Prosthetic management of large nasal septal defects

Hussein S. Zaki, DDS, MS, a and Eugene N. Myers, MD b

University of Pittsburgh, School of Dental Medicine, Pittsburgh, Pa.

Large nasal septal defect is defined as a defect that exceeds in size a stretched nostril. Large nasal septal defects c a n n o t be closed by hard acrylic resin nasal septal obturators because of access and path-of-insertion problems. However, obturation can be achieved by construction of a nasal stent that fits into one of the nasal cavities. This article describes a procedure used to manage a large nasal septal defect with an intranasal heat-processed acrylic resin stent. The medial wall of the stent indirectly allows for the partition o f the two nasal cavities. The stent is rendered patent to allow for comfortable breathing. The impression making and c o n s t r u c t i o n o f these stents is n o t difficult. These nasal stents indirectly separate the two nasal cavities and effective obturation of large nasal septal defects is achieved. (J Prosthet Dent 1997;77:335-8.)

the field o f r h i n o l o g y the symptom complex o f septal perforation is one o f the most t r o u b l e s o m e ) The symptom complex o f uncorrected nasal septal defects include episodes o f epistaxis, postnasal discharge, rhinorrhea, air turbulence, and mucus crusting. Patients with nasal septal perforations usually complain o f nasal dryness, whistling on inspiration, excessive mucus crusting, and epistaxis. 2-7The importance o f nasal septal defects varies in most cases in direct proportion to the etiologic factors producing it. The etiology o f nasal septal perforation is more often due to local factors than to systemic complications. Local complications after septal surgery or intranasal trauma 2,3 are among the c o m m o n causes o f nasal septal perforation. Many patients have previously undergone submucous resection to correct a deviated septum. 2 Intranasal trauma includes nose picking and the use o f c a u t e r y or caustics on both sides o f the anterior nasal septum to treat epistaxis. Local exposure to cocaine; irritants such as lime, tar, and pitch; calcium nitrate; sulfuric acid; arsenicals; salt; and glass and chromic acid fumes may cause septal perforations. In a series o f 45 patients examined by Kern et al. 4 the cause o f nasal septal perforations could not be discerned for all patients. However, the authors indicated that the perforation was related to nose picking (8 patients), external trauma (6 patients), septal surgery complications (14 patients), cautery for epistaxis (3 patients), and lupus erythematosus (1 patient) and sarcoidosis (1 patient). Rarely does nasal septal perforation occur as a complication o f some systemic disease. Snyder et al. s reported on two patients with nasal septal perforations resulting from systemic lupus erythematosus adding to seven previously reported cases in the literature. They also concluded that all nine reported cases showed certain comm o n characteristics. Septal perforation and episodes o f
aAssociate Professor of Prosthodontics and Director of Maxillofacia[ Prosthodontic Program. bProfessorand Chairman of Otolaryngology, University of Pittsburgh Medical Center. MARCH 1997

In

epistaxis became clinically evident during an exacerbation several months to years after the diagnosis o f systemic lupus erythematosus. Rheumatoid arthritis, 6 syphilis, tuberculosis, typhoid, and diphtheria are described as other systemic causes. With exacerbation o f the underlying systemic disease, the perforations tend to enlarge and epistaxis is a constant initial symptom. Surgical or mechanical obturation o f these defects will help alleviate the problem o f bleeding and mucus crusting and will add greatly to the comfort of patients. Attempts at surgical closure have included the use o f mucosal flaps,8 septal shortening, 1a composite flee graft from the anterior end o f the middle turbinate and fascia,9 and free pericranium autografting with cranial periosteum. 2 The major drawback in surgical closure is a significant breakdown at the repair site. This has led to the recommendation o f no surgical repair, especially in cartilaginous perforations with healed nasal margins, l Prosthetic closure of the anterior nasal septal perforation is the treatment o f choice in most o f these cases. ~lqs Mechanical closure o f the nasal septal defect by artificial means has proved to be a safer and more predictable approach than surgical treatment has. Some clinicians have made two-dimensional tracings o f the defect to fabricate an obturator. The use o f blotting paper to soak up mucus, except in the area o f perforation, was used to determine the outline o f the defect) 3 The dry part was cut out and placed over a piece o f soft Silastic silicone rubber (Dow C o m i n g Corp.) sheeting approximately 4 to 5 m m in thickness. This sheet was then trimmed to form the Silastic silicone rubber button. Kern et al.4 used a piece o f paper in one nasal cavity and outlined the margins o f the perforation in the other cavity with a cotton ball dipped in thimerosal. This template was used to hand carve a nasal button from medical-grade Silastic silicone rubber. Constructing the nasal septal obturator from an actual impression o f the defect has proved to be the most logical approach in managing these defects. 7,I2,14,1sNasal septal obturators are constructed o f either medicalTHE JOURNAL OF PROSTHETIC DENTISTRY 335

