Prosthodontic Rehabilitation of a Completely Edentulous Patient with Sunken Cheeks Using Detachable Cheek Plumper Retained with Customised Ball Attachments and Orthodontic Separators: A Case Report

Abstract

Prosthodontic rehabilitation is incomplete without taking aesthetic considerations into mind, even in the elderly, who are assumed to be mainly concerned about the loss of masticatory ability rather than an alteration in appearance. The ageing process brings changes in facial appearance, which if more pronounced lead to unacceptable facial aesthetics. A common means of restoring the support of ageing-induced sunken cheeks is the use of cheek plumper. This case report describes an economical method of retention of cheek plumper using customised cast ball attachments and orthodontic separators. The modified prosthesis design did not negatively affect the retention of the prosthesis, resulting in a satisfactory resolution of the patient’s complaints.

Introduction

The prosthodontist plays a crucial role in the rehabilitation of patients with ageing-induced changes in the stomatognathic system including not only the loss of teeth and alveolar process but also the changes in the soft tissue features like the loss of muscle tone and skin elasticity.[1] Owing to their visual prominence, cheeks are an integral part of facial aesthetics, and their appearance is dictated by the underlying support of the teeth and alveolar process or the denture.[2] Tooth loss, alveolar resorption, and loss of facial muscle tone associated with ageing affect facial aesthetics significantly; resulting in sunken or hollow cheeks, which are aesthetically undesirable.[3] This aesthetic challenge is resolved using cheek plumpers, which support and plump the cheek to give it a youthful appearance. In addition to aiding the completely edentulous, it is also of utility in patients with facial palsy and patients with maxillectomy. The non-detachable cheek plumper, however, has the disadvantages of increasing the bulk of the prosthesis, making insertion of the prosthesis cumbersome, interference with the action of the masseter and buccinator muscles, and coronoid process of the mandible,[2] and is contraindicated in patients with microsomia. Detachable cheek plumpers have been used with magnets[1,4,5] and push buttons,[3,6,7] and modified orthodontic lingual buttons[8] as attachments as an alternative to the non-detachable cheek plumper. Therefore, this case report describes the aesthetic rehabilitation of a completely edentulous patient using detachable cheek plumper retained using customised ball attachments and orthodontic separators.

Case History

A 58-year-old male patient reported to the Department of Prosthodontics complaining of difficulty in chewing food due to missing teeth for the past year. The patient gave a history of pain and non-restorable carious teeth, for which he underwent extraction, eventually losing all his teeth. Extra-oral examination revealed a grossly symmetrical face with bilaterally sunken cheeks [Figure 1A–C]. Intraoral examination revealed completely edentulous maxillary and mandibular arches.

Figure 1.

(A) Pre-rehabilitative frontal view. (B) Pre-rehabilitative right lateral view. (C) Pre-rehabilitative left lateral view

Prosthetic rehabilitation was planned using a removable complete denture prosthesis with a detachable cheek plumper in the maxillary denture. Primary impressions were made using irreversible hydrocolloids (Imprint, Dental Products of India, Mumbai, India) [Figure 2 A and B].

Figure 2.

Primary impression of (A) maxillary arch and (B) mandibular arch

Border moulding and secondary impressions were made in a conventional manner followed by the pouring of the definitive casts [Figure 3].

Figure 3.

Definitive impression of (A) maxillary arch and (B) mandibular arch. Definitive cast of (C) maxillary arch and (D) mandibular arch

Maxillomandibular relation was recorded [Figure 4A–C] followed by mounting of the maxillary and mandibular cast, and trial insertion was done.

Figure 4.

(A–C) Maxillomandibular relation record

During try-in, cheek plumpers measuring 15 mm × 8 mm × 5 mm were made using modelling wax and were attached over the buccal flange of the maxillary denture extending from the distal of the first premolar to the mesial of the second molar. The plumpers were inspected for adequate cheek support, contour, and interference with functional movements and adjusted accordingly [Figure 5].

Figure 5.

(A–C) Trial insertion with wax-up of cheek plumper

Acrylisation of the denture and the plumpers was done using the conventional compression moulding technique.

For the fabrication of the attachment mechanism, a putty impression (Neopure, Orikam Healthcare, Gurugram, India) of the male component of an implant ball attachment system was made, and patterns were fabricated out of pattern resin (Pattern Resin LS 1-1PKG, GC America Inc., Alsip, IL, USA). The patterns were invested and cast conventionally to retrieve cast metal replicas of the attachment. The attachments were incorporated into the cheek plumper using auto-polymerising acrylic resin [Figure 6A–F].

Figure 6.

(A) Implant-compatible ball attachment. (B) Putty impression, fabrication of pattern using pattern resin. (D) Resin pattern of ball attachment. (E) Customised cast metal ball attachment. (F) Ball attachment incorporated in cheek plumper

After curing of denture and cheek plumpers, two 1.5 mm deep and 8 mm diameter holes on either side were made on the buccal flanges of the maxillary denture and corresponding area of cheek plumpers. Orthodontic separators were incorporated as the female retentive component for the attachment using auto-polymerising acrylic resin [Figure 7].

Figure 7.

(A–C) Final prosthesis with orthodontic separators in the buccal flange

The denture was delivered to the patient with instructions on maintenance of the dentures and was advised periodic follow-up [Figure 8A–F].

Figure 8.

(A–C) Definitive prosthesis in situ. (D) Pre-rehabilitative extra-oral frontal view. (E) Post-rehabilitative extra-oral frontal view. (F) Post-rehabilitative smile

Discussion

Denture aesthetics is not confined to the selection of teeth based on parameters like form, shape, colour, and arrangement of the teeth but must also comprise the restoration of facial aesthetics.[4,9] The loss of posterior dentition, subcutaneous fat, connective tissue elasticity, and a decrease in vertical dimension lead to an alteration of cheek contours, giving a sunken appearance.[3,10] Various treatment modalities exist to correct these deformities, including reconstructive plastic surgery, botulinum toxin injections, and the use of prostheses. The non-prosthetic treatment approaches have the attendant risks of postsurgical scarring, allergic manifestations, and skin irritation, and may be contraindicated in the elderly who are likely to be under polypharmacy for various systemic ailments. The prosthetic rehabilitation approach, characterised by the use of cheek plumpers, or cheek-lifting appliances, does not have any of the aforementioned disadvantages. However, the classical appliance was not detachable and was associated with muscle fatigue and difficulty in insertion and removal, which paved the way for detachable cheek plumpers. The mechanism for retention of the plumper should be, such as to facilitate easy insertion and removal by the patient as well as require infrequent replacement as possible, and if they do require replacement, it should be economical.[7] In this context, the use of customised ball attachments and orthodontic separators was proposed. They are simple in design, economical, and provide clinically acceptable retention.

The above technique, however, requires periodic replacement of both the male and female components due to frictional wear of the male component and loss of elasticity of the female component.

The technique is also contraindicated in patients who do not possess sufficient manual dexterity to attach the cheek plumpers to the prosthesis, where non-detachable cheek plumpers or magnet-retained cheek plumpers might have to be considered.

Conclusion

A simplified convenient technique of fabrication of a detachable cheek plumper has been described aiming for prosthetic rehabilitation with aesthetic restoration in cases with facial aesthetic deterioration. Successful restoration of facial contours was achieved without negatively affecting the retentive property of the prosthesis.

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.