Surgical nasal prosthesis

Surgical Philip

nasal prosthesis

E. Hutcheson,

D.D.S.,

M.S.D.,*

and Ariyadasa Udagama, D.D.S.,

Medical University of South Carolina, College of Dental Medicine, Texas System Cancer Center, M.D. Anderson Hospital and Tumor

M.S.D. **

Charleston, S. C., and The University Institute, Houston, Texas

of

T

he diagnosis of cancer and the necessity for rapid and often radical treatment may produce severe psychological trauma in a patient. The fear and anxiety characteristic of patients who must undergo surgery for treatment of cancer’ may be increased if the procedure mutilates the head and neck region, particularly the face. Surgical ablation of facial structures is feared by most persons because the defect which results tends to lower the person’s image of his social acceptability. The technique of providing an immediate replacement prosthesis helps a patient through an emotionally taxing procedure and allows him to maintain his concept of self-dignity. An excellent example of this type of immediate replacement prosthesis is the immediate denture. Various authors describe the technique for creating this type of prosthesis, and these authors invariably list immediate replacement for psychological support as a distinct advantage of The surgical nose prosthesis may such prostheses.‘-” be used for psychological and esthetic support in patients who are to undergo nose resection, who are receptive to its use, and who possess sufficient physical and mental capabilities to use and maintain it properly. Fabrication of an immediate prosthesis has generally followed the method used for the production of a conventional postsurgical prosthesis. A facial impression and working cast are obtained, the surgical defect is estimated, and a sculpting is formed. Molds are fabricated and the prosthesis is processed. A distinct disadvantage of this method is that considerable time is expended in completing the surgical prosthesis. A much shorter and less complicated alternative technique has been developed by one of the authors to fabricate this type of prosthesis.4 *Assistant Professor, Department of Prosthodontics. **Assistant Dental ‘OnEologist, Department of Dental OncologY.

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1980

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Fig. 1. Cotton is inserted into the nostrils prior to impression-making.

TECHNIQUE

OF FABRICATION

An improved RTV silicone is used for rapid fabrication of an immediate nasal prosthesis. This material has easy handling characteristics, and some approved RTV silicone rubber materials have the capability to withstand temperatures of 250” to 300” C, well above the curing temperature of polyvinyl chloride (PVC) plastisols. Prior to impression making, the patient is seated in the near-upright position in the dental chair and cotton is inserted into the nostrils, with care being taken to avoid distortion (Fig. 1). The silicone rubber impression material is mixed and applied to the nose and surrounding region. Prior to complete vulcanization of the rubber, strips of wire mesh are pressed into the rubber to maintain the shape and improve strength, and a second backing of silicone rubber is

0022-3913/80/010078

+ 04$00.40/O

0 1980 The C. V. Mosby

Co.

SURGICAL

NASAL

PROSTHESIS

Fig. 3. The completed med.

Fig. 2. The silicone impression face.

OF PROSTHETIC

is inspected and trim-

is in place on the patient’s

applied (Fig. 2). Upon complete vulcanization, the entire impression is removed, inspected for accuracy and voids, and trimmed (Fig. 3). If the face is disfigured from the lesion or previous surgical procedures, an impression is made with hydrocolloid impression material and a working cast is poured in dental stone. The feature is sculpted to the proper shape using wax, as silicone may not set in contact with oil-base clay. Impressions of the sculptured cast may be obtained as described using silicone rubber. The appropriate base shade of polyvinyl chloride (PVC) plastisol is selected and preheated for 2 minutes at 200°C. The silicone impression is also preheated for 5 minutes at 200°C. A layer of clear PVC plastisol is applied to the inside of the silicone impression. Nylon flocking is applied where appropriate and cured for 3 minutes at 200°C. Preheated base shade PVC material is painted into the impression with a brush to produce a 1 to 2 mm thick even layer of material inside the “impression-mold” (Fig. 4). The mold is kept in the oven at 200” C for 10 minutes for final curing.

THE JOURNAL

impression

DENTISTRY

Fig. 4. Polyvinyl chloride base shade is p.3inted into the refractory impression mold. The cured prosthesis is removed from the oven, checked for voids, allowed to bench cool, removed from the silicone mold, and trimmed to anticipated margins, allowing for a little excess (Fig. 5). Because of the lack of precise indication of the extent of the surgical margins, two PVC prostheses are fabricated for possible use (Fig. 6). Reproduction of color and anatomic detail is outstanding (Fig. 7).

79

HUTCHESON

AND

UDAGAMA

Fig. 5. The cured prosthesis is removed from the mold and is ready to trim.

