Prosthetic Rehabilitation of a Patient with Nose Defect

Prosthetic Rehabilitation of a Patient with Nose DefectCase notifyAuthors Satyabodh S Guttal, MDS,MFPT 1, Blessy Bangera, BDS,2 Adarsh Kudva,MDS,3 Basavaraj R Patil, MS, 4AbstractMidfacial defects are enormous defects that result from cancer treatment that rarely are corrected by surgical reconstructive memory alone they generally require a facial prosthetic device to restore function and appearance. Surgical reconstruction may be viable for few defects, which are done with different flaps. But for the total penniless resection, prosthetic option would be more feasible. Nasal cartilaginous anatomy is complex due to the vary contours. Therefore it may be difficult for the surgeon to reconstruct the entire curve. This clinical breed describes the replenishment of a large midfacial nose defect with a dental graft retained emaciated prosthetic device. The diligent had adenocystic carcinoma of the medial maxillary wall extending to the nose.IntroductionThe face being the mos t noticeable initiate of the ashes when disfigured may lead to an impaired social smell stemming from esthetical problems. 1, 2 Among facial defects, hard up defects produce severe cosmetic impairment. . Rehabilitation of such defects subsequent to surgery is done in a sequential manner, which includes a surgical, provisional, and classical prosthesis. 3 Prosthesis helps restore the longanimouss self-esteem and confidence, hence affecting the tolerants and their life style. 4-6Adenoid cystic carcinoma (ACC) is a rare malignant perineural tumour of the major and minor salivary glands, accountancy for 2% of all head and neck malignancies and approximately 10% of all salivary gland neoplasms. 60% to 70% of ACCs arise in the minor salivary glands, which may be localized in the palate, paranasal sinuses and nose, although they may also occur in the parotid or submandibular glands.7In the past, nasal prostheses were held in position with strings or straps fastened behind the head ,8 intranasal or intraoral extensions,9,10 and gold strings or leaves.11-13 Spectacle frames fuddle been accepted for securing nasal prostheses.14,15 Today, with the development of biomaterials, prosthetic substitutes are secured with readily available adhesives that are effortlessly use 16 however, the effectiveness of adhesives is questionable con facial expressionring presence of mobile tissues in the defect, nasal secretions, and moist air associated with respiration.17 These factors would via media the adhesiveness. The concept of osseointegration 18 has enabled a more reliable mode of retaining nasal prostheses. 19 This clinical report describes the refilling of a large midfacial defect victimization an implant retained nasal prosthesis.Clinical ReportA 63-year-old female patient who account to the B.R Patil Cancer hospital, Navanagar, Dharwad was diagnosed with adenocystic carcinoma of the medial maxillary wall. Patient had no medical co-morbidity. Patient gave history o f nasal barricade due to nasal mass on left side of the nostril for which medial maxillectomy was done via endoscopic approach in the year 1993. Then in 2012 she reported back with the complaint of nodular swelling over nasal dorsum with tearing and nasal obstruction with no orbital symptoms. Intra-orally patient had destruction of palate on the left side crossing midline. Upon advertize investigation, biopsy revealed adenocystic carcinoma of the nose and left maxilla with no involvement of orbit or anterior skull base ( common fig 1). dickens cycles of chemotherapy with cisplatin, 5 flurouracil and paclitaxel according to body surface area was given.The defect resulting after excision had to be cover at the earliest. Hence, prior to surgical intervention, prosthetic consultation was suggested to the patient who was thus referred to our Department of Maxillofacial Prosthodontics. Since an speedy definitive prosthesis was not feasible, the patient was suggested for temporary reh abilitation with an interim silicone nasal prosthesis with an attached eyeglass frame. However, since the patient expressed her displeasure towards spectacles