Adaptation of a relocatable head frame for stereotactic radiotherapy

Mark F. Mathews, DDS, MS,a and Rick M. Smith, DDS, MSb Wilford Hall Medical Center, Lackland AFB, Texas
An important role of the maxillofacial prosthodontist is to support the radiotherapist in the administration of therapy. For example, a device can be made that properly and repeatedly positions the patient for each radiation treatment. This article describes a procedure for adapting a relocatable head frame to be used during stereotactic radiotherapy, a treatment modality for malignant intracranial tumors. (J Prosthet Dent 2000;84:585-8.)

ne important role of the maxillofacial prosthodontist is to support the radiotherapist in the administration of therapy. This is often accomplished through the use of positioning guides or stents. Beumer et al 1 described several categories of these devices. One type of positional stent moves or displaces normal tissue out of the radiation field. Another accurately directs an external radiation source to its target. A third guide predictably positions a diseased area within the radiation field. An example of this third device is the relocatable head frame, used during stereotactic radiotherapy (SRT). SRT is a treatment modality for malignant intracranial tumors. 2 The term stereotactic is defined as pertaining to types of brain surgery that use a system of 3-dimensional coordinates to locate the site to be operated on. 3 SRT combines techniques of stereotactic radiosurgery with radiation fractionation therapy. This necessitates a relocatable immobilization system to precisely reproduce patient position during the multiple treatment sessions in which radiation is administered. This article describes the adaptation of a relocatable head frame to a patient using the Gill-Thomas-Cosman (G-T-C) head frame system.4

PROCEDURE
1. Ensure that the entire contents of the G-T-C Relocatable Head Frame kit are present (Radionics, Inc, Burlington, Mass.). 2. Select an appropriately sized maxillary clutch from the kit, paint it with tray adhesive (Kerr Corp, Romulus, Mich.), and load it with a high viscosity vinyl polysiloxane (VPS) material (Extrude Extra, Kerr Corp, Romulus, Mich., or Panasil Putty, Kettenbach Dental, Eschenburg,
The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or other Departments of the US Government. Presented as a table clinic at the AAMP Meeting in Philadelphia, Pa., October 12, 1999. aMaxillofacial Prosthetics Fellow. bDirector, Maxillofacial Prosthetics Fellowship. NOVEMBER 2000

Fig. 1. Clutch seated parallel to interpupillary line.

Germany). Coat the underside of the clutch with impression material as well. 3. Place the clutch in the mouth parallel to the interpupillary line, and have the patient lightly close on it (Fig. 1). When set, remove the clutch and inspect it for completeness and retention. Trim excess material, leaving only an occlusal index to the height of contour of the teeth. 4. Secure the clutch to the base of the head frame. Select the appropriate plate to allow the head to be centered within the frame. Insert the clutch into the patients mouth while positioning the frame over the head. The patient can help support the frame manually, keeping it at or below the mastoid protuberances.
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Fig. 2. Occipital pad formed using VPS putty.

Fig. 4. Head frame secured on patient. Head strap helps support its weight.

Fig. 3. Accurate relationship of clutch and occipital pad to head and their rigid attachment to frame provide reproducible head-to-frame relationship during each treatment session.

5. Choose a set of posterior vertical brackets that allows a 1-cm gap between the occipital plate and the back of the head when the frame is closed. Secure the vertical brackets to the head frame using a vertical subplate that maintains this position. Slide the frame open. Mix a VPS putty (Panasil, Kettenbach Dental), and place it on the occipital plate. Lay a sheet of plastic over this, and close the frame.

Fig. 5. Head frame secured to table.

Adapt the putty to the patients occipital area by pushing the vertical brackets forward and locking them in place. Support the patients head while doing this (Fig. 2). Figure 3 shows the completed impressions with the assembled head frame.

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6. Stabilize the head frame using a loop-and-hook fastener, drawn as tightly as the patient can comfortably tolerate (Fig. 4). Mark the strap positions for future reference. Ensure all screws are tightened and covered with tape so they will not be changed between appointments. 7. Position the patient on the table, and secure the head frame to it (Fig. 5). 8. Verify position of the head in the framework. Lock the Depth Helmet (Radionics, Inc, Burlington, Mass.) onto the frame. Measure the distance between the outer surface of the Depth Helmet and the cranium with the depth probe (Fig. 6). Insert the probe through each guide tube in the helmet, allowing it to rest passively on the skin surface each time, and record the 24 measurements for reference. A second operator should reapply the frame and independently confirm the original measurements. All corresponding measurements must be within 1 mm of one another for each treatment session.

DISCUSSION
The G-T-C head frame relies on the dentition and occipital area of the skull for immobilization. Accurate impressions of these hard point areas make head positioning within the frame repeatedly precise. Kooy et al2 claim that the apparatus works reliably on edentulous patients as well. Head position can be verified before each treatment session using the Depth Helmet, a hemispheric dome that temporarily becomes part of the frame. The distance between the dome and cranial surface is measured at 24 points with a depth probe and verified before each radiation treatment. A radiographic verification of position is not required.2 The head and brain are properly oriented to the radiation beam when the head frame is locked onto the treatment table. Various sized extension plates and brackets permit heads of virtually all sizes to be properly positioned in the center of the frame. The frame is relatively comfortable and easy to adapt to each patient. The G-T-C frame is contraindicated in some instances. Because it can allow up to a 1-mm error in head position, it is not recommended for use in stereotactic radiosurgery (SRS), a single-session treatment modality in which deviation is acceptable.2 A position error in SRS results in the total radiation dose being shifted relative to the tumor volume. A slight error in an SRT fractionation dose would only increase the penumbral region of the total dose. SRS therefore requires that a frame be screwed into place on the skull. Another contraindication to the G-T-C frame is its use in young children unable to cooperate with the therapist. These patients

Fig. 6. Depth Helmet attached to frame. Twenty-four measurements are made between helmet and head surface to confirm patient position relative to frame.

must be anesthetized, thus precluding the use of the maxillary clutch that could obstruct the airway. A modified frame, using ear canal supports, is used in those instances. One alternative to the G-T-C head frame is thermoplastic head netting. It is also fast and easy to fabricate. However, it does lack a built-in verification feature.

