CASE REPORT |
https://doi.org/10.5005/jp-journals-10005-2653 |
Surgical Nasal Stent Fabrication Using Innovative Multisegmental Cast to Rehabilitate Anatomic and Functional Dynamicity of Upper Airway: A Case Report
1–6Department of Prosthodontics and Crown and Bridge, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India
Corresponding Author: Sandeep Singh, Department of Prosthodontics and Crown and Bridge, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India, Phone: +91 9603410117, e-mail: drsandeepsingh011@gmail.com
ABSTRACT
Aim: The purpose of this case report is to provide a simple, efficient, and novel technique for fabricating a nasal stent utilizing a multisegmental cast to rehabilitate the anatomic and functional dynamicity of the upper airway following primary cleft lip and primary rhinoplasty surgery.
Background: Nasal deformity is often associated with congenital unilateral or bilateral cleft lip and palate. Despite primary nasal reconstruction at the time of definitive lip repair, the long-term postoperative outcome of the nasal correction frequently falls short of the surgeon’s or patient’s expectations. This condition is more prevalent in the Asian population due to undeveloped, thin alar cartilage and thick skin.
Case description: A 4-month-old female infant was referred from the Department of Plastic Surgery for the fabrication of a nasal stent after surgical cleft lip repair with nasal reconstruction. A customized nasal stent using a multisegmental cast followed by relining with tissue conditioner was planned to minimize relapse of the nasal defect.
Conclusion: The technique described in the present case for nasal stent fabrication is simple, cost-efficient and innovative. Postoperative use of this nasal stent helps to maintain the corrected position of the nose after primary lip and nasal correction, resulting in significantly improved esthetic results.
Clinical significance: Nasal surgical correction deteriorates over time, especially within the 1st year of surgery due to tissue memory and contraction of the scar tissue. Hence a nasal stent should be worn after the surgery to maintain the corrected nasal form.
How to cite this article: Singh S, Rathee M, Alam M, et al. Surgical Nasal Stent Fabrication Using Innovative Multisegmental Cast to Rehabilitate Anatomic and Functional Dynamicity of Upper Airway: A Case Report. Int J Clin Pediatr Dent 2023;16(S-2):S220–S223.
Source of support: Nil
Conflict of interest: None
Keywords: Case report, Cleft lip and palate, Facial esthetics, Multisegmental cast, Nasal deformity, Nasal stent, Pediatric prosthesis, Primary surgical closure
INTRODUCTION
Nasal deformity is often associated with congenital unilateral or bilateral cleft lip and palate. The degree of nasal deformity is proportional to the severity of the associated cleft lip. The entire nasal pyramid is wide, depressed, and asymmetric with collapsed alar cartilage, deviated nasal septum, altered nasal floor and blunt, and downshifted nasal tip.1 Nasoalveolar molding for approximation of cleft segments followed by primary surgical closure of the lip and nasal reconstruction has become an expected standard treatment of infants with cleft lip and palate.2
Maintenance of the achieved nasal surgical correction via nasal stent is extremely important as there are chances of relapse. Postsurgical nasal stent maintains the surgical correction and reduces scar contracture thereby maintaining the anatomic and functional dynamicity of the upper airway. A multisegmental cast offers precise orientation of patency of the nostril while fabricating a nasal stent.3 The aim of this case report is to describe an innovative technique of fabrication of nasal stent using a multisegmental cast following a primary cleft lip and primary rhinoplasty surgical procedure.
CASE DESCRIPTION
A 4-month-old female infant was referred from the Department of Plastic Surgery for the fabrication of a nasal stent after surgical cleft lip repair with nasal reconstruction. The patient had a history of bilateral cleft of the lip including philtrum, columella, and cleft of the right side of the alveolus extending till premaxilla (Veau class III cleft lip and palate). She underwent presurgical nasoalveolar molding for up to 4 months to obtain an optimum approximation of the soft tissues of the lip before primary surgical closure. Extraoral examination revealed brownish scar tissue in the columella region. The upper lip was cupid bow-shaped with slight irregularity in the columella region. The nose was placed in the midline with the left external nare placed slightly higher than the right external nare. The base of the nose was flat with flared nostrils (Fig. 1). A customized nasal stent using a multisegmental cast followed by relining with tissue conditioner was planned to minimize relapse of the nasal defect.
Figs 1A and B: Frontal view
CLINICAL STEPS
Impression Making
The infant was seated comfortably in head down position on the mother’s lap. Petroleum jelly was applied to the external and internal surface of the anterior nares which acts as a separating media and facilitates the comfortable removal of the impression. The nostrils were blocked with a petroleum jelly-coated gauze piece attached to a thread to prevent the impression material from being displaced deep into the nasal cavity (Fig. 2A). Impression was made using light body polyvinyl siloxane impression material (Aquasil, Dentsply) backed up by putty addition silicone impression material (Zhermack Putty soft, Zhermack, Italy) (Fig. 2B). The intra- and extranasal combined impression was retrieved (Fig. 3A). Impression was inspected for all details and was disinfected.
