Silicone nasal prosthesis retained by an intranasal stent: A clinical report

Reiyal Goveas, BDS,a Ongart Puttipisitchet, DDS, MSc,b Binit Shrestha, BDS, MSc,c Sita Thaworanunta, DDS, MS, MSc,d and M.L. Theerathavaj Srithavaj, BS, MS, DDSe Faculty of Dentistry, Mahidol University, Bangkok, Thailand
Nasal defects after tumor excision can leave a patient functionally and esthetically impaired. Loss of nasal septal cartilage support causes the soft tissue to collapse or undergo stenosis, further compounding the problem. Intranasal stents can be used to maintain the patency of such nasal defects. This clinical report describes the use of an acrylic resin nasal stent bonded to a silicone nasal prosthesis to rehabilitate a patient with a nasal defect. (J Prosthet Dent 2012;108:129-132) After tumor excision, external nasal defects are difficult to restore prosthetically, especially when there is a loss of underlying cartilage.1 Because of the unstable soft tissue base, both the initial impression procedure and the final prosthesis fabrication become difficult. Although the use of adhesives is advocated, retention may be compromised. Alar stents can be used to manage this problem.2,3 Intranasal stents have a wide range of applications in the treatment of nasal defects. They serve many functions such as (1) supporting nasal alae that collapse on inspiration; (2) expanding nasal vestibules when the airway is obstructed by soft tissue scar bands or a deviated nasal septum; (3) improving facial appearance by supporting collapsed nasal tips; and (4) correcting partial or complete occlusion of the nasal passage for patients with atrophic rhinitis.4 The materials used to fabricate these nasal stents are usually acrylic resin or silicone polymer. A combined prosthesis obtained by bonding acrylic resin to a room temperature vulcanizing (RTV) facial silicone polymer can be used to treat patients with nasal defects.1 This clinical report describes the use and fabrication of a nasal prosthesis with a customized heat-polymerized acrylic resin alar stent to prevent the alar collapse of a nasal defect. the tumor mass recurred, a wide excision was performed, and reconstruction was done with a paramedian forehead flap and conchal cartilage. Pathology reports indicated a moderately differentiated squamous cell carcinoma with perineural invasion (grade IV). The patient underwent radiotherapy with a total dose of 5000 cGy. After the radiation therapy, a nasal stent was placed to prevent closure of the right nasal aperture. During a follow-up visit in 2009 the patient complained of loosening of the stent and the inability to use it. The diameter of the right nasal aperture had decreased, and stenosis of the left ala had occurred. However, the resected margins were negative for any tumor mass, and the treatment plan was to fabricate a silicone nasal prosthesis. The treatment plan consisted of fabricating a custom acrylic resin intranasal stent, which was done by first obtaining the approximate dimensions of the nasal apertures with low-fusing modeling plastic impres-

CLINICAL REPORT
A 61-year-old male was referred to the Maxillofacial Prosthetics Service, Mahidol University for the prosthetic rehabilitation of his nasal defect. Past medical history showed a wide surgical excision performed at the right alar region of the nose after the discovery of a nodular mass in 2005. After the excision of the tumor mass, reconstruction was performed with nasolabial flap and right auricular cartilage. Pathology reports indicated the mass was a papillary squamous cell carcinoma with a TNM staging of T2N0M0 (grade II). However, in 2007

Presented at the 7th Biennial Congress of the Asian Academy of Prosthodontics (AAP), Shanghai China, Oct 28-30, 2011 (Poster presentation). Resident, Maxillofacial Prosthetics Service, Faculty of Dentistry. Instructor, Maxillofacial Prosthetics Service, Faculty of Dentistry. c Instructor, Maxillofacial Prosthetics Service, Faculty of Dentistry. d Assistant Professor, Maxillofacial Prosthetics Service, Faculty of Dentistry. e Assistant Professor, Maxillofacial Prosthetics Service, Faculty of Dentistry.
a b

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1 Definitive impression of nasal aperture.

2 Acrylic resin plugs (plugs or stents) made of heat polymerized acrylic resin.

3 Chairside expansion of the nasal stent done with baseplate wax. sion compound (Kerr Green Sticks; Kerr Corp, Orange, Calif ). A light bodied vinyl polysiloxane (Multisil Epithetik soft and hard form; Bredent GmbH, Senden, Germany) was used to fabricate the definitive impression by coating low-fusing compound and inserting it into the nasal apertures (Fig. 1). The impressions were trimmed, flasked, and converted into heat-polymerized polymethyl methacrylate (PMMA) resin plugs (Acrylic resin; Vertex Dental, Zeist, Netherlands) (Fig. 2). Expansion of the nasal apertures was performed by relining the acrylic resin plugs with wax (Cavex T T 100 soft; Cavex, Haarlem, Netherlands) (Fig. 3) and then converting the wax into heat-polymerized PMMA resin. The procedure was performed in 2 sequential visits over a 1 month period and was done until the patient felt comfortable breathing without

