Intra- and Extraoral Prostheses Retained by Zygoma Implants

Following Resection of the Upper Lip and Nose

Letcia Machado Goncalves, DDS, MS, PhD,1 Thais Marques Simek Vega Goncalves, DDS, MS, PhD,2

Rodrigues, DDS, MS,3 Marcos Dias Lanza, DDS, MS, PhD,3

Antonio
Henrique Correa
Paulo Roberto Gomes do Nascimento, DDS, MS,3 & Francisco Mauro da Silva Girundi, DDS, MS2
1

Lus, Maranhao,
Brazil
Graduate and Post Graduate Program in Dentistry, Ceuma UniversityUniCEUMA, Sao
Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of CampinasUNICAMP, Piracicaba, Sao Paulo, Brazil
3
Department of Prosthodontics, The Pontifical Catholic University of Minas GeraisPUCMG, Belo Horizonte, Minas Gerais, Brazil
2

Keywords
Upper lip carcinoma; maxillofacial prosthesis;
zygoma implants; oral rehabilitation.
Correspondence
Letcia Machado Goncalves, Post Graduate
Program in Dentistry, Ceuma
UniversityUniCEUMA, Rua Josue Montello,
Lus,
01, Renascenca II, 65075-120, Sao
Brazil. E-mail: lets.mg@gmail.com
Maranhao,
The authors declare no conflict of interest.
Accepted December 13, 2013
doi: 10.1111/jopr.12178

Abstract
Upper lip cancers are infrequent lesions, being aggressive unless diagnosed and treated
early. After the surgical resection, maxillofacial defects require special care in rehabilitation. This article describes the maxillofacial rehabilitation of an edentulous patient
diagnosed with upper lip squamous cell carcinoma. The treatment consisted of a large
amount of upper lip and nose tissue resection, followed by chemoradiotherapy. After
the first surgical healing, zygoma implants were inserted in a two-step procedure.
The maxillary and nasal prostheses were installed and fixed by a titanium framework.
After 6 years follow-up, no recurrences were observed, and the patient did not develop
metastases. Tissues around implants were in good health, and the prostheses remained
well-fitted. The use of implant-retained prostheses improved the quality of life, and the
patient was extremely satisfied with the final result. The implant-retained prostheses
are well accepted by the patient, improving comfort and safety during function while
recovering her esthetic apperance.

Lip cancer is the most prevalent tumor of the oral cavity.1 Malignances of the upper lip are usually common compared to those
found in the lower lip due to the anatomical protection from
solar radiation,2,3 which is accepted as a main cause of this type
of tumor.4 Most upper lip cancers are squamous cell carcinomas (SCCs), which are extremely aggressive unless diagnosed
and treated early.5 For treatment purposes, surgical removal of
the entire lip and adjacent tissues is the gold standard, which
can be associated with radiotherapy and chemotherapy.6 After
treatment, however, maxillofacial defects may have a profound
impact on the patients quality of life, resulting in loss of function and esthetic problems which could impair social life.7-9
Hence, early management and maxillofacial rehabilitation procedures are required.
Rehabilitation procedures can be accomplished either by surgical and/or prosthetic procedures.10,11 Moreover, surgical reconstruction has been considered a safe and successful procedure; nevertheless, it is limited in large defects that include bony
and cartilaginous structures.12 In such cases, prosthetic maxillofacial rehabilitation has been advocated as a predictable of
treatment option.13-15 Unfortunately, the retention and stability of these prostheses remain patients primary complaint.7,16
Therefore, with the advent of osseointegration, the use of dental
implants has been shown to be a more indicated form of reten172

tion for prostheses.17,18 This type of prosthesis enhances both

retention and stability, improving the patients comfort during
function while increasing the esthetic appearance, confidence,
and sense of security.7,16,19-22 Thereby, in cases where extensive bone and soft tissues have been lost, the use of zygoma
implants could also be a good option.15
In this report, we describe the treatment of an edentulous
patient diagnosed with upper lip SCC who underwent extensive maxillary and nose resection, followed by maxillofacial
rehabilitation with zygoma implant-retained prostheses.

