with a silicone prosthesis using conventional retention procedure. Key Words. Auricular Prosthesis, Basal Cell Carcinoma, RTV Silicone. Adhesive. Auricular ...
Rehabilitation. with a Prosthetic Ear: A case report Bhaskar Agarwal1, Mohit Kumar2, Sauymendra
V Singh3, Gaurav Singh4
lSenior Resident, 3Assistant Professor,Department of Prosthodontics, Faculty of Dental Sciences,CSMMedical University (upgraded KGMC),Lucknow, Uttar Pradesh, India, 2Professor,Department of Prosthodontics, Santosh Dental College and Hospital, Ghaziabad, Uttar Pradesh, India, 4Department of Prosthodontics, Faculty of Dental Sciences,Alighar Muslim University, Alighar, Up,Lucknow
Prosthetic ears are needed when the natural ones are missing or lost. They are indicated when surgical procedures cannot be performed or when patient does not desire for future surgery. This case report describes successful rehabilitation of an acquired auricular defect with a silicone prosthesis using conventional retention procedure.
Key Words Auricular Prosthesis, Basal Cell Carcinoma, RTV Silicone Adhesive.
Auricular defects resulting from skin cancer surgery present reconstructive challenges. Smaller defects may be repaired by primary closure, wedge repair, skin grafts, advancement or transposition flaps, or the chondrocutaneous helical rim advancement flapl. Larger defects involving significant loss of cartilage often require staged island pedicle or interpolation pedicle flaps2. Complete loss of the auricle may be reconstructed with the use of an autogenous rib cartilage graft in a multistage procedure. However, some patients prefer not to undergo additional surgical procedures once the cancer has been extirpated. In addition, some patients may require a long delay before reconstruction because of an underlying medical condition or the need to monitor the area for recurrence of an aggressive skin malignancy, in these situations, creation of a silicone auricular prosthesis is an alternative approach towards rehabilitation.
Case Report A 38 year old male patient was referred to the Department for fabrication of an auricular prosthesis. He underwent surgery, due to basal cell carcinoma. (Fig.1)As reconstruction by plastic surgery was ruled out to periodically examine for recurrence of tumor, it was decided that a silicone prosthesis retained by adhesives would be made. Severe undercuts, convolutions and translucency of the natural ear make its replication very challenging. Surgical reconstruction of the ear is the management of choice but may not be indicated
because of complex procedure and several other factors. The folloWing case report details such a case, hich was successfully rehabilitated using a silicone auricular prosthesis.
A towel was fastened around the head at the hairline and facial hairs were protected by a light application of petroleum jelly [Vaseline, Hindustan Unilever td.]. ring of boxing wax was built around the auricular area to confine the alginate, [Zelgan 2002, Dentsply India Pvt. Ltd. Gurgaon, Haryana, India] which was mixed i 1.25 times the normal amount of water, to adjus its 0 properties. After pouring the hydrocolloid in a smoo h layer over the area, gauze pieces were embedded in i 0 provide retention for the rigid plaster backing req ired for tear free removal of the impression. The plaster ype II) [Dentex, Prevest Denpro Ltd., Jammu, India] mix as spread over the gauze and its setting was verified by tapping sound. After inspection of the impression or any defects, it was poured with vacuum spatulated den al stone (Type IV) [Kalabhai, karsor Pvt. Ltd. Mumbai, I dia] in two stages to avoid distortion by the weigh 0 s 0 e, making at least a 1cm thick base at the deepes pa 0 the mold. Fororientation, markings were made superiorly, in eriorly, anteriorly and posteriorly, on the resultant stone cas . A wax base [Supermal Modelling Wax, RLD Co., uc now, India] was adapted and a pattern was constructed to duplicate the patients other ear asclosely aspossible, (also making an ear hole in the pinna, Fig.2) followed by a ry in
appointment to check for fit of the prosthesis, horizontal alignment with normal ear,its projection in relation to side of the head and integrity of the margins during simple jaw moments from all positions. After obtaining satisfactory results the pattern was invested to create a mold in three parts to allow removal of the prosthesis without tearing and to produce life like characterization. Following dewaxing, the mold cavity was initially coated with a thin layer of catalyzed uncolored silicone material [Cosmesii MS-llJ for translucency. A previously matched base color mixture of silicone was prepared to fill the mold cavity using silicone pigments to provide skin color and opacity to the mixture. The colored, catalyzed, bubble free silicone was placed into the mold cavity, taking care to allow the liquid to flow into all thin areas followed by assembling the separately characterized mold parts. Excesssilicone was expressed using light pressure, processed, and finished follOWing manufacturer's instructions. Extrinsic coloration was done after separating from mold (Fig. 3) in required areas and the patient was trained to correctly place the ear using adhesive [PSA 1b silicone adhesive (G603)]. Instructions were given on prosthesis hygiene and maintenance and recall checkups. The patient was also advised to camouflage the prosthesis by growing his hair to divert attention (Fig.4). ,