4 Definitive nasal stent. sally, and light-bodied, then mediumbodied vinyl polysiloxane impression material (Multisil Epithetik soft and hard form) was injected over it. The medium-bodied vinyl polysiloxane was used as a support for the lightbodied impression material; wooden sticks (Dalian Goodwood Medical Care Ltd, Liaoning, China) were used as further reinforcements to prevent distortion of the impression. Then a transfer impression was made with irreversible hydrocolloid impression material (Fig. 5). The impression was poured in Type IV dental stone (Nok Stone; Lafarge Prestia). Carbide burs (SS White Burs Inc, Lakewood, NJ) were used to make perforations and grooves on the flange portion of the acrylic resin extension to increase the surface area and to provide mechanical interlocking. Base plate wax (Cavex T T 100 soft; Cavex) was used

distention of the remaining nasal tissues. Subsequently, a diagnostic facial impression was made with irreversible hydrocolloid as the impression material (Jeltrate Fast Set; Dentsply, York, Pa) and the impression was poured with Type II dental stone (Prestia Dental; Lafarge Prestia, Meriel, France). The stent was then inserted into the stone mold, and the left and right nasal stents were stabilized by 21 gauge orthodontic wire (Knight Precision Wire; Potters Bar, UK). Then autopolymerizing PMMA resin (Orthojet; Lang Dental Mfg Co Inc, Wheeling, Ill) was used, by the sprinkle-on technique to cover the orthodontic wire and was further extended laterally (5 mm) and superiorly (10 mm) to form a flange. The margins of the flange were confined to the borders of the final prosthesis (Fig. 4). The newly extended stent was placed intrana-

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5 Definitive impression of defect area made with lightbodied and medium-bodied vinyl polysiloxane and transferred with irreversible hydrocolloid.

6 Application of primer A330 G on flange of acrylic resin stent before silicone packing.

A
7 A, Patient pretreatment. B, Patient posttreatment. to fabricate a primary nasal prosthesis and was modified until suitable esthetics was obtained. The counter portion of the mold was prepared with Type IV stone (Lafarge Prestia), and wax was boiled out. The mold was cleaned and separating medium (Tinfoil substitute; Factor II, Inc, Lakeside, Ariz) was applied over the mold except on the acrylic resin stent. The flange portion of the stent was prepared by lapping with a 60 grit silicon carbide waterproof abrasive paper (60 Grit Sandpaper; 3M, Irvine, Calif ). The acrylic resin surface was washed with water and air-dried. Then acetone was applied on the acrylic resin stent and left to dry for 30 minutes. Before silicone packing, a resin primer (A 330-G; Factor II, Inc) was applied on the flange of the nasal stent to facilitate bonding with the RTV silicone (MDX 4-4210; Factor II, Inc) (Fig. 6). The RTV silicone was mixed according to the manufacturers instructions along with a thickening agent (Thixo; Factor II, Inc) to increase the viscosity of the silicone elastomer during intrinsic staining. After completion of intrinsic staining, the silicone elastomer was polymerized at room temperature and extrinsically stained (Dry earth pigments; Factor II, Inc) before delivery. Figure 7A shows the patient without the prosthesis during the initial visit. Figure 7B shows the patient after the insertion of the definitive nasal silicone prosthesis with improved esthetics. The intranasal retention provided by the stent was adequate to retain the prosthesis, and no other mode of retention was used.

DISCUSSION
Resections involving critical areas of the face, such as the nose, are difficult to reconstruct surgically. The surgical option includes the use of skin flaps for facial reconstruction, and although these skin flaps do provide a large amount of skin tissue, they are both esthetically and functionally poor.5 Furthermore scarring of the tissue due to repeated surgeries to remove recurrent tumors might compromise the acceptance of the skin flaps. For such patients, suitable alternatives are facial prostheses, which are primarily retained by means of adhesives. However, the disadvantages associated with the use of adhesives are allergic irritation and difficulty in placement, especially for patients with poor coordination. In addition,

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prosthesis margins secured to unsupported tissue may need constant reattachment, and routine removal of the prosthesis may damage its thin feathered margins.2 The use of an alar stent to retain such an external nasal prosthesis avoids the use of adhesives. Due to the difference in the chemical structures between MDX 4-4210 and PMMA acrylic resin, bonding between the 2 surfaces is difficult. This necessitates the use of a primer, which is a dilute solution of silane coupling agents and other active ingredients. These silane coupling agents act as an interface between the RTV silicone and PMMA acrylic resin.6 The primer activates the 2 surfaces with etching and by increasing hydrogen bonding and covalent coupling, thus promoting bonding by increasing the wettability of the substrates. This bonding between the RTV silicone and PMMA resin surface helps the 1-piece nasal prosthesis to withstand the repeated forces experienced during removal and insertion. The disadvantage of a single-piece prosthesis is that the alae will collapse on removal of the prosthesis especially during the night. Another alar stent without a silicone prosthesis attached may be required to maintain the tissue contour of the nasal passages at night.

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3. Davenport JC, Brain DJ, Hunt AT. Laboratory techniques for the construction of intranasal prostheses. J Prosthet Dent 1984; 51:577-80. 4. Seals RR, Bohnenkamp LG, Parel SM. Intranasal prostheses, splints, and stents. J Prosthet Dent 1988;60:595-601. 5. Cordeiro PG, Disa JJ. Challenges in midface reconstruction. Semin Surg Oncol 2000;9:218-25. 6. Witucki G. A silane primer: Chemistry and applications of alkoxy silanes. J Coating Technol 1993;65:57-60. Corresponding author: Dr M.L. Theerathavaj Srithavaj Maxillofacial Prosthetic Service Mahidol University 6th Yothi Street Rajthevee Pharayathai Bangkok 10400 THAILAND Phone: +66816999000 Fax: +6623548491 E-mail: dttst@mahidol.ac.th Copyright 2012 by the Editorial Council for The Journal of Prosthetic Dentistry.

SUMMARY
By bonding the alar stent to the nasal prosthesis, the stent has a dual function: (1) primarily to maintain the patency of the nasal airway and (2) to retain the nasal prosthesis.

REFERENCES
1. Parel SM. Intranasal conformers. J Prosthet Dent 1980;43:439-44. 2. Parel SM. Diminishing dependence on adhesives for retention of facial prostheses. J Prosthet Dent 1980;43:552-60.

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