Fabrication of a radiation bolus prosthesis for the maxillectomy patient

Mary Elizabeth Brosky, DMD,a Chung Lee, MD,b Timothy Scott Bartlett, DDS, LT, DC, USNR,c and Simon Lo, MDd School of Dentistry, University of Minnesota, Minneapolis, Minn.
Radiation therapy has been used in the treatment of numerous head and neck malignancies. Unfortunately, this treatment also causes complications by increasing the morbidity to the surrounding tissues. The fabrication of a tissue bolus prosthesis is recommended to compensate for the loss of tissue and to help distribute the radiation homogeneously to the tissues. This article describes the procedures necessary for making an impression and fabricating a tissue bolus prosthesis. This custom-made prosthesis is simple, efficient, and atraumatic for the patient. Use of a tissue bolus prosthesis allows the radiation oncologist to adequately irradiate the tissues. (J Prosthet Dent 2000;83:119-21.)

dvances in radiation therapy have allowed megavoltage radiation to develop and expand into the treatment of head and neck malignancies.1 Although adjuvant radiation therapy provides an immense benefit to the patient, it also causes multiple side effects.2 After surgical excision of a malignancy, the resultant irregular borders and dead tissue spaces produce an uneven dose distribution of radiation to the tissues.3-5 Because the electron density of air is much lower than that of normal body tissues, the radiation beam penetrates much more deeply beyond an air cavity and results in a larger radiation dose being delivered beyond the air cavity, along with a lower dose to the surface of the cavity. To compensate for the decreased attenuation in the air cavity, it has been recommended that some form of tissue equivalent bolus be placed into or on the area to be irradiated.3,4 The tissue equivalent bolus will make the radiation dose distribution more homogeneous (Fig. 1).6 Megavoltage X-ray beams are used in radiation therapy for the treatment of cancers. The 3 most important interactions between X rays and tissues are photoelectric effect, Compton effect, and pair production. The first and third interactions depend on the atomic number Z, whereas the second interaction, Compton effect, is the predominant process that is caused by megavoltage X-ray beam interacting with loosely bound electrons in the outer shell of an electron.7 The Compton effect probability of occurrence increases with increased electron density of the material. The electron density is the product of the number of electrons per gram and the density of the material.

Fig. 1. Typical computer plan image shows isodose curves for radiation therapy, after maxillectomy. Bolus prosthesis in surgical cavity will allow more homogenous distribution of radiation dose.

aAssistant

Professor, Department of Prosthodontics. Department of Therapeutic Radiology and Radiation Oncology. cResident, Department of Prosthodontics. dResident, Department of Therapeutic Radiology and Radiation Oncology.
bProfessor,

Dosimetrically, water is the best available tissue equivalent bolus; however, its use may involve lengthy setup time for daily radiation treatments. Acrylic resin is an alternative to water. It has a slightly lower but similar number of electrons per gram as that of water and
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Fig. 2. Bolus prosthesis processed in heat-cured acrylic resin.

Fig. 4. Bolus prosthesis inserted into maxillary defect.

The purpose of this article is to present a method for making an impression of a maxillectomy defect and fabricating a tissue bolus prosthesis.

PROCEDURE
1. Use an interim obturator to confine the impression medium and to act as a stabilizer for the tissue bolus prosthesis. 2. Make an impression of the maxillary defect by injecting tissue conditioner (Coe-Comfort, GC America, Inc, Chicago, Ill.) into the defect area with a 60-cc syringe. Place tissue conditioner into the bulb portion of the interim obturator as well. (Placement of tissue conditioner into the hollow bulb prevents the material from flowing away from the tissues and into the hollow bulb.) 3. After the tissue conditioner is placed into the defect and hollow bulb portion of the obturator, seat the obturator into the oral cavity. 4. Once the tissue conditioner is set, remove the entire complex from the patients mouth and inspect it for detail. (If the tissue conditioner does not capture the entire defect area, more material may be placed as needed on the existing tissue conditioner and reinserted into the oral cavity.) 5. Remove the tissue conditioner from the hollow bulb and process it in acrylic resin (Fig. 2). 6. Relieve the inferior portion (stem) of the tissue bolus prosthesis so that it can be inserted into the hollow bulb portion of the obturator (Fig. 3). 7. Adjust and polish the prosthesis to prevent trauma to the tissues (Fig. 4).