Figs 2A and B: (A) Internal nares block out with gauge piece; (B) Light body impression material backed by putty consistency
Figs 3A to D: (A) Final impression; (B) Plaster boxing and beading in putty; (C) Division of impression in three equal parts; (D)Three-part cast
Fabrication of Three-part Cast
To delineate the area of interest, beading and boxing of the retrieved impression was done (Fig. 3B). Impression was divided into three equal vertical parts, the right and left lateral half of ala of nose and columella of the nose (Fig. 3C). Each part was poured with different color of dental stone with consecutive notching of each segment for the precise assembly of the multisegmental cast (Fig. 3D).
Centralization of Internal Nares
Three parts of the multisegmental cast were separated and the internal anatomy of both nares was traced and engraved with a round bur. A 21 gauge orthodontic wire was adapted in accordance with the traced internal anatomy to achieve the centralization of internal nares with a wire protruding out of nares (Fig. 4A). Multisegmental cast was then assembled using sticky wax.
Figs 4A to C: (A) Centralization of internal nares with orthodontic wires; (B) Gutta-percha and hollow plastic tube; (C) Placement of hollow plastic tube to maintain patent airway
Two similar-length plastic hollow tubes were selected and inserted around orthodontic wires to maintain a patent airway. Separating media was applied on the cast and the nasal stent was fabricated using clear self-cure acrylic (DPI-RR Cold Cure; Dental Products of India). Gutta-percha points were incorporated into both the lateral wings and into the midline of the stent to impart radiopacity (Figs 4B and C). Finishing, polishing, and disinfection of the nasal stent was done.
Fabrication of the Retention Assembly
Two 1 mm holes were made on both the wings of the nasal stent, with the help of round bur, and dental floss was tied at both ends (Fig. 5A). A flexible and adjustable strap of the face mask was attached to both the ends of floss to provide support from the occipital region (Fig. 5B).
Figs 5A to D: (A) Fabrication of stent; (B) Stent attached with floss and face mask strap; (C) Stent in situ; (D) Postsurgical follow-up after 3 months
Insertion of the Appliance
Before insertion, the nasal stent was relined with a soft reliner (Visco-gel, Dentsply) (Fig. 5C). Parents were instructed to keep the appliance for full-time use. They have demonstrated the insertion and removal of the appliance and were instructed to maintain the hygiene of the appliance.
Follow-up
The patient was scheduled for a monthly follow-up and every time relining was done at each visit to help in nasal molding with advancing age (Fig. 5D).
DISCUSSION
In patients with cleft nasal deformity, postoperative preservation of the corrected shape is critical for achieving a symmetric and well-proportioned nose.4 To correct the nasal deformity, especially in Asian patients, sustaining the shape of the repaired nose after corrective surgery is extremely important, as the Asian population is prone to recurrence following surgery due to undeveloped, thin alar cartilage and thick skin.5 Surgical repositioning during primary lip surgery aids in the natural development and growth of the nose. Despite the improved results with primary rhinoplasty at the time of lip repair, a large majority of patients still suffer from residual nasal abnormalities such as sagging of alar cartilage, asymmetrical nostril size, and inadequate tip projection due to a tilted columella. Nasal splints should be worn for at least 6 months after surgery to counteract these side effects.5
Numerous designs of nasal stent such as hollow nasopharyngeal airway tube, application of soft silicone rubber stents, Koken stents, bending hollow acrylic tubing into a horseshoe shape, and methylmethacrylate expansile stent are present in literature that has been used postoperatively and all of which need a screwdriver to expand. The use of these sophisticated devices in babies are limited as they may necessitate active patient cooperation.6,7
In the present case, the innovative multisegmental cast fabricated by pouring the final elastomeric impression in three parts provided a better view of the internal aspect of the nose and facilitated three-dimensional pattern fabrication. Tracing the internal nasal anatomy on multisegmental cast helped in the precise centralization of internal nares and fabrication of nasal stent which maintained a patent airway.
In the present case, clear self-cure acrylic resin which is a readily available and cost-effective material has been used for the fabrication of a nasal stent which is assembled with a dental floss and easily available face mask strap to provide extranasal retention. Face mask provides a more adjustable, flexible, and economical alternative to other forms of extranasal retention.
As the stent was made of polymethylmethacrylate which is radiolucent, radiopaque gutta-percha points were incorporated in lateral wings and midline of the stent to safeguard against accidental aspiration of appliance. Two equal hollow plastic tubes were incorporated with centralization of internal nares which maintain equal pressure in both lungs. Before insertion nasal stent was relined with a soft reliner to prevent injury to the delicate nasal mucosa and relining was done in every visit which facilitated nasal molding with advancing age.
CONCLUSION
The technique discussed in the present case for nasal stent fabrication is simple, cost-efficient, and innovative. Postoperative use of this nasal stent serves to preserve and maintain the corrected position of the nose after primary lip and nasal correction, resulting in considerably improved esthetic results.
Limitation
Patient cooperation is required.
Recommendation
The benefits of the surgical stent can be best harvested if the patient is referred timely, that is, immediately after the surgery as scar contracture is minimum at that time.
ORCID
Sandeep Singh https://orcid.org/0000-0001-7823-7364
Manu Rathee https://orcid.org/0000-0002-0007-542X
Prachi Jain https://orcid.org/0000-0002-4560-8330
Divakar Santhanam https://orcid.org/0000-0003-1337-8128
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