Orbital rehabilitation of a COVID-19-induced mucormycotic defect – A case report

ABSTRACT

The surgical removal of the maxilla and the orbit and its content, which leads to degraded esthetics, weakened functioning, and arrested psyche, has caused widespread fury among coronavirus disease (COVID-19)-produced mucormycosis patients. It has been stated that a patient with an ocular deformity due to surgical excision of a mucormycosis infection can be rehabilitated. Obtaining a healthy location for prosthesis acceptance is critical for the success of many resected patients. The advantages of anatomical and mechanical retention were fully exploited. The report includes an appropriate treatment plan for the rehabilitation of such faults, as well as a follow-up period and maintenance. Such rehabilitation not only improves the cosmetic outcome but also helps to elevate the patients’ spirits mentally. The following case report defines the treatment guidelines for rehabilitation of a patient with orbital and intra-oral defect owing to COVID-19-induced mucormycosis. It also establishes the steps required for the fabrication along with materials required and suitable pertaining to the above-mentioned scenario. The text is duly supported by images wherever necessary.

Uniqueness of the Case Report

The case report presents the sequential management of a case of prosthetic rehabilitation of a defect caused due to surgical resection of a post-coronavirus disease (COVID-19) mucormycotic defect. The challenges which are faced in such patients include the selection of means of retention which can be used for the preservation of the health of underlying tissue, the method for iris orientation, the treatment protocol along with the material which should be used and their solutions mentioned. With the cases of mucormycosis increasing with the epitome of COVID-19, this case report will prove to be a sure help for many clinicians across the globe to rehabilitate such defects and uplift the spirits of the suffering patient.

Introduction

Since the advent of coronavirus disease (COVID-19) in India, with Maharashtra serving as the epicenter of mucormycotic infections, the illness has earned the moniker “A Threefold Wrath.” Exenteration of the damaged orbital contents causes poor esthetics, weakened functions, and a halt in mental activity. An orbital prosthesis can help such patients by prosthetically replacing the orbital content. The choice to prosthetically rehabilitate a patient is based on many considerations, including the size and location of the defect, the source of the damage, and the patient’s general health. Silicone or acrylic can be used to make such a prosthesis, with silicone being the preferred material. Several ways exist for retaining an orbital prosthesis, including the use of anatomical undercuts, mechanical assistance, surgical treatments, and chemical adhesives. The following case report deals with the rehabilitation of the orbital defect owing to COVID-19-induced mucormycotic defect with various treatment regimens for the benefit of such patients which becomes the “first case report” to establish guidelines for fabrication of such prosthesis. The primary care workers are at a war frontier when dealing with patients with resective defects caused due to surgical treatment of COVID-19-induced mucormycosis. The guidelines for prosthetic rehabilitation of the defect have been mentioned for such patients which will lead to enhancement of quality of life with minimal requirement of time along with these guidelines. The goal is to maintain the biological health of the underlying post-surgical tissue bed, assure the prosthesis’ durability, provide cosmetic results, and ensure proper prosthesis retention.

Case Report

A 60-year-old male patient reported to the Department of Prosthodontics with the chief complaint of loss of esthetics and missing upper teeth owing to surgical treatment of COVID-19- induced mucormycosis since 3 months. Before a period of 5 months, the patient complained of watering of eyes with pain when he was hospitalized for COVID-19 infection in a government hospital. Written consent was taken from the patient to publish the case report. Ketone bodies were discovered in the urine and glycated hemoglobin (HbA1c) of the patient was 8.3%. A specimen was collected from the right eye of the patient and after a KOH culture, the diagnosis of mucormycosis was given. The patient was given an oral antifungal regimen of amphotericin B (1 mg/kg/day for 4 weeks) and had his renal function monitored frequently. The patient experienced orbital exenteration of the left eye four months before visiting the Department of Prosthodontics. After confirmation of no active infection and desired healing of the defect, approval from the Department of Medicine, Ophthalmology, and Histopathology was obtained and the prosthodontic phase was initiated.

The resultant defect after surgery was cylindrical in shape with 3.5–4 cm width externally, gently tapering downwards medially to about 10 cm in length. The defect showed well-healed tissue and rounded margins [Figure 1]. The patient underwent maxillectomy along with the extraction of all maxillary teeth. Intra-orally the patient presented with a shallow sulcus and well-healed denture-bearing surface. Interim hollow denture with silicone orbital prosthesis was planned for the patient keeping into account all the undercuts in the defect site. The orbital defect was categorized into orbital exenteration class I.