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Fig. 1. Examination of nasal septal defect with lighted otoscope and nasal speculum.

Fig. 2. Diagrammatic representation of nasal cavity in sagittal section. 1, Hypophysis; 2, sphenoid sinus; 3, perpendicular plate of ethmoid; 4, nasa[ spine of frontal bone; 5, nasal septal cartilage; 6, nasal vestibule; 7, maxillae; 8, vomer; 9, irregular large nasal septal defect.

used to manage a large nasal septal defect with an intranasal heat-processed acrylic resin stent. TECHNIQUE The examination of the nasal septal defect (Fig. 1) is done by placing a nasal speculum in one nostril and a lighted otoscope or fiberoptic light in the other nostril. The extent and configuration of the defect (Fig. 2) and proper identification of the remaining structures should be determined before any attempt to make the impression. It is helpful to aspirate mucus crusting before final determination of the defect. If the defect is found to be grossly larger than the stretched nares, the use of a rigid heat-processed acrylic resin nasal septal obturator will be precluded. The defect can be indirectly obturated by use of a hollow intranasal stent in one of the nasal cavities. The medial wall of the stent will prosthetically replace the missing part of the nasal septum. An impression of the nasal cavity is made with RTV silicone (Silicone Inc., High Point, N.C.). Immediately after the silicone is mixed, one or two cotton-tipped applicators are wetted thoroughly with the silicone. This will prevent separation of the silicone from the cottontipped applicators during removal of the final impression. The nasal speculum is used to widely open the nostril. The applicators are placed passively through the contralateral nostril into the nasal cavity without touching any of its walls. The cotton-tipped applicators should be visible through the speculum and the defect. A disposable syringe (Monojet 4 / 1 2 , Sherwood Medical, St. Louis, Mo.) is used to inject the silicone impression material into the opposite nasal cavity (Fig. 3.). A lubricated spatula is then used to adapt the material around the periphery of the septal defect. During impression malting attempts are made to record only one nasal cavity and only the perimeter of the defect. It is preferable not to record in the impression both sides of the septum, contrary to the impression technique used to construct nasal septal obturators.14,15 After the impression has set, the cotton-tipped applicator acts as a handle to help remove the impression.
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grade Silastic silicone rubber or heat-processed acrylic resin. Both materials are biocompatible; however, medical-grade Silastic silicone rubber cannot be highly polished and it is porous and friable. These inherent problems of silicone may lead to sorption of fluids, irritation of tissues from adhesion of mucus crust, and tearing of the material. In contrast, heat-processed acrylic resin can be highly polished, has less tendency for water sorption, and mucus crust seldom adheres to its highly polished surface. The main disadvantage of constructing nasal septal obturators from heat-processed acrylic resin is its lack of flexibility. For septal defects that are larger than the stretched nostril, insertion of the rigid heat-processed acrylic resin obturator is often impossible and construction of a rigid acrylic resin nasal septal obturator is precluded. In an attempt to support collapsed alae of the nose, Young 16used hollow heat-processed intranasal inserts. These inserts were constructed by the use of lowheat modeling plastic with an impression wax surface. Each impression covered an area of approximately 2 cm into each nostril. The impressions were invested and processed in clear polymethyl methacrylate. The final acrylic resin block was hollowed out to provide a patent nasal airway. The internal surface of the stent was highly polished to reduce mucus adhesion to the surface. Seals et al) 7 reviewed the indications, impression techniques, and laboratory procedures for different clinical situations that required intranasal prostheses, splints, and stents. They concluded that, although they presented techniques for managing common clinical problems, a unique clinical situation may arise. Heat-processed acrylic resin conformers were used ~8 to maintain structural support of facial tissue that was injured from trauma or altered by surgical treatment. Holt and Pare118 fabricated a twopiece conformer joined together in situ by Velcro interlocldng (Velcro USA, Inc.) inserts to prosthetically replace the lost nasal septum. The purpose of this article was to present a technique
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Fig. 3. Impression of nasal septal defect. Two cotton-tipped applicators saturated with silicone placed in one nasal cavity and injected remainder of silicone impression material from other nasal cavity through defect.

