|Year : 2014 | Volume
| Issue : 2 | Page : 134-139
Enhancing the quality of life: Prosthetic rehabilitation of nasal defect
Natarajan Kalavathy1, Janakirama Reddy Sridevi1, Sunitha Roy2, Neeladri Verma1, Sonali Chhabria1
1 Bengaluru, Karnataka, India
2 Oxford Dental College and Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||7-May-2014|
Department of Prosthodontics Crown and Bridge, D.A.P.M.R.V. Dental College and Hospital, J.P. Nagar, 1st Phase, Bengaluru - 560 078, Karnataka
Face is an important part of one's personality and body image. Facial disfigurement can have extremely negative psychological impact on any individual, which may include feeling of being ugly, deformed, disfigured, and complete loss of self-confidence. A facial prosthesis is fabricated to restore any such anatomical compromise, which can be congenital, due to trauma or oral/facial malignancies. Patients who need such prosthesis usually present a wide array of rehabilitation challenges mainly associated with restoring normal appearance. The following case report illustrates the prosthetic rehabilitation of a 9-year-old boy who was diagnosed with basal cell carcinoma of the nose and underwent partial rhinectomy. Surgical reconstruction was also done for the same, which was unsuccessful due to failure of graft. This led to loss of right lateral ala of the nose and depression of the upper half of the bridge of the nose. This case was then prosthetically managed with a spectacle retained nasal prosthesis made up of acrylic.
Keywords: Acrylic, basal cell carcinoma, facial prosthesis, nasal prosthesis, partial rhinectomy
|How to cite this article:|
Kalavathy N, Sridevi JR, Roy S, Verma N, Chhabria S. Enhancing the quality of life: Prosthetic rehabilitation of nasal defect. SRM J Res Dent Sci 2014;5:134-9
|How to cite this URL:|
Kalavathy N, Sridevi JR, Roy S, Verma N, Chhabria S. Enhancing the quality of life: Prosthetic rehabilitation of nasal defect. SRM J Res Dent Sci [serial online] 2014 [cited 2021 Dec 3];5:134-9. Available from: https://www.srmjrds.in/text.asp?2014/5/2/134/132095
| Introduction|| |
Face is said to be our window to the world and in today's appearance conscious society living with any change in the appearance of one's face, as a result of congenital anomaly, injury, disease, burns, trauma, or malignancy is a very challenging task. An individual's perception of esthetics and self-esteem are often adversely affected by any sort of facial defect, acquired, or congenital.
Head and neck cancers are one of the most common causes of acquired facial defects. Basal cell carcinoma (BCC) is by far the most common type of skin cancer. Basal cell cancer, also called the "rodent ulcer," develops in the basal cell layer of the epidermis and can be very destructive and disfiguring. It is described by the World Health Organization as "a locally invasive, slowly spreading tumor, which rarely metastasizes." 
Basal cell cancer occurs mainly on hair-bearing and sun exposed skin areas and around 88-90% of BCCs are seen mainly areas like the upper two-thirds of the face and neck. People with fair skin, red hair, and freckles are at a higher risk of developing BCC. There is a much greater incidence of BCC in males than females. ,
Basal cell carcinomas are usually successfully treated through one of the following methods: Mohs micrographic surgery, surgical excision, liquid nitrogen cryosurgery, radiation therapy and curettage, and electrodessication. Chemotherapy is a newer modality of treatment. Choice of treatment depends on the size, depth, and location of the neoplasm. Early diagnosis and treatment will lead to higher success rates. Recurrence is a frequent problem with BCC. The aims of any therapy for the treatment of BCC are to ensure that the lesion is removed completely, there is the preservation of function, and a good cosmetic result. 
Majority of nasal defects are the result of treatment of cancers and some are secondary to trauma. Smaller nasal defects can be managed by surgical reconstruction, but larger defects are best managed prosthetically.  Nasal prosthesis can be temporary, which is given 3-4 weeks following surgery for cosmetic reasons, or definitive which is given after 3-4 months so that the surgical wound has healed completely and wound contraction and organization is over. Furthermore, the prosthesis can be fabricated in heat cure acrylic or silicone material.
This case report describes the use of a definitive nasal prosthesis which was given 3 months postpartial rhinectomy as the surgical reconstruction failed due to graft failure. The usage of this prosthesis enabled the patient to resume social interactions.
| Case report|| |
A 9-year-old boy, diagnosed with BCC of the nose, was referred to Department of Prosthodontics, D.A.P.M.R.V Dental College Bangalore, before surgery. Extra-oral examination was done and preoperative photographs were made and the patient was recalled after surgery [Figure 1] and [Figure 2]. Patient reported back 1 week after surgery. The nasal defect was surgically corrected with forehead flap hence no interim nasal prosthesis was necessary [Figure 3]. Three months later, the patient again reported back with failure of graft. On examination, there was the loss of the right lateral ala of the nose and depression of the upper half of the bridge of the nose [Figure 4]. An acrylic nasal prosthesis was planned for the patient based on the age factor. The procedure of fabrication of nasal prosthesis and its usage, benefits, and limitations were explained in detail to the patient and his parents.