Figure 1.

Steps followed for fabrication of orbital prosthesis

The following steps were undertaken to fabricate the orbital prosthesis [Figure 2]:

Figure 2.

The extra-oral orbital defect of the patient

1. Fabrication of facial moulage: Facial moulage is required for proper diagnosis, treatment plan, and fabrication of a well-adapted orbital prosthesis. The impression is made with irreversible hydrocolloid impression material, i.e., alginate. Beading wax was applied surrounding the defect site and the contralateral anatomical eye. Coltene alginate was used to paint the defect surface initially and later. The impression was poured with type III gypsum to obtain a facial moulage [Figure 3].

2. Impression procedure: For accurate treatment planning, assessment, and creation of a well-adapted orbital prosthesis, facial moulage is essential.[1] It is manufactured with irreversible hydrocolloid impression material because of its advantages including ease of availability and manipulation, as well as superior detail recording. The impression included the defect site as well as the contralateral normal eye. The area was boxed on all sides with boxing wax, and the irreversible hydrocolloid substance was mixed, painted, and poured on the surface. Wet gauze was placed over the material as it was ready to reach its final set. To stabilize the impression, fast-setting dental plaster was placed over the gauze. Facial moulage was obtained after pouring the impression with type III gypsum.

3. Working cast fabrication: Once the study model was complete, a second impression was formed using putty consistency and maybe body elastomeric addition silicone substance to preserve the defect’s specifics. The wax pattern was created using this cast.

4. Mode of retention: Spectacles, adhesives, or surgically implanted implants, as well as anatomical undercuts, are all used to keep the maxillofacial prosthesis in place.[2] Using the naturally occurring undercuts on the superior portion of the eye, glasses were chosen as the form of retention because of evident benefits such as simplicity of availability, no extra surgery necessary for retention, and the ability to hide the edges of the prosthesis.

5. Prosthetic eye orientation: The prosthetic eye must be oriented in accordance with the facial harmony of the remaining components. On the right eye, the grid approach was used to position the pupil’s center and measure the iris’ dimensions [Figure 4]. The color of the sclera and iris were taken into consideration while choosing a stock eye shell. The stock eye shell was cut and inserted in the wax pattern according to the patient’s exposure. The wax pattern was carved with the details of the patient on the other side.

6. Evaluating the trial prosthesis: The wax pattern, as well as the implanted eye shell, was placed in the patient’s defect [Figure 5].

7. Shade selection, material selection, and processing: Silicone was chosen above other materials for prosthesis manufacture due to its greater marginal adaptability and lifelike look. The material of choice was determined to be room temperature vulcanizing medical grade silicone. It was blended with intrinsic pigments to match the patient’s color, as per the manufacturer’s recommendations. The silicone was put in the mold after shade matching, and the prosthesis was extracted and completed [Figures 6 and 7]. To give the prosthesis a lifelike look, donor hair that matched the contralateral side of the patient’s eyelashes was chosen and stitched into the prosthesis. The prosthesis was put into the patient’s defect [Figure 8]. After outlining the treatment strategy and course of action to the patient, informed consent was acquired [Figres 9 and 10].

Figure 3.

Facial moulage

Figure 4.

Try-in of orbital prosthesis

Figure 5.

Guttal’s grid method used to orient the iris for orbital prosthesis

Figure 6.

Packing of the mold with the shade-matched silicone

Figure 7.

Cured orbital prosthesis

Figure 8.

Finished orbital prosthesis

Figure 9.

Post-operative picture of silicone prosthesis post insertion

Figure 10.

Post-operative picture of the patient after insertion of the orbital prosthesis

The following steps were carried out to fabricate hollow dentures:

1. Impressions: Diagnostic impressions were made with irreversible hydrocolloid (Coltene) impression material. After the border molding, the final impression with light body consistency elastomeric impression material, a definitive impression was made which was poured with type IV gypsum [Figure 11].

2. Fabrication of hollow denture: After a successful try-in, the denture was flasked and de-waxing was done. A layer of salt was placed between the acrylic layers and it was cured conventionally. After deflasking, with the help of a syringe, hot boiled water was pushed in through the hole made in the posterior aspect of the denture to make it hollow. The denture was finished and polished. The occlusion was checked and high points were reduced [Figure 12].