Fig. 5. Finished intranasal stent, held by long tweezers during final insertion should be trimmed sufficiently to conceal its margins completely beyond mucocutaneous junction of external nares for better esthetics.

Fig. 4. Patency of this highly polished intranasal stent is demonstrated by having cotton-tipped applicator placed through stent.
A 1

The impression should demonstrate proper extension into the ventricle o f the nasal vestibule, the lateral wall o f the nasal cavity, and imprint o f the defect periphery. An acceptable impression is flasked in dental stone and processed in clear processed polymethyl methacrylate. After recovery, the stent is hollowed with burs and rendered smooth with rubber points. To eliminate any areas o f remaining roughness in the internal surface o f the stent, a thin layer o f autopolymerizing acrylic resin is painted and allowed to polymerize for 20 minutes at 20 psi in a pressure pot. It is preferred to use heat-processed acrylic resin for the bulk o f the stent and only the hmer surface is to be covered with autopolymerized resin. All sharp edges and projections are smoothed and the outer surface o f the stent is highly polished (Fig. 4). Care must be taken not to reduce the retentive extension posteriorly onto the floor o f the nasal cavity or anteriorly into the ventricle. The acrylic resin extensions interfering with insertion and withdrawal o f the stent are modified at the time o f insertion. The stent should not extend past the mucocutaneous junction o f the external nares for better esthetics and ease o f manipulation (Figs. 5 and 6).
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Fig. 6. A, Large nasal septa[ defect with irregular margins. B, Nasal septal stent. It is advisable to duplicate the finished stent after temporary obturating its lumen with artist's clay. The stent is lubricated with petroleum jelly and invested in a crown and bridge flask. After setting o f the stone, the flask is opened and the stent cleaned with ultrasonic cleaner. A new heat-processed acrylic resin stent can then be constructed. The duplicated stent is hollowed and stored in water in a sealed plastic bag for future use in case o f loss o f the original stent. Patients should be instructed on how to insert and remove the stent. Proper orientation o f the stent is highly emphasized during the insertion phase. Removal o f the stent can usually be achieved by digital pressure to the side o f the nose; however, the patient should be instructed on how to remove and insert the stent with the aid o f long tweezers. The patient is instructed on daily cleaning o f the stent with mild soap and water. Frequent postinsertion appointments are necessary to ascertain that pressure areas are eliminated, the tissues surround337

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ing the stent are not inflamed, and the patient is comfortable. SUMMARY Large nasal septal defects can be indirectly obturated by the use of heat-processed acrylic resin intranasal stent. The medial wall of the stent will allow for partition of the two nasal cavities and the patency of stent will allow for comfortable breathing. Construction of conventional heat-processed nasal septal obturators is limited to small defects that occur in the anterior septum.
REFERENCES
1. Seely RC. Repair of the septal perforation--a rhinoplastic approach. Laryngoscope 1949;59:130-3. 2. Fairbanks DN, Fairbanks GR. Surgical management of large nasal septal perforations. Br J Plast Surg 1971 ;24:382-3. 3. Davenport JC, Hunt AT. The construction of nasal septal obturators. Quintessence Dent Tech 1985;9:233-8. 4. Kern EB, Facer GW, McDonald TS, Westwood WB. Closure of nasal septal perforations with Silastic buttons-results in 45 patients. ORL Digest 1977;39:7-17. 5. Snyder GG, McCarthy RE, Toomey JM, Rothfield NF. Nasal septa[ perforation in systemic lupus erythematosus. Arch Otolaryngol 1974;99:4567. 6. Sharon E, Viewx U, Sheckler G. Giant synovia[ cyst of the shoulder and perforation of the nasal septum in (a patient with) rheumatoid arthritis. Mt Sinai J Med 1978;45:103-5. 7. Moergeli JR Jr. An improved obturator for a defect of the nasal septum. J Prosthet Dent 1982;47:419-21.