Fig. 3: Ear prosthesis before final characterization
i i
due to cancer surgery, amputation, burns and/or congenital defects. Cancers of the head and neck region can profoundly affect patients quality of life and are emotionally debilitating to patients and their families3A•5,6. The delicate structures remaining after surgery for ear carcinoma are covered by thin, highly sensitive skin, and must be kept free from irritation and debris from the environment. Apart from psychological, aesthetic and protective benefits, the function of the prosthetic ear is also to direct sound waves into the auditory canal and to maintain a proper environment for the inner ear membranes, which can improve hearing by about 20%. Such an ear can also retain eye glasses,and a hearing aid if necessary. Auricular Prosthetic replacement has several advantages over surgical reconstruction, in terms of being inexpensive, allowing for periodic evaluation and cleaning of the surgical site, and providing an alternative to candidates unsuitable for surgery? The fabrication process is relatively short, and the maxillofacial clinician has control of color, shape, and position of the prosthesis. Further, reconstructive surgery is not reversible in contrast to prosthetic restoration. Its disadvantages include a skin-prosthesis margin which is hard to hide, difficulty in matching skin color which changes throughout the year, need for regular replacement and/or repair, and extra precautions reqUired to avoid removal whenever the individual is involved in rigorous activity. The properties of the ideal material for ear prostheses have been enumerated and include biocompatibility, flexibility, lightness, low thermal conductivity, durability, moldability, easy cleansing, patient comfort, and chemical and physical inertness8,9,1O. The currently available facial prosthetic materials include methacrylate or acrylic resins, polyurethane elastomers, and silicone elastomersll. Silicone prostheses offer a cost-effective, cosmetically elegant means to camouflage large auricular defects? Several skin adhesives are compatible with silicones, adhere well under moist conditions, and are simple to use. Adhesives require patience on part of wearer to obtain correct placement of the prosthesis which may be
very difficult for older patients. Water-based adhesives are milder but are not moisture resistant and therefore do not adhere as long as silicone-based adhesivesll,12,13. RTVSilicone adhesive was used in this case as it utilizes moisture in the atmosphere to react with chemical cross links and enabls the formation of an elastomer. Once he adhesive is applied, the solvent evaporates and a tacky adhesive results, which can bond with skin. These adhesives require solvents for cleaning the prosthesis, which accelerate deterioration of the prosthetic margins, Allergic contact dermatitis is also known to occur with skin adhesives?,
3.
4. 5.
6.
7. 8. 9.
hough the patient and the clinician were satisfied with he aesthetics and function provided by the auricular prosthesis, obtaining long term compliances from the patient would be challenging, considering the limitations,
10.
11.
12.
2.
Mellette JR. Ear reconstruction with local flaps. J Dermatol Surg Oncol1991 ;17:176-82. Johnson TM, Fader DJ. The staged retroauricular to auricular direct pedicle (interpolation) flap for helical ear reconstruction. JAm Acad DermatoI1997;37:975-8.
13.
Gritz ER, Hoffman A. Behavioural and psychological issues in head and neck cancer. In: Beumer J, Curtis TA, Marunick MT, editors. Maxillofacial rehabilitation: prosthodontic and surgical considerations. St Louis: Ishiyaku Euro-America; 1996:1-14. Gotay C. Moore 1. Assessing quality of life in head and neck cancer. Qual Life Res 1992;1 :5. Gotay C, Korn E, McCabe M. Quality of life in cancer treatment protocols: research issues in protocol development. J Natl Cancer Inst 1992;84:575. Strauss R. Psychosocial responses to oral and maxillofacial surgery for head and neck cancer. J Oral Maxillofac Surg 1989;47:343. Butler DF,Gion GG, Rapini RP.Silicone auricular prosthesis. J Am Acad Dermatol 2000;43:687-690. Bulbulian AH. Facial Prosthesis. Philadelphia: W. B. Saunders Company; 1945:157. Tchalian V, Maxillofacial Prosthesis, Houston: University of Texas, Dental Branch; 1960:1-2. Fonseca EP. The importance of form, characterization, and retention in facial prosthesis. (Translated into English by Dioracy Fonterrada Vieira) J Prosthet Dent 1966:338-343. Moore DJ, Glaser ZR, Tabacco MJ, Evaluation of polymeric materials for maxillofacial prosthetics. J Prosthet Dent 1977;38:319-326. Parel SM. Diminishing dependence on adhesives for retention of facial prostheses. J Prosthet Dent 1980;43:552-560. Kiat-amnuay 5, Gettleman L, Khan Z, Goldsmith U. Effect of adhesive retention on maxillofacial prosthetics. Part 1: skin dressings and solvent removers. J Prosthet Dent 2000;84:335-340.