Figure 11.

Master cast of the maxillary arch of the patient

Figure 12.

Maxillary obturator prosthesis

Discussion

Mucormycosis is an angioinvasive disease caused by the Mucorales fungus Rhizopus, Mucor, Rhizomucor, Cunninghamella, and Absidia. Mucormycosis is prevalent in India with 0.14 cases per 1000 individuals, about 80 times more than in developed countries. COVID-19 infection has been associated with fungal infections.[3] Mucormycosis is more frequent in immunocompromised individuals, and steroid-related ophthalmic and brain complications are common. In India, diabetes mellitus is the most common risk factor for mucormycosis. The infection spreads swiftly and can infect fat, tissues, muscles, and bone in the surrounding area.[4]

In the presenting case, prosthetic rehabilitation was initiated after resection of the right orbital contents and maxillary ridge resection along with the extraction of all maxillary teeth due to mucormycosis. The patient showed a surrounding narrow bony rim of the orbit which was lined by soft tissue because of which the retention of the prosthesis a challenge. The maxillary arch showed a shallow sulcus with no supporting bone which proved as a challenge for the retention and functional efficiency of the denture. Water-based tissue adhesive was put into action for the purpose of retention of the orbital prosthesis. The denture was made light in weight by making it hollow. The labial flange was modified in such a way to maintain the labial fullness and generate adequate esthetics and also reduce the lateral displacing forces owing to the function of the upper lip.[5]

The orbital prosthesis was placed in the defect, and the patient was taught how to remove and replace it. The patient was taught how to clean the adhesive off the skin and how to re-apply the adhesive to the prosthesis. To keep proper hygienic maintenance of the defect site, minimize recurrence of the infection, and keep a check on prosthesis retention, a follow-up regimen was devised at 3-month intervals for the first year, then every 6 months after that. Comorbidities such as diabetes mellitus must be detected and reduced for a successful prosthetic phase. The patient was started on regular blood glucose monitoring and oral hypoglycemic medications.[6]

In patients with maxillary ridge resection and minimal bony support owing to surgical resection of mucormycosis, retention persists as a major issue. Other retentive modalities like mucosal inserts cannot be placed owing to no bony support, suction cups and discs can lead to further bone resorption, and adhesive pastes and powders also do not support well for proper functional efficiency. In the present case, once the denture was inserted, it was again relined with a soft liner to engage the minor undercuts in the sulcus to maximize the retention. The patient was trained how to apply the reliner after a period of 15 days. A definitive treatment option of implant-supported orbital and maxillary denture is planned.[7]

Because there was so much tissue removed in this case, choosing the best position for the iris and ensuring retention was difficult. Out of the several methods available for iris localization, including facial measurements of anatomic landmarks, ocular locator, and inverted anatomic tracings, the graph grid approach was chosen in this case. Spectacles were used to hold the prosthesis in position while also masking its edges.[8]

With the use of digital scanning methods and mold production using 3-D printing techniques, better marginal adaptability, zero-patient touch, enhanced esthetics, and accurate duplication of the intricacies of skin from the contralateral side may be implemented.

Conclusion

“To appear human is a blessing for the affected and under-privileged,

for it is the almighty who creates and destroys but it is us to re-create and stabilize!”

The defects of face cost the patient his self-esteem along with his functional ability. For such patients, to appear like the rest of the population is a blessing. It is, however, the God, the master creator and destroyer who creates us but once they are lost, it is the prosthodontist who re-creates the anatomy to bestow the bliss.

For vast defects which have occurred secondary to surgical resection of mucormycotic tissue owing to COVID-19 infections, retention possesses as a major problem for the interim prosthesis. Use of soft liner or hard liner and making it hollow aids in the same when no other modality is available. With the proper exploitation of undercuts in the orbital defect along with the proper use of adhesive, the problem of retention can be dealt with in such defect rehabilitation as seen in the following case report. The prosthesis has been appropriately secured using spectacles, adhesives, and undercut areas in the current example to maintain the health of the underlying tissues and to improve the being’s psychological health. This sequential planning will not only aid in the restoration of esthetics but will also adhere to the procedures for maintaining the defect site following mucormycotic orbital excision.

Consent to publish

Duly taken from all authors.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.