ABSTRACT
This article describes the prosthetic treatment in a head and neck cancer terminal patient with midfacial bony and muscular-cutaneous defect to improve the masticatory and phonetical functions ⁽¹⁾ and the quality of life of the patient ⁽²⁾.

INTRODUCTION
The prosthetic rehabilitation of head and neck cancer patient is often complex, both for the operation's outcomes and for the frequent concomitance of radiation treatment and/or chemotherapy; this rehabilitation becomes still more difficult when maxillary and midfacial defect is present, with consequent communication between oral cavity and the nasal fossae or the maxillary sinus, or between the oral cavity and the external ⁽³⁾.
The aim of this article is to describe the palliative prosthetic treatment for a head and neck cancer patient operated for some tumoral relapses with a large maxillary and facial defect.

CLINICAL REPORT
The patient, sixty-seven years old, was surgically treated for the relapse of previous epithelioma of nasal wing. The management included reconstructive surgery and radiation therapy.
From the dental point of view, there was on the maxillary arch the dental elements from left central incisive to left second molar, and from right first premolar to right second molar. On the mandibular arch there was the dental elements from right second molar to left second molar; all these mandibular dental elements were of good condition.
Residual maxillary teeth was not of sufficient quality to realize a fixed partial denture so that a removable partial prosthesis was realized for aesthetic restoration. The prosthesis was made with a palatal bar connector, anterior denture base saddle, double Bonwill's clasp on maxillary left first and second premolar, Akers' clasp on maxillary right first and second premolar and cingulum rests on maxillary left central incisive and canine.
After 1 year the patient was reoperated for a new tumoral relapse, that caused the loss of all maxillary dental elements and of anterior maxillary bone portion with oro-sinusal communication and microstomia; the management included radiation therapy and also chemiotherapy.
For this reason a complete denture was realized with an anterior vestibular flange replacing maxillary lip to obtain a correct position of artificial frontal dental elements without interferences; moreover on vestibular side of the flange a pair of artificial moustaches was stuck. The complete denture was realized with transparent resin (Vertex Clear Self-Curing, Vertex Dental, B.V., Netherland) to mask its presence out of the oral cavity, considering it like a resin epithesis.
After about one year the progression of tumoral relapse caused a large defect of the left cheek and of the zygomatic bony tissue, and exophthalmus of the left globe for tumoral infiltration of the stroma.
For this reason the complete denture was no stable during masticatory and phonatory acts and no precise as to defect's borders, with consequent passage of liquids from the oral cavity to nasal fossae and vice versa.
For this reason a new resin prosthesis was realized able to replace the defective left cheek and the zygomatic bony tissue. It was made a first impression of defect with irreversible hydrocolloid (Alginoplast; Heraeus Kulzer, Hanau, Holland), doing attention to close the cavity in communication with external with proper vaselinates gauzes to avoid the inhalation of the impression material ^(4) (5).
After doing the plaster cast (Dental Hydrocal White; Kerr Italia S.p.A., Torino, Italy), a wax mask (Moyco Beauty Pink-X-Hard; Moyco Industries Inc., Philadelphia, USA) was made such as to fit defect both on the borders and on the depth. This mask was afterwards tried on the patient and modified to guarantee a simple insertion, because undercuts were present.
To restore the defective maxillary teeth, a baseplate wax was realized added to the mask. Occlusal vertical dimension was established and a centric relation record was made with dental stone (Contura, PD swiss Quality; Vevey, Switzerland).
Afterwards, the maxillary cast with the wax mask and the mandibular cast were assembled on nonadjustable articulator and then the maxillary artificial teeth were assembled on the wax; during the subsequent visit it was tried in intraorally.
The prosthetic device was finally put in a hydromuffle (Ivomat IP3, Ivoclar Vivadent; Bolzano, Italy) and was realized with transparent resin (Vertex Clear Self-curing, Vertex Dental B.V.; Netherlands). After the positioning in the oral cavity of the patient, a pair of artificial mustaches was stuck to improve the aesthetic appearance.
Tissue displacements were not found after a week; besides the patient referred an improvement during the masticatory and phonetical function and the absence of liquid passage. The aesthetic and functional result was appreciable.

DISCUSSION
This prosthetic rehabilitation is a palliative treatment to improve the life quality of a terminal cancer patient, although the quality of tissues around the prosthesis was not perfect and bony supports were not present.
The advantage of this prosthetic device is the possibility to restore the patient from a functional and aesthetical point of view. As the obturator and epithesis are only one whole, during the masticatory and deglutition movements the light mobility of the prosthesis interests the epithesis too. Nevertheless, as the resin is well polished, it has not caused any trauma on the patient's brittles tissues. Besides this type of device is easier to clean for the patient than a silicon epithesis, because the tissues produce secretions daily.

SUMMARY
This prosthetic device is a palliative treatment in an oncologic head and neck terminal patient and it works at the same time both like an obturator and an epithesis.

REFERENCES
1. Jacobs JR, Marunick MT. Surgical considerations in maxillofacial prosthetic rehabilitation of the maxillectomy patient. J Surg Oncol. 1988 Jan; 37(1):29-32.

2. Newton JT, Fiske J, Foote O, Loh IM, Radford DR. Preliminary study of the impact of loss of part of the face and ist prosthetic restoration. J Prosthet Dent 1999 Nov; 82(5):585-90.

3. Marunick MT, Harrison R, Beumer J 3^rd. Prosthodontic rehabilitation of midfacial defects. J Prosthet Dent 1985 Oct; 54(4): 553-60.

4. Beumer J 3^rd, Curtis TA, Marunick MT. Maxillofacial Rehabilotation: Prosthodontic and Surgical Considerations. 1st ed. St. Louis: Ishiyaku EuroAmerica, Inc; 1996. p. 377-453.

5. Benoist M. Réhabilitation et prothÈse maxillo-faciales. Paris: Julien Prélat, Editeur; 1978. p. 295-357.

Defect's frontal vision of the left cheek and of the zygomatic bony tissue.

Detail of the defect with a gauze to close the oro-sinusal communication to take the impression.

Wax baseplate and mask in the plaster cast.

Assembly of the maxillary artificial teeth on nonadjustable articulator.

Final prosthesis with artificial mustaches: frontal vision.

Lateral vision of final prosthesis.