8. Imperatori GJ, Burman HJ. Diseases of the nose and throat. 1st ed. Philadelphia: Lippincott, 1939. 9. Ismail HK. Closure of septa[ perforation--a new technique. J Laryngol 1964;78:620-3. 10. Philips WC. Disease of the ear, nose, and throat. 1st ed. Philadelphia: FA Davis, 1928. 11. Ginsberg NA, Van B[arcom GW. Fabrication of a septal obturator prosthesis for inoperable septal perforations. Rhinology 1972;10:32-3. 12. Van Dishoeck EA, Lashley FO. Closure of a septal perforation by means of an obturator. Rhinology 1975;13:33-7. 13. JanekeJB. Nasal septal perforations closed with a Si[astic button [letter]. S Afr Med J 1976;50:1246. 14. Zaki HS. A new approach in construction of nasal septal obturators. J Prosthet Dent 1980;43:654-7. 15. Gay WD. A simplified method of treating septal defects. J Prosthet Dent 1981 ;45:430-1. 16. Young JM. Internal nares prosthesis. J Prosthet Dent 1970;24:320-3. 17. Seals RR, Bohnenkamp LG, Parel SM. Intranasa[ prostheses, splints and stents. J Prosthet Dent 1988;60:595-601. 18. Holt GR, Pare] SM. Prosthetics in nasal rehabilitation. Facial Prosthet Surg 1984;2:74-84.

Reprint requests to: DR. HUSSEINS. ZAKI MAXILLOEACIAL PROSTHODONTICS PROGRAM SCHOOLOF DENTALMEDICINE UNIVERSITY PITTSBURGH OF 2058 SALKHALL 3501 TERRACE ST. PITTSBURGH,PA 15261 Copyright 1997 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/97/$5.00 + 0. 10/1/79328

Clinical evaluation o f five adhesive systems: Three-year results. Tyas MJ. Int DentJ 1996;46:10-4. Purpose. This article reported on the clinical performance of five dentin adhesive systems in nonundercut Class V abrasion lesions over a period of 3 years. Material and Methods. One hundred nonundercut Class V abrasion lesions were restored in 15 patients aged 36 to 79 years (mean age 63 years). Five different systems were used to place 20 restorations: All-Bond (Bisco Dental Products), Photobond (Kuraray), Denthesive (HeraeusKulzer GmbH), Pertac-Bond (Espe GmbH) and Geristore (Den-Mat Corp). The microfill resin composite (Silux, 3M Dental Products) was used as the final restorative material except for the Photobond material, with which Clearfil Photo anterior material (Kuraray) was used. All products were used according to the manufacturer's directions. The resin composite was placed and cured in a single increment and finished and polished immediately after curing. Restorations were examined after 3 months, 6 months, and 1, 2, and 3 years. They were recorded as present or absent and the cumulative survival rate was calculated with life table analysis. The results were analyzed statistically. Results. There was no significant difference among the materials tested with respect to patient age or teeth restored. The loss rate of restorations varied from 26% to 95% among the five systems at the 3-year observation period. Products that bonded to the dentin via a hybrid layer (All-Bond and Photobond) were more retentive than those designed to bond chemically (Denthesive and Pertac-Bond) to dentin. Two products (Geristore and Pertac-Bond) that attempted to achieve bonding between their carboxyl groups and dentin calcium were hydrophilic, which probably contributed to their lack of clinical success. 32 References. RP RENNER
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