Clinical report
A 60-year-old woman presented with a nodular mass in the
upper lip. The painless nodule was over 0.5 cm in diameter
with little swelling. Her medical history was unremarkable.
The lesion was resected under local anesthesia, and the first
histopathologic diagnosis was a keratoacanthoma; however,
2 months after the primary operation, the nodular mass reappeared involving the upper lip and nose areas (Figs 1A and B).
Due to this aggressive characteristic, a review of the histological analysis was requested. The new evaluation confirmed to
be a well-differentiated SCC with tumor node and metastasis
(TNM) stage established at T4 N0 M0 .

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Rehabilitation Following Resection of the Upper Lip and Nose

Figure 1 (A) Preoperative frontal and (B) lateral view of the patient presenting a nodular mass involving both upper lip and nasal region. (C) Dimensions
of tumor removed. (D) Postoperative view after upper lip and nasal excision.

After routine preoperative examination, the tumor was surgically excised from the upper lip and nose region (Figs 1C
and D) followed by concurrent chemoradiotherapy (radiation
dose 60 Gy). This therapy resulted in a complete remission of
the tumor. After that, total upper lip reconstruction was realized with a skin flap, and a provisional silicone nasal prosthesis
was fabricated and stabilized with proper adhesive (Pros-Aid;
ADM Tronics Unlimited Inc., Northvale, NJ). Meanwhile, the
patient did not adapt to the nasal prosthesis due to the lack of
retention of the adjacent structures to the prosthesis fixation.
Notwithstanding this suboptimal approach, it was presumed
that the patient would greatly benefit from an implant-retained
maxillofacial prosthetic rehabilitation. Thus, 6 months later, a
combined implant surgery and prosthetic treatment plan was
made to improve esthetics and restore the normal masticatory
functions.
Considering bone loss, the initial rehabilitation plan consisted of placing four zygoma implants (Neodent Zygomatic
External Hex; Curitiba, Brazil, 40 mm) 6 months after the conclusion of chemoradiotherapy; however, due to postoperative
complications, the right maxillary sinus was exposed to the
oral environment. In this region, a zygomatic implant did not
osseointegrate and had to be removed. After 6 months of osseointegration, the three zygomatic implants were uncovered
and demonstrated no mobility or clinical signs of infection, although they have demonstrated a large amount of bone loss,

exposing the implants threads. Due to financial and physical limitations for new surgical procedures, the initial plan
was maintained even in the presence of only three implants
(Fig 2A).
For prosthodontic procedures, a preliminary stone cast of the
maxillary region was required; however, because of minimal
elasticity of the upper lip after surgical reconstruction, it was
not possible to insert a stock tray to create a preliminary impression. Thus, silicone impression material (Zetaplus; Zhermack,
Badia Polesine, Italy) was prepared to a doughy consistency
and adapted by hand directly to the patients mouth, obtaining a negative copy of the jaw as well as the inner part of the
nose. The material demonstrated acceptable elastic recovery to
allow the copy of both the maxilla and nasal extension at the
same time, creating a preliminary stone cast allowing the assembling of an acrylic resin and customized open tray. Then the
open tray was inserted, and the implant position was recorded
using silicone impression material (Express XT; 3M ESPE,
Seefeld, Germany). After removal of the open tray, the implant
analogs were connected to the impression, and the final cast
was poured with Type IV stone (Durone; Dentsply Ind Com,
Rio de Janeiro, Brazil). In this way, the implant location and
the denture-bearing area were reproduced (Fig 2B).
Thereafter, conventional prosthodontic procedures were followed for the fabrication of the implant-retained maxillary prosthesis. In this occasion, a conventional mandibular prosthesis

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Rehabilitation Following Resection of the Upper Lip and Nose

Goncalves et al

Figure 2 (A) View of maxillary alveolar ridge after zygomatic implant placement. Arrow indicates the position of a partially submerged implant.
(B) Stone cast obtained with zygomatic implant analog captured. (C and D) Design planned for the titanium framework.