|Figure 3: Postoperative picture after 1 week of reconstruction surgery of nose|
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Petroleum jelly was applied to eyelashes and eyebrows. Nostrils and all the undesirable undercuts were blocked out using moist gauze and the patient's face was boxed using boxing wax. The patient was asked to breathe through the mouth throughout the procedure. Impression was made with alginate and reinforced with pins and plaster of Paris [Figure 5] and [Figure 6]. Facial moulage was thus obtained by pouring this facial impression in Type III dental stone. On this preliminary cast, a special tray was fabricated with acrylic. This special tray was used to make the final impression of the anatomic defect using alginate and the master cast was obtained [Figure 7]. ,
A wax pattern was made on the master cast using modeling wax and sculpted to reproduce the contours and texture of the nose taking the preoperative photographs as reference [Figure 8]. The margins were feathered so that the prosthesis would blend with the surrounding tissues. The wax pattern was then tried on the patient and the desired changes were made [Figure 9] and [Figure 10].
The wax pattern was then invested and dewaxed [Figure 11] and [Figure 12]. A carefully selected base shade was mixed with the heat cure acrylic and the material was packed and processed according to the manufacturer's instructions [Figure 13]. The processed prosthesis was then finished [Figure 14] and evaluated on the patient and then chair-side external characterization was done. The final prosthesis was mechanically retained using spectacles [Figure 15] and [Figure 16].
|Figure 14: Try in of internally characterized prosthesis retained with spectacles|
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|Figure 15: Lateral view of externally characterized prosthesis retained with spectacles|
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|Figure 16: Frontal view of externally characterized prosthesis retained with spectacles|
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The patient and his parents were taught how to wear the prosthesis and all the home care instructions were given. The patient was recalled for a post insertion checkup after 24 h and was scheduled for a follow-up appointment once in 3 months for subsequent evaluation of the prosthesis and observation of any recurrence.
| Discussion|| |
Most cases of BCC are seen in elderly male patients with the peak incidence seen in the seventh decade of life. BCC in the pediatric population is rare and is usually found in association with some genetic defect. Sporadic incidences of BCC in children with no known genetic syndromes have also been reported.  Surgery is usually the treatment of choice in such cases.
One of the most important risk factors for BCC is considered to be sun exposure. The areas on the body most susceptible to skin cancer are those that are least protected from the sun. In particular, the ala and tip of the nose are most outwardly protruding areas on the face, thus are most vulnerable. Around 30% cases of BCC are reported in the nasal area. 
Nose is a prominent feature on the human face. Any defect or deformity related to it easily catches the attention. Thus, while restoring a nasal defect with prosthesis absolute care must be taken to keep it as inconspicuous as possible.
The nasal defects secondary to tumor removal surgeries or accidental trauma can be restored ideally by plastic surgery, which sometimes when not possible, the defect can be restored using either a silicone or an acrylic prosthesis. The nasal prosthesis can be fabricated in acrylic or silicone materials. Acrylic prosthesis is inexpensive and can be adjusted during the healing phase postsurgery, thus is preferred for the interim prosthesis and silicones are the material of choice for the definitive prosthesis due to superior color match and esthetics. The methods used to retain the prosthesis include medical adhesives, use of mechanical support (e.g., eyeglasses) and osseointegrated implants. Medical adhesives can cause tissue irritation and may damage the margins of the prosthesis during removal for maintenance and cleaning. Osseointegrated implants are relatively expensive, require adequate bone for implant placement and involve a longer duration of time. Nasal prosthesis supported by eyeglasses are cost-effective, provides sufficient retention and may serve as interim prosthesis until a more definitive prosthesis could be made. 
The prosthesis can be fabricated using the conventional technique and recently several authors have used laser scanning, computer aided design/computer aided manufacturing techniques and rapid prototyping to fabricate the prosthesis thereby reducing the time for the appointment and improving the quality of the prosthesis.  Computerize color matching and three-dimensional photography can aid in fabricating esthetically more pleasing prosthesis. Impressions of the defect can be made by using noncontact optical impression techniques. Thus, a wax pattern can be virtually fabricated and corrections can be made on the three-dimensional images of the patient. This reduces the duration of appointments and eliminates all the discomfort the patients have to go through. However, we are still at a very early stage in the introduction of these breakthrough technologies. 
The facial moulage and detailed impression of the defect in this case were made with thin consistency alginate, which does not compress the underlying tissue bed and easily flows. 
In this case, the definitive prosthesis was fabricated in heat cure acrylic as the patient was 9-year-old and would undergo age changes and gradually the prosthesis will have to be replaced from time to time until the patient attained full maturity.
The prosthesis was intrinsically colored using titanium based water soluble acrylic colors and the later chair-side extrinsic tints were applied to characterize it.
Spectacle frame retention was chosen for the present patient. Eyeglasses not only provided a mode of retention, but also concealed the margins of the prosthesis and enhanced the appearance. , Implant retained prosthesis can be planned once the child completes the skeletal growth.
| Conclusion|| |
Patients who survive cancer have a very distressing experience as such and postsurgical deformity adds up to the trauma.  Maxillofacial prosthetics is an art and science which is not very popular. Patients are usually not aware of the fact that the disfigurement can be prothetically managed. As prosthodontists, it is our duty to spread the information regarding such prosthesis. This will help in enhancing the quality of life for such patients and will help them regain their lost confidence.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]