CLINICAL REPORT

Orofacial rehabilitation with zygomatic implants: CAD-CAM bar

and magnets for patients with nasal cancer after rhinectomy
and partial maxillectomy
Elizabeth King, BDS(Hons), MSc,a Carl Abbott, BSc(Hons)(Eng),b Lawrence Dovgalski, BSc(Hons),c and
James Owens, BDS, MScd

Malignancy of the nasal ABSTRACT

septum or vestibule is rare
Nasal carcinoma extending into the premaxilla requires radical surgical excision including rhine-
affecting 0.3 per 100 000 of the ctomy and partial maxillectomy. Rehabilitation is complex and involves the use of removable
1
population. The risk factors prostheses. Three patients treated with zygomatic implants and custom-milled bars to retain an
are poorly understood, but a obturator and nasal prosthesis are presented. (J Prosthet Dent 2016;-:---)
high number of patients are
smokers.2 The most common signs and symptoms after radiotherapy, and the esthetic outcome is unpre-
include nasal obstruction, epistaxis, and nasal masses.2 dictable and often poorer than a nasal prosthesis.3,6 For
Squamous cell carcinoma (SCC) is the most common nasal rehabilitation, a nasal prosthesis is often better
histologic type, followed by adenocarcinoma.2 Malig- than reconstruction as it allows easier postoperative
nancies can invade the nasal fossa, premaxilla, upper lip, monitoring and a more predictable esthetic outcome.7
3
or nasal crest. If metastasis occurs, the lung is the most Nasal prostheses are most commonly made of silicone
common site followed by the brain, bone, and skin.3 and traditionally rely on tissue undercuts and adhesive
Treatment depends on the extent of disease and for retention. More recently, zygomatic implants have
includes surgical excision and radiotherapy. Surgery is been shown to provide successful and predictable
often the modality of choice, and if bone is involved, retention of nasal prostheses.8,9 Obturators that restore
2,4
rhinectomy is indicated. Overall 5-year survival rates the maxilla and associated dentition are frequently used
are approximately 58%,3 with a high recurrence rate of for the rehabilitation of maxillary defects and also benet
43% occurring after a mean of 9.4 months.5 from osseointegrated implants for improved retention.10
Because of the nature of surgical treatment, patients Anecdotally, patients who require restoration of orofacial
with nasal malignancy can be left with substantial defects by using both obturators and nasal prostheses
orofacial defects. In rare situations, nasal malignancies experience problems with loss of retention of the
locally invade the maxilla, and thus treatment nasal prosthesis because of movement of the obturator
involves partial maxillectomy along with rhinectomy. during function when adequate retention is not
Rehabilitation includes ap reconstruction or the provided. This clinical report describes the prosthetic
provision of a maxillofacial (nasal or oral) prosthesis. rehabilitation of 3 patients who underwent rhinectomy
Surgical reconstruction of small defects and even com- and partial maxillectomy for the treatment of nasal
plete reconstruction of the nose are possibilities. malignancy, using zygomatic implant-supported nasal
However, surgical morbidity is increased, particularly and oral prostheses.

a
Specialty Registrar, Restorative Dentistry, Moriston Hospital Restorative Department, Swansea, Wales.
b
Lead Restorative Technologist, Moriston Hospital Restorative Department, Swansea, Wales.
c
Maxillofacial Prosthesist, Moriston Hospital Restorative Department, Swansea, Wales.
d
Consultant in Restorative Dentistry, Moriston Hospital Restorative Department, Swansea, Wales.