for lifelong usage, she was given the option of implant-retained definitive silicone nose prosthesis. The patient agreed for the same. An orthopantomograph and computerized tomography scan were made as a part of the investigation to evaluate the bone height for implant placement.Left total maxillectomy with palatal resection across midline and total nasal resection done via weber ferguson incision, left modified radical neck dissection type 3 via macfee incision was made. The glabellar bone was evaluated on the act table and upon conclusion that adequate bone was available a single implant of 4.2 diameter x 6.5mm length, (Toureg S Adin implants, Nazareth, Israel) was displace (Fig 2). The advantage of placing the implant on the operation table was that the patient would be under general anesthesia, and the mental trauma of undergoing another surgical result was avoided. sideline a healing period of 3 months the open tray embossment posts were placed and the final impression was made. The abutment was placed on the implant and a custom made acrylic sleeve was fabricated for the abutment (Fig 3). A develop sculpted nose on the master cast was made to adapt to the margins of the healing wound. On either sides of the acrylic resin sleeve, two neodymium-iron-boron magnets, 5mm diameter x 1.2mm thick (Magnatech Mumbai, India) were infix into extensions made come start of autopolymerising resin. The structure hence resembled a winged sleeve which was cemented on to the abutment using zinc-phosphate cement (Harvard Dental, Hoppegarten,Germany) (Fig 4). An acrylic resin index was fabricated over this structure which would harbor the respective magnetic keepers. The acrylic index was placed at its position over the magnets and was picked up by the wax nose that was placed on it using a drop of cyanoacryl ate. The resulting wax nose thus incorporated an acrylic index with the magnetic keepers. This wax nose was carefully invested and the packing procedure using silicone and acrylic resin border framework, natural coloring was carried out as mentioned for the interim above. Extrinsic coloring and pigmentation was done and patient was happy with the esthetic results. Digital weighing scale revealed that the definitive nasal prosthesis weighed around 12.2gms. The retentive force offered by the two neodymium-iron-boron magnets (Magnatech Mumbai, India) was rig to be 7.2N. The prosthesis was delivered to the patient (Fig 56). Following this, home-care instructions were given. In the subjective evaluation, the patient was very happy with the esthetics outcome of the prosthesis and expressed her great pleasure towards her ability to suck up liquids. The ryles tube continued to remain in place considering the general health condition of the patient and the hold to feed semi solid food an d protein supplements. The prosthesis was light in weight and could be substantially placed in position as it was self-aligning due to the use of magnets. Patient, who is now on regular semestral follow-up ie, recalling at every 3 month period, is found to be doing well.DiscussionNasal reconstruction modalities comprises of primary closure, healing by secondary intention, skin grafts and local flaps and regional flaps. Small surgical defects can be treated well with different types of local flaps. The forehead flap is the better option for the large nasal defects. 20 The complex anatomical configuration may cause difficulty in surgical rehabilitation. In such occurrences, prosthetic closure is predictable and hence usually the treatment of choice. 