SUMMARY
A step-by-step procedure has been described for adapting a relocatable head frame to a patient for use during stereotactic radiotherapy. Accurate impressions of the dentition and occiput, and their rigid attachment to the frame provide a reproducible head-to-frame relationship during each treatment session. This relationship can be confirmed with a depth helmet that allows precise measurement of the head-to-frame orientation. The head and brain are properly oriented to the radiation beam when the head frame is locked onto the treatment table.
REFERENCES
1. Beumer J, Curtis TA, Marunick MT. Maxillofacial rehabilitation: prosthodontic and surgical considerations. St Louis: Ishiyaku EuroAmerica; 1996. p. 55-8. 2. Kooy HM, Dunbar SF, Tarbell NJ, Mannarino E, Ferraro N, Shusterman S,

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et al. Adaptation and verification of the relocatable Gill-Thomas-Cosman frame in stereotactic radiotherapy. Int J Radiat Oncol Biol Phys 1994;30:685-91. 3. Dorlands illustrated medical dictionary. 28th ed. Philadelphia: WB Saunders; 1994. p. 1578. 4. Duffy P, Munroe M. Gill-Thomas-Cosman (GTC) relocatable head frame operators manual. Burlington, Mass.: Radionics Inc; 1996.

Reprint requests to: DR MARK F. MATHEWS 2724 VICKIE DR BEAVERCREEK, OH 45434-6449 10/1/110254 doi:10.1067/mpr.2000.110254

Noteworthy Abstracts of the Current Literature

A laser-powered hydrokinetic system Hadley J, Young DA, Eversole LR, Gornbein JA. J Am Dent Assoc 2000;131:777-85.

Purpose. This randomized, single-blind clinical trial compared the laser-powered hydrokinetic system (LPHKS) (Millenium System, BioLase Technology Inc, San Clemente, Calif.) with a conventional air/turbine bur for dental cavity preparation and retention of restorations. Material and methods. Sixty-eight subjects participated in the study with a total of 75 tooth pairs. All patients were at least 18 years old and had at least 1 carious lesion on 2 separate teeth that represented Class I, III, or V cavities. None of the caries extended more than two thirds of the distance through the dentin as assessed clinically and/or radiographically. All the teeth tested vital when an electric pulp tester was used; none of the teeth required more than 1 restoration; and none of the included teeth presented with radiographic evidence of periapical radiolucencies. The teeth were randomly selected for 1 of the 2 types of treatments. Group A teeth received LPHKS preparation, and group B teeth received preparations with a conventional air/turbine water-cooled bur. Two dentists and 3 blinded evaluators participated in the study. With the use of the LPHKS, the enamel was prepared at a power setting of 5.5 to 6.0 W. When dentin was reached, the power was reduced to 4.0 to 5.0 W. Retention points were not placed in dentin, and the cavosurface margins were not flared or beveled. Air/turbine/bur preparations with air-water spray were completed at 20,000 to 24,000 rpm by using the same general preparation guidelines. Thirty-seven percent phosphoric acid was used to etch the enamel of all preparations for 10 seconds, and all prepared cavities were restored with a light-polymerized hybrid composite. During the procedure, the dentist recorded the patients physical discomfort level; the level was reassessed immediately after completion of the preparation and 3 additional times at 48 hours, 30 days, and 6 months postoperatively. The discomfort scale was as follows: 1 = no discomfort, 2 = mild discomfort, 3 = moderate discomfort, 4 = high level discomfort, and 5 = extreme discomfort. Thirty days postoperatively, restoration retention was assessed by using a 4-point scale: 1 = retained with no breakdown, 2 = retained with marginal breakdown, 3 = partial loss, and 4 = total loss. At that time, vitality measurements and discomfort levels were again measured as previously described. At the 6-month recall appointment, the teeth were evaluated for restoration retention and integrity, marginal recurrent caries, vitality, and discomfort levels. The McNemar 2 and corresponding P value (where there were non-zero differences between the 2 treatments) were computed. Results. The results of this study were based on the 66 pairs of restorations with complete data. All restorations were without recurrent caries and loss of restorative material, and all teeth remained vital at the 6-month recall. During cavity preparation, 98.5% of the laser-treated teeth were without discomfort, and 1.5% had moderated discomfort. Of the air/turbined bur teeth, 87.9% had no discomfort during the preparation, and 12.1% had some degree of discomfort. These data from the 2 groups were found to be significantly different. Immediate postoperative discomfort levels were not identical; however, the data were found to be similar. Discomfort level assessments at 48 hours, 30 days, and 6 months revealed that 100% of the teeth in both groups were without discomfort. One tooth in the air/turbine bur group exhibited marginal breakdown at the 30-day recall visit. Conclusion. LPHKS is an effective method for preparing Class I, II, and V cavities. Within the parameters of this study, composite restorations placed in LPHKS-prepared teeth were retained satisfactorily. 39 References. DL Dixon

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