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Figure 1. Surgical stent in situ to guide placement of zygomatic implants
after rhinectomy and partial maxillectomy (blue arrows indicate
approximate position of planned zygomatic implant position) (Patient 1).
CLINICAL REPORTS
Patient 1
A 69-year-old man received a diagnosis of SCC of the
nasal vestibule and oor of the nasal cavity in September
2013. His medical history included well-controlled
hypertension. He had a smoking history of 5 cigarettes
per day for 30 years and an alcohol intake of 28 to 35 units
per week. He underwent rhinectomy, partial max-
illectomy, and bilateral neck dissection. The upper lip skin
and muscle was preserved. Bilateral zygomatic implants
were placed at the time of surgery to provide magnetic
retention of a complete nasal prosthesis, and a surgical
obturator was provided. Histopathology revealed a
completely excised, poorly differentiated SCC. Along with
surgery, he received radiotherapy, 60 Gy in 30 fractions.
Patient 2
In June 2013, SCC of the nasal septum was diagnosed in
a 70-year-old woman. The cancer extended to the
anterior maxilla. Her medical history included depres-
sion, chronic fatigue syndrome, and hyperlipidemia. Her
social history included smoking 30 cigarettes per day for
30 years and an alcohol intake of 10 units per week. She
underwent rhinectomy, partial maxillectomy, and bilat-
eral neck dissection with preservation of the muscle and
skin of the upper lip. Bilateral zygomatic implants were
placed at the time of surgery to provide magnetic
retention of a complete nasal prosthesis, and a surgical
obturator was provided. Histopathology showed com-
plete excision of poorly differentiated SCC. She received
postoperative radiotherapy of 60 Gy in 30 fractions.
Patient 3
Squamous cell carcinoma of the nasal septum was
diagnosed in a 76-year-old woman in September 2012.
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Her social history included smoking 10 cigarettes a day
for 20 years and alcohol consumption of 7 units per week.
She initially underwent partial rhinectomy, followed by
radiotherapy of 60 Gy in 30 fractions. Histopathology
revealed residual SCC, and more radical surgery,
including rhinectomy, partial anterior maxillectomy, and
selective neck dissection was undertaken. During the
second surgical procedure, bilateral zygomatic implants
were placed for the magnetic retention of a complete
nasal prosthesis, and a surgical obturator was provided.
Planning of obturator and nasal prosthesis retention
For each patient, zygomatic implants were planned pre-
operatively to provide retention for a nasal prosthesis.
Computed tomography scan data were used to plan the
zygomatic implant position, and a surgical stent was
made to use at the time of surgery to guide the zygomatic
implant placement (Fig. 1). To simplify the orofacial
rehabilitation process, it was decided that the zygomatic
implants would also be used to retain the obturator
prosthesis. Zygomatic implants emerging into the nasal
defect were planned, as emergence into the oral cavity
would limit their use for the obturator prosthesis only.
Although placement of 4 zygomatic implants with both
oral and nasal emergence would have been possible, this
would have signicantly increased surgical complexity
and the risk of implant perforation. Alternative options
included dental implant placement; however, placement
in the anterior maxilla would require a composite free
ap (bone and soft tissue), and placement in the poste-
rior maxilla would require bilateral sinus lifts. Both of the
surgical procedures would have signicantly increased
the surgical complexity, introduced further morbidity,
and in the case of the free ap, introduced the need for a
donor site. Therefore, use of the zygomatic implants for
both the nasal prosthesis and obturator signicantly
simplied the rehabilitation process and reduced poten-
tial surgical complications.
Denitive obturator construction
In each situation, a denitive obturator was fabricated by
a consultant in restorative dentistry and a dental labo-
ratory technician. Maxillary and mandibular irreversible
hydrocolloid impressions (Jeltrate; Dentsply Intl) were
made in stock impression trays and poured with Type IV
dental stone (Galaxy; Platres & Mineraux), and a maxil-
lary custom-made impression tray was fabricated with
light-polymerizing acrylic resin (Magilight; Schottlander).
Maxillary impressions were then made with medium-
bodied polyvinyl siloxane (Aquasil Ultra; Dentsply Intl)
and poured in Type IV stone. The stone casts were
duplicated with silicone (Z-Dupe; Henry Schein), and
heat-polymerized acrylic resin baseplates covering the
edentulous areas and obturating the maxillary defect
were fabricated along with wax occlusion rims to record
King et al
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Figure 2. Magnet polymerized into position in obturator (Patient 1).

Figure 3. Silicone impression of zygomatic implants and nasal defect
with obturator in situ (Patient 1).
centric relation. The denitive tooth arrangement was
developed on the baseplates and evaluated chairside, and
the obturator was processed with acrylic resin (PalaX-
press Ultra; Heraeus Kulzer Inc). After the computer-
aided design and computer-aided manufacturing
(CAD-CAM) bar was evaluated for t, an impression of
the magnet in situ on the bar was made in the denitive
obturator with medium-bodied polyvinyl siloxane
(Occlufast Rock; Zhermack SpA). The magnet was then
secured with autopolymerizing acrylic resin (Meadway
Rapid Repair; MR. Dental) (Fig. 2).

CAD-CAM bar construction

After the denitive obturator was tted, computed to-
mography data were evaluated to establish the osseoin-
tegrated hard tissue support provided by the zygomatic
implants, and it was determined that the implants could
be used to retain a CAD-CAM bar which would simul-
taneously retain both maxillofacial prostheses.
For Patient 1, a polyvinyl siloxane impression
(Aquasil Ultra; Dentsply Intl, Occlufast; Zhermack) of the
implants and nasal defect was made with the denitive
obturator in situ (Fig. 3). Type IV dental stone with 2
xture replicas (Multi-unit Abutment Plus Replica; Nobel Figure 4. Resin bar verication of zygomatic implants (Patient 1).
Biocare) was used to produce a denitive cast. Two
nonengaging interim abutments (Abutment Replica (3D Shape). The anatomy was assessed, and a crucix-
Multi-Unit Brnemark System; Nobel Biocare) splinted shaped bar was designed to allow the horizontal
with acrylic resin (GC Pattern Resin LS, GC America) splinting of the implants, incorporation of 2 magnets
were used to verify the accuracy of the impression and to (Brnemark Mini Magnabutment; Technovent Ltd) for
ensure that the bar could be removed passively, nasal prosthesis retention and incorporation of an
considering the divergence of the implants (Fig. 4). The attachment on the inferior aspect to retain a magnet
working cast was scanned (D800 Desktop Scanner; (Brnemark Maxi Magnabutment; Technovent Ltd) for
3Shape), and data were imported into CAD software obturator retention (Fig. 5). An acrylic resin prototype of