was also fabricated. For this, acrylic resin record bases with
wax occlusion rims were fabricated and used to determine the
occlusal vertical dimension (OVD) and to record the maxillomandibular relationship. The wax rim position was stabilized
with silicone paste (Express XT) and transferred to an articulator. Acrylic artificial teeth (SR Vivodent PE; Ivoclar Vivadent,
Schaan, Liechtenstein) were selected and arranged on the record
bases for a trial arrangement. The esthetics, phonetics, and OVD
were verified, and the final arrangement were approved by the
patient.
After determining the final arrangement of the maxillary
prosthesis, a titanium framework using Locator attachments
(Zest Anchors, Inc., Escondido, CA) was planned. The trial
maxillary prosthesis was recorded with silicone impression
material (Zetaplus) to serve as an index guide to fabricate the
framework. We idealized a design that allowed the connection
of both maxillary and nasal prostheses. The framework pattern
was waxed and melted with titanium alloy (Figs 2C and D) in
the final stone cast. The patrices of Locator attachments were
fixed in the framework by laser welding, whereas the Locator matrices were captured in an acrylic substructure that was
subsequently covered by silicone to restore the esthetic natural
appearance. Framework adaptation and the interocclusal space
were checked intraorally. Next, both maxillary and mandibular
dental prostheses were processed and finished.
For the nasal prosthesis, a final impression of the whole face
was made. The patient was draped, and petroleum jelly was applied to her eyebrows and eyelashes. Moist gauze was packed
174

to prevent the flow of material into undesired areas. An impression of the defect and adjacent tissues was taken by hand using putty-consistency silicone impression material (Zetaplus).
A final stone cast was poured with Type IV stone (Durone)
and used to sculpt the nose in wax. Taking into account the
patients general appearance and previous photographs, the esthetic contours were developed. The wax pattern adaptation on
the patients face was checked, especially in the border area.
After trial placement and approval by the patient, the nasal
prosthesis was fabricated over the acrylic resin base, previously
attached to the framework by the Locator device. The use of silicone elastomer (Multisil; Bredent GmbH & Co. KG, Senden,
Germany) improves the natural appearance of the nasal prosthesis.
With both intra- and extraoral prostheses processed (Fig 3A),
the titanium framework was fitted in the maxilla (Figs 3B and
C), allowing the fixation of the maxillary and nasal prostheses
simultaneously by the union of the patrices and matrices of
the Locator attachment. Adjustments were made for pressure
areas and occlusion, and both prostheses were delivered to the
patient (Fig 3D). Instructions about the insertion and removal
of both prostheses and hygiene methods were given. The patient was also regularly called every 6 months for follow-up.
In each evaluation, no mobility or clinical signs of infection
were detected in the implants. Strict hygiene control was also
reinforced.
After 6 years follow-up, no lesion recurrences were noticed,
and the patient did not develop metastases. Tissues around

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Rehabilitation Following Resection of the Upper Lip and Nose

Figure 3 (A) Titanium framework, attachments, maxillary and mandibular prostheses, and nasal prosthesis processed and finished. (B) Placement of
the titanium framework with the Locator attachments on the zygoma implants. (C) Locator attachments placed for the nasal prosthesis retention. (D)
Posttreatment frontal view of patient with the prostheses in place. Note acceptable esthetics.

implants demonstrated good health, and the prostheses remained well-fitted. In addition, the patient was extremely satisfied with the final result.

Discussion
Maxillofacial rehabilitation has many challenges; particularly
in patients who suffer from facial defects after surgical tumor resection. In these cases, normal function and esthetics
are very complex to achieve simultaneously. Nevertheless, advances in dental technology have made prosthetic rehabilitation more reliable, especially if the prosthesis is retained by
osseointegrated implants. Accordingly, our report shows the
integration of surgery reconstruction procedures and implant
and prosthodontics principles during the rehabilitation of an
edentulous patient who had undergone upper lip and nose resection.
The patient was diagnosed with advanced SCC of the upper
lip, requiring surgical removal of a large amount of the upper lip
and nose followed by chemoradiotherapy. This therapy showed
satisfactory results, with no recurrences or metastases during
the 6-year follow-up period. Although several investigations
have shown high survival rates up to 5 years,1,3-5 they did not
emphasize the high morbidity caused by the esthetic sequelae.
Actually, the presence of extended facial defects results in functional limitations, both in terms of nutrition and speaking, as
well as social problems reducing the patients self-esteem.7,8