Fig. 3. Final bolus prosthesis with interim obturator.

a specific gravity of 1.16 to 1.20.8 Its electron density is about 1.14 times that of water.8 The use of an intracavitary acrylic resin bolus prosthesis can simplify the setup for daily radiation therapy. There are few published articles concerning the fabrication of these devices. Normally the devices are fabricated out of tissue equivalent materials such as wax, acrylic resin, or saline/waterfilled balloons. Fabrication of the tissue bolus prosthesis can be difficult and time-consuming.4 Miyamoto9 first described the fabrication of a tissue bolus prosthesis for maxillectomy patients using a water-filled balloon. The balloon, when filled, will obliterate the maxillary defect and allow the tissues to be effectively irradiated, while sparing excessive tissue morbidity.
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DISCUSSION
The fabrication of this tissue bolus prosthesis is simVOLUME 83 NUMBER 1

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ple and effective. It provides a reasonable alternative to water as a tissue equivalent bolus. The acrylic resin obliterates the air-filled surgical defect so that postoperative radiation therapy is more homogenous. Its ease in placement and removal, by either the patient or radiation oncologist, is attributed to its custom fit and 2-piece design (bolus and interim obturator prosthesis). Furthermore, the bolus is stabilized by the prosthesis, ensuring its proper position and security during radiation therapy. The procedure in this article describes the fabrication of a tissue bolus prosthesis that is simple, efficient, and atraumatic for the patient.
REFERENCES
1. Seagren SL. Recent advances in radiation therapy of head and neck cancer. Head Neck Surg 1982;4:227-32. 2. Humphries SM, Boyd K, Cornish P, Newman FD. Comparison of Super Stuff and paraffin wax bolus in radiation therapy of irregular surfaces. Med Dosim 1996;21:155-7. 3. Kaanders JH, Fleming TJ, Ang KK, Maor MH, Peters LJ. Devices valuable in head and neck radiotherapy. Int J Radiat Oncol Biol Phys 1992;23:63945. 4. Beumer J, Curtis T, Marunick M. Maxillofacial rehabilitation. St Louis: Ishiyaku Euro America Inc; 1996. p. 60-1.

5. Khan FM. The physics of radiation therapy. Philadelphia: WB Saunders; 1984. p. 254. 6. Murphy W. Radiation therapy. Philadelphia: WB Saunders; 1967. p. 31-8. 7. Khan FM. The physics of radiation therapy. Philadelphia: WB Saunders; 1984. p. 84-6. 8. Khan FM. The physics of radiation therapy. Philadelphia: WB Saunders; 1984. p. 177. 9. Miyamoto RH, Fleming TJ, Davis MG. Radiotherapeutic management of an orocutaneous defect with a balloon-retaining stent. J Prosthet Dent 1992;68:115-7. Reprint requests to: DR MARY ELIZABETH BROSKY DEPARTMENT OF PROSTHODONTICS SCHOOL OF DENTISTRY UNIVERSITY OF MINNESOTA 9-470 MOOS TOWER 515 DELAWARE ST SE MINNEAPOLIS, MN 55455 FAX: 612-626-1496 E-MAIL:brosk001@tc.umn.edu Copyright 2000 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2000/$12.00 + 0. 10/1/103747

Noteworthy Abstracts of the Current Literature

Patient expectations of oral implant-retained prostheses in a UK dental hospital Allen PF, McMillan AS, Walshaw D. Br Dent J 1999:186:80-4.

Purpose. A prosthesis supported by osseointegrated implants often provides a satisfactory solution for individuals who are completely edentulous. However, little information is available about what patients expect of their implant-retained prosthesis. The aim of this study was to assess these expectations in a group of edentulous patients desiring implants. Method. This study included 2 patient populations: (1) a group of edentulous adults who requested implants (implant group) (n = 37; median age of 57 years) and (2) an edentulous control group (n = 34; median age 64 years) of similar age and gender as the implant group, who were to be treated with conventional complete dentures. After a clinical and radiologic examination of both groups, data were collected by using a validated questionnaire. Both groups made a subjective assessment of their complete dentures. In addition, the implant group completed a questionnaire that was used to assess the expectations of the implant-retained prosthesis. Data were collected and subjected to statistical analysis. Results. The baseline satisfaction with current dentures was low for both groups, with the implant group significantly less satisfied with the comfort and stability of their mandibular dentures. Perceived ability of the implant group patient to chew hard food was less than the control group. The implant groups expectations of an implant-retained prosthesis was significantly greater than for a conventional denture. Conclusion. The authors recommend that a careful assessment of the patients expectations of implant therapy is essential to determine appropriate patient treatment needs and to highlight unreasonable patient expectations. 14 References. RP Renner

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