Preliminary impressions of the normal mandibular arch as well as remaining maxillary arch along with the intraoral defect were made using high viscosity irreversible hydrocolloid (Dentalgin; Prime Dental Products, Mumbai, India). The impressions were poured in type III gypsum material (Kalstone; Kalabhai Karson, Mumbai, India). Maxillary custom impression tray was fabricated and adjusted for proper extensions. The tray was border molded with green stick impression compound (Pinnacle; Dental Products of India, Mumbai, India) including the palatal defect. The impression compound was relieved and a physiologic definitive impression was made using a medium viscosity polyvinyl-siloxane impression material (Reprosil; Dentsply DeTrey GmbH, Konstanz, Germany). Conventional prosthodontic protocols of boxing and pouring the impression with type III gypsum material were used to create a maxillary definitive cast. A 19 gauge hard, round, stainless steel orthodontic wire (KC Smith & Co, Monmouth, UK) was manipulated to make a fitted labial bow from the mesial aspect of the left central incisor to the distal aspect of left second molar. Though the surgical defect was completely healed chance of recurrence of the lesion was suspected hence a cast metal framework was not planned. A processed record base was fabricated from heat-polymerizing polymethyl-methacrylate (PMMA) (Trevalon; Dentsply, York, PA, USA) in conventional manner and adjusted with the aid of pressure indicating paste to allow complete seating.9 The definitive cast (used to fabricate the processed record base) was damaged on the lateral aspect during retrieval of the record base from the undercut areas. A sheet of baseplate wax (Modelling wax; Deepti Dental Products, Ratnagiri, Maharashtra, India) was adapted and contoured over the palatal defect portion of the processed record base to restore normal palatal contour and close the palatal portion of the defect intraorally. The adapted wax sheet was removed from the record base without distortion, flasked and processed in heat-polymerizing PMMA. The palatal piece was secured to the processed record base with auto-polymerizing PMMA and an occlusion rim was fabricated with baseplate wax. Jaw relation was recorded and transferred onto a semi-adjustable articulator with the help of face-bow. Teeth arrangement and wax contouring were carried out and the waxed-up prosthesis was tried in patient's mouth. After try-in the waxed-up obturator was processed in heat-polymerizing PMMA using conventional technique.9 After finishing and polishing the obturator, the gingival portion of the prosthesis was color modified with the auto-polymerizing clear PMMA (Cold cure-clear, Dental Products of India, Mumbai, India) mixed with acrylic-colors to match the normal melanin-pigmented gingiva of the contralateral side. The prosthesis was delivered to the patient and final occlusal refinement was completed (Fig. 2). The patient experienced improvement in speech intelligibility and deglutition after the placement of the maxillary obturator. A pair of Cobalt-Samarium magnets 30 mm in diameter and 2.5 mm in thickness (Jobmasters, Randallstown, MD, USA) was selected for mutual retention between intraoral and extraoral prostheses. One of the magnets was embedded in the superior-lateral aspect (portion which was exposed extraorally) of the obturator by using auto-polymerizing PMMA thus completing the intraoral section of the IECP (Fig. 3).

The patient was instructed to close in maximum intercuspal position with obturator placed in the mouth. The second magnet was placed over the obturator magnet. An irreversible hydrocolloid facial-moulage was made to record the facial defect along with surrounding normal extraoral structures and the extraorally exposed portion of the obturator with the second magnet placed over the obturator-magnet. A definitive cast was formed from type III gypsum. A single thickness baseplate wax was adapted over the extraoral defect area of the definitive cast. The wax sheet was flasked and processed in heat polymerized clear PMMA (Trevalon clear; Dentsply, York, PA, USA) using conventional technique.9 The inner PMMA framework was tried over the patient's extraoral defect by placing obturator and second magnet in position. An indentation for the second magnet was formed on the tissue surface of the framework. A cellophane paper (DPI, Mumbai, India) was placed in between the obturator magnet and the second magnet to act as a separating medium. Auto-polymerizing clear PMMA was mixed and placed in the indentation of the second magnet formed inside the tissue surface and the framework was seated over the defect area. After completion of polymerization, the second magnet was embedded in the framework (Fig. 4). An artificial stock-eye globe was selected to match size, shape and color of the normal left eye. The sclera was further color modified (from back side leaving front clear polished surface intact) with auto-polymerizing clear PMMA mixed with acrylic-colors to match the normal left eye sclera. The eye globe was positioned on the framework with reference to normal left eye and fixed with auto-polymerizing clear PMMA.

A sheet of baseplate wax was adapted over the inner framework in such a way that it would provide uniform thickness of the silicone for future facial contour over the defect area (Fig. 5). This was carried out by completely filling the wax on the inner framework and contouring the wax according to the facial contour, which was further cut back uniformly (4 mm in depth) from all over the facial surface. Petroleum jelly was applied over the cut back surface and a single thickness wax sheet was adapted to ensure uniform 3 mm of space for future overlying silicone layer. The adapted wax sheet was separated from the underlying wax surface without distortion and separately flasked for processing in heat-polymerizing PMMA. The underlying wax over the framework was removed by dewaxing procedure. The processed top layer framework was secured in position with inner framework using the auto-polymerizing PMMA thus completing a hollow PMMA substructure (Fig. 6).

The final portion of the facial prosthesis was sculpted with baseplate wax over the completed hollow PMMA substructure (Fig. 7). The wax sculpture was evaluated by positioning it on the patient's face. The wax sculpture of the prosthesis was invested in type IV gypsum material (Ultrarock; Kalabhai Karson, Mumbai, India) to form a mold for packing the silicone. Dewaxing was carried out in usual manner.9 The prosthesis was packed with a MDX4-4210-base silicone (Dow Corning Corp, Midland, MI, USA) and colored using intrinsic stains (KT-699, Silicone Coloring Kit; Factor II, Lakeside, AZ, USA) selected according to the patient's skin color. The silicone was heated for 2 hours at 90℃, deflasked, trimmed, cleaned, and bonded to the underlying framework with medical adhesive type A (Factor II) under vacuum as described by Lemon et al.10 Polyurethane lining was applied to the margins to increase the tear resistance of the marginal silicone.10,11 The prosthesis was trial fitted and extrinsically colored with trichlorethane, medical adhesive type A and oil pigments (Factor II) thus completing the fabrication of extraoral section of the IECP. The gypsum-mold was preserved for future re-packing in case of discoloration or damage of the overlying silicone layer.

The patient was referred to an ophthalmologist for routine evaluation of the left eye. He was found to have hypermetropia. A spectacle frame was selected and the left glass of the spectacle was fabricated according to the specifications provided by the ophthalmologist to treat the hypermetropia of the left eye. During the prosthesis insertion appointment the maxillary obturator was placed intraorally and the facial prosthesis was positioned extraorally against the obturator magnet (Fig. 8). The patient was given hygiene instructions for cleaning the IECP. The patient attended recall visits every 4 to 5 months. During these visits, the obturator and facial prosthesis were thoroughly cleaned with a disinfectant (MD 520; Dürr Dental GmbH, Bietigheim-Bissingen, Germany). Two years after prosthesis insertion the prosthesis was still serviceable and the patient was pleased. The patient has been able to maintain 100% of his weight with a normal diet and nutritional supplements ingested orally. A cosmetic improvement, the ability to speak more intelligibly, improved deglutition and improved mastication was achieved for this patient with this IECP.