Physical appearance plays an important role in a patient’s psychological well-being . When they are young, many people try to pursue a sunken cheek look as it improves the aesthetics of the face. But the same look adds years to one’s age as aging kicks in. Aging brings many changes in the body, especially the mid face, which is the most prominent part of our face. Aging is associated with the loss of teeth and supporting alveolar bone. This causes loss of facial fat and muscle strength, leading to wrinkles and sagging of cheeks and lips . Various treatment modalities have been mentioned in the literature for the treatment of sunken cheeks.
When a patient is not interested in reconstructive surgery, cheek augmentation prostheses should be considered. A fuller cheeks will lift the cheeks to correct the contours without discomfort to the patient [3-9]. It gives sufficient support to sagging cheeks and lips. Various types of cheek pluckers have been mentioned in the literature. They can be broadly classified into detachable and non-detachable cheeks, each with its own merits and demerits.
This report describes a case of a completely edentulous patient who was rehabilitated with a non-removable cheek augmentation prosthesis.
A 70-year-old male patient presented to the prosthodontist department for replacement of missing teeth due to difficulty eating. The patient also asked for the aesthetics of his sunken cheeks to be improved. The anamnesis showed that the patient had been toothless for two years.
On intraoral examination, the patient had moderately resorbed maxillary and severely resorbed mandibular edentulous ridges. Extraoral examination revealed sunken cheeks. The patient was presented with all options, including fixed and removable cheek plungers that were feasible, along with their pros and cons. The patient was allowed to make a conscious choice for the treatment that best suited him and written informed consent was obtained prior to its implementation. The patient chose a single prosthesis, which would serve both functionally and aesthetically. He didn’t want the hassle of attaching the fuller part of the cheek after inserting the prosthesis.
For both maxillary and mandibular prostheses, preliminary impressions were made with an impression mass (DPI Pinnacle Impression Compound, Dental Products of India Ltd, Mumbai, India). After edge molding of custom trays (DPI RR Cold Cure, Dental Products of India Ltd, Mumbai, India) using low fusion impression compound (DPI Pinnacle Tracing Sticks, Dental Products of India Ltd, Mumbai, India), final prints made with light body poly (vinyl siloxane) impression material (Express™, 3M Company, Saint Paul, Minnesota, United States). Jaw relations were recorded and mounted on a mean value articulator. The neutral zone was recorded using a soft tissue conditioner (Visco-Gel, Dentsply Sirona, Charlotte, North Carolina, United States). The same procedure was followed for the inclusion of the neutral zone as reported by Kursoglu et al. . The setting of the teeth was done in the neutral zone, which was obtained by the phonetic and functional method. During the try-in, additional wax was added in the premolar molar region of the maxillary buccal flange (Figure 1).
The neutral zone was recorded by applying a thin layer of tissue conditioner separator to the waxed area of the plumper, followed by the application of tissue conditioner and asking the patient to perform functional movements. The adequate support and size of the cheeks were confirmed by an extraoral appearance and a neutral zone. When fitting dentures, the patient’s opinion of aesthetics and comfort was also taken into account.
After investing and dewaxing the dentures, a small amount of silicone putty impression material (Express, 3M Company, Saint Paul, Minnesota, USA) was placed in the cavity formed by the cheek filler. Trial closure was performed (Figure 2).
The dentures were processed according to the manufacturer’s instructions using heat-polymerized acrylic resin (DPI Heat Cure, Dental Products of India Ltd., Mumbai, India) using a conventional compression molding technique. Upon retrieval of the prosthesis, silicone impression material was removed by making a small hole with an acrylic drill (Figure .) 3).
The area was then repaired with autopolymerized acrylic resin (DPI RR Cold Cure, Dental Products of India Ltd, Mumbai, India). The prosthesis was placed in the water and checked for air bubbles to verify that the repair was properly sealed (Figure .) 4)
The prosthesis was delivered to the patient after proper finishing and polishing. The patient was recalled one day, three days, one week, and one month after insertion to check for function, aesthetics, comfort, and phonetics. The patient was also recalled three months, six months and a year after insertion to check for any problems with the dentures. The patient was very comfortable with the fit and comfort during recall visits and showed no signs of muscle fatigue over time (Figures.) 5, 6).
Appearance plays an important role in both social and professional life. Sunken cheeks are clearly visible and give the face an aged look. Several methods have been mentioned in the literature to improve the aesthetics of sunken cheeks. Dentists play an important role in improving facial aesthetics by not only replacing missing teeth, but also replacing surrounding structures. In an edentulous patient, this can be achieved by correct contouring and extensions of the prosthetic flange. Sunken cheeks may require extra support to lift the cheek to an adequate level. Cheek fuller prosthesis can be a great solution for such patients [3-9]. Cheek fuller can be of detachable and non-detachable types. With removable cheek filler, the fuller is made separately and attached to the dentures with various attachments such as magnets [3-6]punching spin snap button and custom attachments [8,9]. Magnets tend to lose magnetic properties over time and need to be re-magnetized . In addition, they can contribute to corrosion if not encased in a stainless steel housing. Custom attachments require additional time in manufacture. Push buttons are not readily available in dental offices and must be purchased from outside. In the present case, a non-detachable cheek plunger is made of materials readily available in the dental office.
Wang Fuller was originally designed as a single denture attached to a maxillary prosthesis. This contributed to additional weight on the prosthesis and compromised the retention of the prosthesis. The added weight will also cause muscle fatigue over time. The patient’s clear request was to make a non-detachable cheek fuller, as he didn’t want the hassle of fastening it after insertion of the prosthesis. In the present case, a hollow cheek filling was planned for the patient. Because it was hollow, it added no weight to the denture and compromised the retention of the dentures. The neutral zone technique also contributed to the stability of the prosthesis. Silicon putty impression material was used to make hollow fuller. Putty impression material has the advantage of not sticking to acrylic resin material. It can also be easily removed from the prosthesis.
To harmonize the prosthesis with the stomatognathic system, the space for the fuller cheeks was entered using the neutral zone technique. The limitation of this technique is that it cannot be used in patients with microstomy due to the larger mediolateral width of the dentures. The patient was recalled one day, three days, one week, one month, six months, and one year after insertion to check for function, aesthetics, comfort, and phonetics. The patient was very pleased with the ease of maintenance of denture hygiene and the fit and contour of the prosthesis on recall visits.
A simple and easily non-removable denture with a fuller cheek was provided to the edentulous patient with sunken cheeks. The fuller cheek not only improved the patient’s facial aesthetics, but also improved his psychological well-being. It can be manufactured with materials that are readily available in dental preparation.