DENTAL TECHNIQUE

Direct chairside fabrication of a two-piece

brachytherapy appliance
Eric Heckenbach, DMDa and Jay Jayanetti, DDSb

Lip cancer is the second most ABSTRACT

common skin cancer of the
This article reviews the prosthodontic steps in the direct chairside fabrication of a two-piece custom
face, with 3600 new cases a brachytherapy appliance consisting of an intraoral and extraoral component. This technique is
1
year in the United States. described through the treatment of a 77-year-old patient with a T1N0M0 squamous cell
Squamous cell carcinoma is the carcinoma of the lower lip vermillion, referred for the most expeditious fabrication of a
most common histologic type, brachytherapy appliance because of the urgency of beginning brachytherapy. Fabrication of the
followed by basal cell carci- appliance consisted of an expedited clinic visit in which both intraoral and extraoral components
noma.2 The mean size at diag- were fabricated chairside. A traditional indirect laboratory-based fabrication of such an appliance
would have been more time-consuming, thereby delaying delivery of radiation treatment of the
nosis is 1 cm. Lip carcinomas of
rapidly progressing malignancy. (J Prosthet Dent 2020;-:---)
stages T1, T2, and T3 can be
treated with surgery or radiotherapy.3 If the tumor is small hours. An advantage of HDR brachytherapy is that there
(about 1 cm) and lip function can be preserved, surgery is is no radiation exposure to anyone other than the patient.
regarded as the best option. In larger tumors, brachytherapy In summary, brachytherapy allows for safe, precise, tar-
of the lip can be an excellent alternative to surgery.4 geted, and customized radiation treatment to cancers
Brachytherapy is a form of internal radiation treat- throughout the body and should be a consideration in
ment, where radioactive sources are placed near or into oncologic multidisciplinary treatment strategies.8
cancer tissues.5 Brachytherapy allows for precise and The purpose of this article was to outline a technique
targeted radiation that delivers high doses to tumors while for providing a direct chairside fabrication of a brachy-
sparing surrounding normal structures. It uses a radiation therapy appliance in an expeditious manner when im-
source that is delivered into the body via an implant.6 mediate treatment precludes the more time-consuming
Implants are designed and placed based on the location alternative of an indirect fabrication technique.
of the tumor, the extent of the tumor, and other factors.
Often imaging such as computed tomography, ultra-
TECHNIQUE
sound, or magnetic resonance imaging is used to guide
implants placement safely into tumors. Some implants Intraoral component
use premade applicators, while others necessitate custom The patient presented with a T1N0MO squamous cell
made applicators specific to a patient's tumor and normal carcinoma of the lower lip vermillion (Fig. 1). Although
anatomy.7 In addition, different radiation sources can be more labor intensive, a two-piece appliance allows for
utilized to further customize the treatment. Low dose rate individual seating and therefore easier placement for
(LDR) brachytherapy uses sources that are implanted for what would otherwise be a large and complex device.
days or in some instances, remain in permanently. High Our patient presented with a dentate maxilla opposing
dose rate (HDR) brachytherapy uses a source (Iridium an edentulous mandible with an implant connecting bar
192) that allows for rapid treatments over minutes to retained complete denture. We selected an anterior

a
Maxillofacial Prosthetics Fellow, Division of Advanced Prosthodontics, University of California, Los Angeles, Calif.
b
Associate Director of Maxillofacial Prosthetics, Division of Advanced Prosthodontics, University of California, Los Angeles, Calif.