Fig. 6. Two PVC prostheses are fabricated latitude of surgical defect margins.

to allow

for

Following surgical removal of the nose, the selected prosthesis is trimmed to fit the surgical defect, the nasal cavity is packed, adhesive tape is applied to the prosthesis, and the prosthesis is placed over the defect. During the postoperative course, the prosthesis may be removed as necessary for changing the nasal pack and wound inspection.

PATIENT

HISTORY

A 65-year-old man had a pigmented lesion removed from the right side of his nose. The lesion reappeared, and the biopsy report indicated malignant melanoma, level V (extending into subcutaneous tissue). The most common sites of malignant melanoma

80

Fig. 7. The PVC prosthesis compares favorably with the patient’s nose. are the head and neck region and the lower extremity.’ The lesion tends to metastasize early and widely,’ and the treatment of choice is wide and deep excision with a skin graft to the areas7 The prognosis of malignant melanoma ranges from poor to grave depending upon metastasis (45% 5-year survival without node involvement; 16% 5-year survival with node involvement).’ Confirmation of tumor slides revealed that one deep margin was positive. Because of the presence of

JANUARY

1980

VOLUME

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SURGICAL

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PROSTHESIS

ble; and (5) psychological trauma is minimized the patient is better prepared for a definitive thetic restoration.

residual tumor, a total nose amputation was recommended by the oncology surgeon and accepted by the patient. The surgeon and the maxillofacial prosthodontist considered that this patient would benefit by the fabrication and placement of a surgical nasal prosthesis. Accordingly, as the patient was being prepared for the surgical procedure, he was treated simultaneously by the maxillofacial prosthodontist for the presurgical fabrication of a surgical nasal prosthesis.

Photographs courtesy of the Department of Dental Oncology, Section of Max&facial Prosthetics, The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute, Houston, Texas.

REFERENCES 1.

2.

SUMMARY

3.

This method of fabrication of an immediate nasal prosthesis has distinct advantages which recommend its use. These are (1) the use of an RTV silicone rubber impression as the refractory cast cuts fabrication time to minutes rather than hours, as compared with other methods of fabricating a nasal prosthesis; (2) the RTV silicone is permanent and stable and provides an exact reproduction of the part to be excised; (3) the initial RTV silicone impression may be used during fabrication of the definitive prosthesis as the mold for production of a wax sculpting model; (4) PVC prostheses offer a unique advantage of being soft enough for trimming with scissors at the time of surgery and are flexible and tissue-compati-

ARITCLES

Herbert

4. 5.

6.

7.

of some denture

J. Mueller,

Functional

Ph.D.,

loading

Edmund0 B. Nery, George E. Rooney,

and

Evan

Rgrint requests to: DR. PHILLIP E. HUTCHESON MEDICAL

UNIVERSE

OF SOUTH

COLLEGE

OF DENTAL

MEDICINE

Frederick

of distortion:

Retention Roger D.D.S.,

THE JOURNAL

Ph.D.

augmented A. Pflughoeft,

alveolar D.D.S.,

Research

ridge-A

Kenneth

pilot

I,. Lynch,

study

Ph.D.,

and

considerations

Ph.D.

Parel,

D.D.S.,

and

and resistance

G. Potts, Ph.D.

OF PROSTHETIC

-

cleansers

Prosthetic support of laryngotracheoplasty infants and children M.

CAROLINA

S. C. 29403

CHARLESTON,

H. Greener,

of bioceramic

D.M.D., D.D.S.

The measurement J. I. Nicholls,

Stephen

Boucher, C. 0.: Swenson’s Complete Dentures, ed 5. St. Louis, 1964, The C. V. Mosby Co. Heartwell, C. M.: Syllabus of Complete Dentures. Philadelphia, 1968, Lea & Febiger Co. Sharry, J. J,: Complete Denture Prosthodontics, ed 3. New York, 1974, McGraw-Hill Book Co. Udagama, A.: Prosthetic restoration of facial defects. Cancer Bull 29:70, 1977. Robin, P., ed: Clinical Oncology for Medical Students and Physicians, ed 4. New York, 1974, American Cancer Society. Clark, R. L., and Howe, C. D., ed: Cance:r Patient Care at M.D. Anderson Hospital and Tumor Institute, Chicago, 1974, Yearbook Medical Publishers, Inc. Neoplasms of the Skin and Malignant Melanoma. Chicago, 1975, Yearbook Medical Publishers, Inc.

TO APPEAR IN FUTURE ISSUES

Characterization

and pros-

D.D.S.,

DENTISTRY

Herbert

George

A. Gates,

for acquired

stenosis

in

M.D.

of preparations T. Shillingburg,

subglottic

for cast restorations Jr.,

D.D.S.,

and

Manville

G. Duncanson,

Jr.,

81