Ageing and long span edentulism is associated with loss of teeth, alveolar ridge resorption, and loss of support and tonicity of facial muscles. This is a great concern in treating completely edentulous patients. Flaccid facial musculature eventually results in sunken cheeks and unesthetic appearance, causing a negative impact on psychological well-being of the patient. Prosthetic rehabilitation of completely edentulous patient with conventional complete denture does not confine to replacement of missing teeth, but may require additional support in some instances. The present clinical report exemplifies the use of non-detachable maxillary cheek plumper prosthesis in a completely edentulous patient with sunken cheeks.
Key words: Cheek Plumpers, Non-Detachable, Lost-Salt Technique
Denture esthetics produced by dental prosthesis
affects the delicacy and attractiveness of an individual. Facial esthetics play a major role in an
individual’s psychosocial and professional life.
The loss of oral structures affects the appearance
of face by changing the contour of jaw bones,
soft tissues & surrounding orofacial musculature.
As age progresses, the loss of subcutaneous fat & elasticity of the tissues causes the cheeks to
become slumped.1
This result in hollowed-out,
sunken appearance & exaggeration of wrinkles
because of tissue laxity2
.
When missing teeth is replaced, it is necessary to
restore the facial contours. A properly extended
and contoured denture flange can adequately support the overlying lips and cheeks. But sometimes,
the denture flange does not provide adequate
support to the facial musculature & requires additional support3.
Cheek plumpers are prosthesis used to enhance
the support of sunken cheeks providing better
esthetics. Earlier, it was used for improving aesthetics & psychosocial profile of patients affected
with Bell’s palsy4
. It can be fabricated either as
conventional or detachable type. Conventional
cheek plumper is single unit prosthesis with extensions on either side, near the premolar-molar
region that supports the cheek. But this design
has many drawbacks1
. The external contour of
the cheek plumper is not contoured to function in
harmony with muscular activity in the region of
its incorporation. This leads to frequent dislodgement of denture during speech. It may interfere
with masseter muscle and coronoid process of the
mandible. Moreover, patients with limited mouth
opening have difficulty in insertion and removal
of dentures as additional thickness hinders it. The
detachable cheek plumper is a separate unit from the denture, thus facilitating easy insertion and
removal of the prosthesis. These plumpers can be
made easily detachable by using various attachments such as press button, magnets, ortho wires or
buccal tubes. These can be also casted using NiCr alloy as a key-keyway attachment4
. Because of
their detachability, they are easy to insert, remove
and clean1. This case report illustrates plumping
of cheek of an edentulous patient with hollow
cheek plumpers.
A 60 year old male patient reported to the department of prosthodontics, KMCT Dental College,
Kozhikode, India for replacing his missing teeth
over upper and lower arches (Figure 1). On intraoral examination, the patient had completely
edentulous maxillary and mandibular arches. He had lost all his teeth following a fall from tree 20
years back. Blackish pigmentations were present
over the labial and buccal oral mucosa. The ridge
was high, well rounded in the maxillary arch and
low, well rounded in the mandibular arch with
sufficient interarch space.
Extraoral findings revealed flaccidity of facial
muscles, wrinkling of skin resulting in sunken and
slumped cheeks. Patient was hypertensive and
was under medication for past 10 years. Patient
was a heavy smoker for past 40 years, who used
to smoke atleast one packet of cigarettes a day.
The patient was seeking an improvement in his
facial appearance, therefore the treatment plan
formulated was a conventional complete denture
with non-detachable hollow cheek plumper.
Preliminary impressions were made with irreversible hydrocolloid and border molding was done
with modelling plastic impression material. Definitive impressions were made using zinc oxide
eugenol impression paste. Jaw relation was recorded, and the teeth arrangement was evaluated.
Wax patterns for cheek plumpers were fabricated
during the clinical evaluation stage.
A roll of softened modelling wax was adapted
over the buccal flanges of the maxillary denture
on either side in the premolar-molar region (Figure
2). The adapted wax was evaluated extraorally for
adequacy of cheek support and contour. This was
later modified to ensure that they did not cause
occlusal interferences, instability of dentures, or
unnecessary tensing of facial muscles.
The dentures with cheek plumpers were fabricated
using heat polymerized acrylic resin. Dewaxing
was carried out and lost salt technique was used
during packing stage for fabrication of hollow
cheek plumpers (Figure 3). After processing, holes
were drilled into the denture base distal to the
most posterior teeth to assist removal of salt. The
holes were sealed with autopolymerizing resin.
The denture was immersed in water to check the
seal of autopolymerizing resin. If no bubbles are
evident, an adequate seal is confirmed. The final
polished denture with cheek plumper (Figure 4)
was inserted and any occlusal adjustments and
plumper contouring was done. The patient was
given post insertion instructions and was motivated
to make efforts to learn to adapt to the new denture with cheek plumpers (Figure 5). Within four
to six weeks, the patient expressed satisfaction in
phonetics and mastication.
Detachable cheek plumpers were claimed easy
to insert, remove and clean. They can be made
detachable using magnets (made of Neodymium-iron-boron alloy), Ni-Cr or Co-Cr alloy. Magents
have poor corrosion resistance and can lose their
magnetic properties over time. The nickel content in Ni-Cr alloy may be allergenic to some individuals. The press stud fastners can break, if not
properly handled. The orthodontic wires can bend
with repeated usage. Elderly patients who need
assistance might not easily seat a cheek plumper
to a complete denture. Also conventional cheek
plumpers can increase the weight of the prosthesis,
causing muscle fatigue and denture instability.
In such situations, a hollow cheek plumper is a
better treatment option.
However, cheek plumpers have certain drawbacks,
such as food accumulation, patient discomfort due
to extra mediolateral extension. The maxillary
cheek plumper may not adequately provide fullness
of cheeks or muscle draping. In such situations,
the insertion of Mandibular cheek plumpers need
to be planned.
Cheek plumpers are straight forward to fabricate
and provide a non-invasive and cost-effective
treatment option for the improvement of facial
appearance with sunken cheeks. This treatment
helps improve esthetics and psychological well-being of patients.