacios-Alquisira J. Preparation of an adhesive in emulsion for maxillofacial prosthetic. Int J Mol Sci 2010;11:3906-21.  Back to cited text no. 5
    
6.
Goiato MC, Ribeiro Pdo P, Pellizzer EP, Garcia Júnior IR, Pesqueira AA, Haddad MF. Photoelastic analysis of stress distribution in different retention systems for facial prosthesis. J Craniofac Surg 2009;20:757-61.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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