21,22 The uncovering for rehabilitation of facial defects with implant-retained prostheses came with the development of the modern silicones and bone anchorage.The limitations of the prosthesis were explained to the patient prior to the treatment, that fact that the prosthesis would enhance esthetics but would contribute less to the functions like speech and masticatory habits. Hence, the patient had no psychological set back on the prognosis of the treatment. In addition, there was a major set-back in terms of achieving outstanding esthetical and functional outcome due to the fact that all the work was carried out under technical constraints. This included a lack of time, chair-side patient availability, and ideal light conditions which, to an extent precluded best color blending.The main objective of treating this case was to close the open defect, to prevent the further spread of contagion in the soft tissues exposed to the environment. The use of a magnetic assembly has eliminated the need for use of spectacle retentivity as per the patients request. The patient indicated that the nasal prosthesis reduced self-consciousness and was comfortable to have without any type of irritation to the surrounding skin. The patient was pleased with her appearance and no longer found the need to wrap a cloth around her face.ReferencesGuttal SS, Patil NP, Thakur S, Kumar MV, Kulkarni S. Implant-Retained Nasal Prosthesis for a Patient Following Partial Rhinectomy A Clinical Report . J Prosthodont 2009 183538.Kumar S, Rajtilak G, Rajasekar V, Kumar M. Nasal prosthesis for a patient with xeroderma pigmentosum. J Pharm Bioallied Sci 2013 5176-8.Marunick MT, Harrison R, Beumer J. Prosthodontic rehabilitation of midfacial defects. J Prosthet Dent 1985 54553-60.Buzayan MM. Prosthetic oversight of mid-facial defect with magnet-retained silicone prosthesis. Prosthet Orthot Int 2014 3862-7.Jain S, Maru K, Shukla J, Vyas A, Pillai R, Jain P. Nasal prosthesis rehabilitation a case report. J Indian Prosthodont Soc 2011 11265-9.Anantharaju A, Kamath G, Mody P, Nooji D. Prosthetic rehabilitation of Oro-nasal defect. J Indian Prosthodont Soc 2011 11242-5.Shimamoto H, Chindasombatjaroen J, Kakimoto N, Kishino M, Mur akami S, Furukawa S. Perineural spread of third tonsil cystic carcinoma in the oral and maxillofacial regions evaluation with contrast-enhanced CT and MRI. Dentomaxillofac Radiol 2012 4114351.Saunders RCH. The gunner with the silver mask. Am Med Hist 1941 3283-5.Kazanjian VH, Rowe AT, Young HA. Prosthesis of the mouth and face. J Dent Res 1932121Kazanjian VH. discussion of nasal deformities. J Am Med Assoc 1925 84177.Bulbulian AH. Facial Prosthetics. Springfield IL, US, Ed 1, 1973 pp. 364-7.Baird WH. An artificial nose. Dent creation 1905 47560.Baker L. An artificial nose and palate. Dent Cosmos 1905 47 561.Rodrigues S, Shenoy VK, Shenoy K. Prosthetic rehabilitation of a patient after partial rhinectomy a clinical report. J Prosthet Dent 2005 93125-8.Guttal SS, Patil NP, Shetye AD. Prosthetic rehabilitation of a midfacial defect resulting from lethal midline granuloma a clinical report. J Oral Rehabil 2006 33863-7.Parel SM. decrease dependence on adhesive for retention of facial p rosthesis. J Prosthet Dent 198043552-60.Parel SM, Branemark PI, Tjellstrom A, Gion G. Osseointegration in maxillofacial prosthetics. Part II extraoral applications. J Prosthet Dent 198655600-6.Brnemark PI, Adell R, Breine U, Hansson BO, Lindstrm J, Ohlsson A. Intra-osseous anchorage of dental prostheses. I. observational studies. Scand J Plast Reconstr Surg 1969381-100.Nishimura RD, Roumanas E, Moy PK, Sugai T. Nasal defects and osseointegrated implants UCLA experience. J Prosthet Dent 199676597-02.Kose R, Okur MI. Reconstruction of the defects in the middle of the nose with subcutaneous pedicled nasolabial island flap report of two cases. Kulak Burun Bogaz Ihtis Derg. 200919(5)272-276Sashi Purna CR, Annapurna PD, Ahmed SB, Vurla S, Nalla S, Abhishek SM. Two-piece nasal septum prosthesis for a large nasal septum perforation a clinical report. J Prosthodont 201322143-7.Goveas R, Puttipisitchet O, Shrestha B, Thaworanunta S, Srithavaj ML. Silicone nasal prosthesis retained by an intr anasal stent a clinical report. J Prosthet Dent 2012108129-32.Figure LegendsFig 1 Preoperative patients photographFig 2 Placement of titanium dental implant in the glabella,-confirmed on the x-ray.Fig 3 Abutment threaded to implant and the trial of acrylic resin sleeve done.Fig 4 Cemented acrylic resin framework embedded with magnets on either side.Fig 5 Comparison between before and after prosthesis placement.Fig 6 Lateral profile of before and after prosthesis placement. Spectacle glasses were given to camouflage the borders of the prosthesis.