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Figure 5. CAD design of crucix-shaped bar (Patient 1).
Figure 7. Example of T-shaped bar and obturator in situ (Patient 2).
the bar was fabricated. The bar was scanned and
imported into the CAD software and sent to a milling
company (Core 3D). The original design could not be
fabricated as the milling unit would not accommodate
the bar shape. This was overcome by redesigning the bar
as 2 separate components, the crucix-shaped bar and
the magnet attachment. At the time, only cobalt-
chromium (Co-Cr) ingots were available; therefore,
components were milled in Co-Cr and laser welded
together. Two magnets were screwed into the bar, and 1
magnet was bonded into the cup-shaped attachment
with dual-polymerizing composite resin (GC Gradia
Composite; Terec Ltd). Figure 6 shows the crucix-
shaped bar and obturator in situ.
Patients 2 and 3 were treated in the same way patient
1 was; however, because of differences in anatomy, a
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Figure 6. Crucix-shaped bar in situ (Patient 1).
Figure 8. Clinical outcome of obturator and nasal prosthesis retained by
crucix-shaped bar (Patient 1).
T-shaped bar (Fig. 7) was used instead of the crucix-
shaped bar. Second, the milling company (Core 3D)
had meanwhile obtained titanium milling ingots, and the
bar components were milled in titanium.
Nasal prosthesis fabrication
Immediately after surgery, each patient was tted
with a nasal prosthesis attached to glasses. After soft
tissue healing, a maxillofacial prosthetist fabricated a
King et al
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magnetically retained nasal prosthesis. In addition, a
polymerized silicone impression with the bar and magnets
in situ was made. Magnet analog xtures were located on
top of the impression magnets, and the impression was
poured in gypsum (Crystacal R Plaster; SWIP Dental). A
baseplate was fabricated with magnets and light-
polymerized resin (Triad Gel; Dentsply Intl) and evalu-
ated to verify the accuracy of the cast. A wax prototype was
fabricated from a preoperative computed tomography
scan in CAD software (Freeform; Geomagics) to dene the
shape. A postoperative 3D surface scan (5-pod; 3DMD)
was made, and the preoperative nose was adjusted to form
a virtual nasal prosthesis. This was fabricated in stereo-
lithography resin (PDR) and duplicated in wax (Anutex;
Kemdent). Finally, the wax prototype was incorporated
into the baseplate, and denitive carving was conducted at
the clinical evaluation appointment. A gypsum cast of the
wax prototype was produced and the wax was eliminated.
The plaster cast was lled with silicone elastomer (Cos-
mesil HC2; Cosmesil), color matched, and polymerized.
Figure 8 shows the denitive nasal prosthesis and obtu-
rator in situ.
DISCUSSION
Rehabilitation of patients after rhinectomy and partial
maxillectomy requires a multidisciplinary team which
includes maxillofacial surgeons, consultants in restorative
dentistry, maxillofacial prosthetists, and appropriately
trained dental laboratory technicians. Reconstructions
should aim to improve esthetics and function in the
immediate and long term, as well as allow examination of
the tissues to monitor recurrence. The benets of the
maxillofacial prostheses described in this article include
active retention of the obturator and nasal prosthesis
with magnetic retention; improved ability to re-establish
functions such as speech, mastication, and swallowing;
improved ability to recover social life as soon as possible
after surgery; ability to remove both prostheses to allow
examination of tissues; ease of insertion and removal of
prostheses by the patient; provision of upper lip support
from the obturator, and avoidance of further invasive
surgical procedures (such as dental implant placement,
bone grafting) for obturator retention. Use of zygomatic
implants for the concurrent retention of obturator and
nasal prostheses signicantly simplies orofacial reha-
bilitation and removes the need of further invasive sur-
gical procedures.
King et al
5
However, maxillofacial prostheses are not without
caveats, and the potential complications of the prosthe-
ses described in this article include risk of zygomatic
implant infection, irritation of supporting tissues, lifelong
prosthesis maintenance, and signicant patient cooper-
ation for successful acclimatization. Specic difculties
described by the patients include degradation of nasal
prosthesis, food leakage, dropping of posterior borders of
the obturator, and generalized discomfort. A specic
problem occurred for Patient 2; the titanium bar fractured
at the welding spot soon after placement. Titanium is
more difcult to weld than Co-Cr because of the need for
a pure argon environment. The weld was repeated with
no further problems. All 3 bars, obturators, and nasal
prostheses t well and were clinically stable and reten-
tive. As of the present writing, 2 patients are functioning
well with their prostheses, but 1 patient struggled psy-
chologically with the appearance of the bar, so it was not
tted. Instead she has a magnetically retained nasal
prosthesis with an obturator retained with soft tissue
undercuts.
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Corresponding author:
Dr Elizabeth King
Morriston Hospital Restorative Dentistry Department
Heol Maes Eglwys
Morriston, Swansea
WALES
Email: elizabeth.king@hotmail.com
Acknowledgments
The authors thank Peter Llewelyn Evans for providing Figure 1.
Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
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