Maxillofacial prostheses improve esthetic appearance with

minimal invasion, and treatment can be initiated almost immediately after primary healing of the surgical site.7,15-19,23
In addition, the prosthesis allows easy access to the area
and the consequent monitoring for any tumor recurrence,
which has been reported to be a common complication of
upper lip carcinoma.23 In addition, patient education is perhaps the first and most important step, because it is crucial
for patients to be familiar with the functional and cosmetic
limitations of the prosthesis.13 The maxillofacial prostheses
should also provide a suitable management of the airway while
improving the patients masticatory function, comfort, and
confidence.7
Concerning implant treatment, the retention of a nasal prosthesis is usually obtained with implants in the glabella and
nasal floor.16,24 However, the glabella is a dense bone with poor
blood supply and little marrow space, which might be related
to the high failure rates of implants in this region, particularly
for irradiated patients.16 Thus, in the case reported, zygoma
implants were chosen because of the resection of the anterior
nasal floor and the large amount of bone loss in the intraoral
sites. In addition, the implant placement should be done before
radiotherapy in patients with oral SCC, considering the risk of
osteoradionecrosis.25 However, in the case described, the patient was extremely unsatisfied with the retention of the nasal
prosthesis. Thus, the implants were placed 6 months after the
conclusion of radiotherapy. In fact, the installation of implants

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Rehabilitation Following Resection of the Upper Lip and Nose

in irradiated bone can damage the osseointegration process, decreasing bone healing capacity.13,26 This healing characteristic
could explain the loss of one implant and the thread exposure of
the other three implants, increasing the risk of infection; however, good hygiene in addition to strict professional attendance
allowed the success of the treatment up to 6 years. As the osseointegrated implants increase the retention of maxillofacial
rehabilitation,26-28 it should be an acceptable option even for
patients after radiotherapy.
Regarding the prosthetic treatment plan, implant positions
and directions are usually determined before considering the final prosthetic design.15 However, in the presented case, the
maxillofacial defect was wide, rendering the implant area
markedly restricted, and making a prosthetic plan more difficult. Thus, implant placement and, thereafter, the prosthetic
treatment, had to be selected by considering the initial surgical conditions. For the implant-retained prostheses, a titanium
framework was fabricated, which included the maxillary and
nasal prostheses (acrylic resin base and silicone coverage) simultaneously retained by Locator attachments. The titanium
framework fulfilled the objectives of strength, support, nontissue impingement, and noninterference with the desired contour
of the prostheses.16
Different retention systems are available for implant-retained
intra- and/or extraoral prostheses, and the cost-effectiveness
and the simplicity of treatment become the main issues for
the choice.29 Systems can use splinting or nonsplinting attachments. Splinting implants by means of a bar-clip construction
is more expensive and time-consuming, involves more complications, and offers no marked differences in patient satisfaction
when compared with nonsplinting attachments.30 Therefore,
magnetic attachments, which allow several types of movements, are extensively used.31 However, this type of attachments allows the prosthesis rotational movements in one or
more directions, besides presenting low resistance to lateral
forces.32 On the other hand, Locator systems are resilient attachments with suitable retention, and high durability, and allow
some built-in angulation compensation.33 Also, these systems
may be better choices from a financial point of view due to
the initial low cost of the components and the reduced number of the parts replacement.31 Considering its mechanical
qualities and financial advantages, the Locator system was an
optimal option for the described case. With the prostheses in
position and functioning, no mobility was observed. Therefore,
such attachments also adequately served to retain the nasal
prosthesis.
The use of implants improves patient quality of life by providing retention and stability of the prostheses, natural esthetics, and comfort.15-18,34 After 6 years of follow-up, the patient
reported improved social life and quality of life with more personal confidence because her defects were less noticeable.

Conclusion
Implant-retained intra- and extraoral prostheses are a successful treatment modality that can achieve satisfying esthetic and
functional results for patients after upper lip and nose resection.

176

Goncalves et al

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