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Figure 1. Patient presentation at time of diagnosis.
Figure 3. Doughy sheet of slow-setting acrylic resin laid over lower lip,
labiomental fold, and handle of intraoral piece, while patient in supine
position. Allowed to polymerize on patient.
sextant, plastic stock dental tray (Vista Impression Tray;
Vista Dental) and thermoplastically altered the handle to
raise it clear off the target lip. We lubricated the implant
connecting bar and maxillary teeth with petroleum jelly.
We used a quick-setting acrylic resin QSAR (Pattern
Resin LS; GC America) to index the tray directly on to the
implant bar, then onto the opposing maxillary teeth,
thereby preserving a repeatable jaw relation, for each
insertion of the appliance (Fig. 2). This also opened the
vertical dimension and raised the maxilla away from the
target area. By using a slow-setting acrylic resin SSAR
(Bosworth RimSeal; Keystone Industries), we impressed
the labial vestibule and inner surface of the lower lip. This
defined the inner lip treatment area and also pushed the
target lip away from the mandible and dental implants
(Brånemark System MK III, Nobel Biocare).
Inner catheters
We attached surface catheters (brachytherapy applicators)
spaced 0.5 cm to 1 cm apart to the modified stock tray
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Figure 2. Completed intraoral component indexed to the implant
connecting bar in the mandible and to the opposing fixed metal ceramic
restorations. Note that the plastic stock tray has been modified
plastically with heat and relined with slow-setting acrylic resin.
Figure 4. Rapid prototyped matrices (nuts) and patrices (bolts).
(Vista Impression Tray; Vista Dental) by using QSAR
(Pattern Resin LS; GC America). In this case, 3 catheters
were accommodated. We applied another layer of SSAR
(Bosworth RimSeal; Keystone Industries) over the
positioned catheters. This step embedded the catheters,
created an even surface, further pushed the lip facially, and
created a separation of the lip mucosa from the catheters.
Extraoral component
With the intraoral component completed and fully
seated, we mixed about 30 mL of SSAR (Bosworth
RimSeal; Keystone Industries) to a doughy consistency.
We placed the mixture onto a lubricated surface and
molded a 70×60×2 mm malleable sheet with a 10 cm
wide Brayer roller (Bastex Brayer Roller, Bastex, Inc).
Petroleum jelly was applied to the lower lip, chin as well
as the exposed surfaces of the fashioned intraoral piece.
With the patient in a supine position, we formed the
extraoral component by adapting the malleable sheet of
SSAR to the treatment area and extending it to the
Heckenbach and Jayanetti
- 2020
Figure 5. Two pilot holes prepared to allow luting of 2 matrices onto
intraoral component.
Figure 7. Completed two-piece brachytherapy appliance assembled at computed tomography simulation.
labiomental crease, chin, and modified tray handle for
added stability (Fig. 3). The molded SSAR was allowed to
autopolymerize and set on the patient’s face.
Indexing the 2 components
Two sets of rapid prototyped attachments were designed
to mimic nuts and bolts and printed in light curable resin
(Fig. 4). They were used to stabilize and retain the
extraoral component to the intraoral one, assuring a
repeatable position. To complete this task, it was
important to align then lute 2 matrices (nuts)done on the
intraoral component and the other on the extraoral
componentdsuch that the patrix (bolt) can passively
screw into both from the outside-in. A pilot hole, just
larger than the matrix, was made to the exposed area of
the intraoral componentdtray handle. A matrix was luted
to this pilot hole with QSAR (Fig. 5). Similarly, a pilot
hole was prepared in line with the first matrix, this time
on the extraoral component. The second matrix was luted
Heckenbach and Jayanetti
3
Figure 6. Chairside fixation. Here both intraoral matrices have been
luted. Right patrix in position, and right extraoral matrix being luted. Left
pilot hole in line with left intraoral matrix prepared. Extraoral catheters
have yet to be positioned.
perfectly in line by having the patrix seated into the luted
intraoral matrix while holding the second matrix within
the prepared hole. When luting the extraoral matrix,
petroleum jelly is used to keep the 2 components from
luting to each other. The procedure was repeated to
obtain 2 sets of attachments (Fig. 6).
Outer catheters
Six surface catheters were luted with QSAR to the ex-
traoral component also 0.5 cm to 1 cm apart (Fig. 7).
DISCUSSION
The two-piece brachytherapy appliance can be more
easily seated compared with a one-piece appliance. With
the help of the rapid prototyped fixtures (Fig. 7), the
technician can predictably assemble the components at
each radiation appointment. For this patient, brachy-
therapy modulation was accomplished with a trans-
mucosal approach with 2 interstitial catheters penetrating
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Figure 8. Four months status posttreatment.
the skin on the right side of the lip and passing through
the lip and out of the left side. The implant was per-
formed with 14-gauge beveled hollow tracers. The 2
catheters were placed 0.5 to 1.0 cm apart. The remaining
9 surface catheters were delivered by means of the
maxillofacial brachytherapy appliance. The lip thickness
at the time of computed tomography simulation
measured 2 cm anteroposteriorly, thus necessitating the
incorporation of 2 interstitial catheters. The required
curative dosage administered solely to the extraoral
catheters would have created hot spots at the surface,
thereby exacerbating postradiation morbidity. The num-
ber of interstitial catheters would have been greater
without the brachytherapy appliance. Given the aggres-
sive and rapidly expanding nature of the patient’s most
recent recurrence, the patient ultimately received 4.25 gy
per fraction twice daily for 5 days. The dose equivalency
yield for a standard 2 gy per fraction over 30 days yielded
a total of 59 gy for the patient. The first 6 weeks saw
moderate erythema and postradiation dermatitis,
inflammation, and fissured bleeding. After 4 months, the
patient was almost completely symptom free with no
erythema or bleeding and minor inflammation (Fig. 8).
The patient recently reported minimal to no discomfort
4 months status postradiation treatment.
SUMMARY
A stable and repeatable jaw relation was recorded
to facilitate the consistent administration of radiation
during treatment. To optimize the intimate contact and
adaptation of the extraoral component to the moveable
lip during treatment, the patient was in the same supine
position in which the extraoral component was initially
molded over the target area. Furthermore, by fixing the
extraoral component to the intraoral component with
the rapid prototyped fixtures, consistent and uniform
adaption of the extraoral component to the lip could be
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Figure 9. Sagittal view of computed tomography simulation.
achieved throughout treatment. The sagittal view of the
computed tomography simulation confirms the appro-
priate adaptation of the appliance (Fig. 9). The scope of
this technique highlights an approach to fabricating a
brachytherapy appliance when a rapidly progressing
malignancy precludes more established laboratory
techniques. If the treatment had spanned 5 weeks or
more, which can be expected with HDR brachytherapy,
stronger and more robust fixtures would be recom-
mended to fix the intraoral and extraoral components
more securely.
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Corresponding author:
Dr Eric Heckenbach
Department of Veterans Affairs
Heinz Campus, Dental Department
1010 Delafield Rd
Pittsburgh, PA 15215
Email: erich4736@gmail.com
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2019.12.024
Heckenbach and Jayanetti