shastry t. et al.: case report - ijohmr made acrylic therapeutic pressure... · shastry t. et al.:...

International Journal of Oral Health and Medical Research | ISSN 2395-7387 | JANUARY-FEBRUARY 2016 | VOL 2 | ISSUE 5 122

CASE REPORT Shastry T. et al.: Custom made Acrylic Therapeutic Pressure Appliance for Auricular Keloid

Correspondence to: Dr. Shastry Tejomaya, Room no 110, KIMS Men’s hostel,

18th cross,24th main, Banashankari 2nd stage, Bangalore Contact Us: www.ijohmr.com

Custom made Acrylic Therapeutic Pressure

Appliance for Auricular Keloid: A Case Report Shastry Tejomaya1, Shetty Shilpa2, Menon Neelima3, Bhola Megha4, Satpathy Soumyadev5

Traumatic injuries or surgical procedures in susceptible areas often lead to development of keloid due to complicated

wound healing. Keloids of ear lobe are a common complication of ear piercing, although its overall incidence is

unknown. Pressure therapy has been employed to treat pinna keloids. The main aim of this therapy is to maintain

constant pressure and duration of therapy is about twenty-five weeks. Pressure therapy has been widely used to help in

the early maturation of scar tissue and to prevent the recurrence of keloid. This article describes the fabrication of

custom made pressure clips which have been used for patients with auricular keloids. KEYWORDS: Custom made appliance, Keloids, Pressure clips, Pressure therapy

AA aaaasasasss A keloid is an abnormal proliferation of fibroblasts with

overproduction of collagen.The clinical definition has

often been used to distinguish hypertrophic scars from

keloids. 1,2

Keloids extend beyond the margins of the original wound

which distinguishes them from hypertrophic scars which

stay within the confines of the injured area. Originating

from the Greek word ‘chele’ which means ‘crab claw’,

the term ‘cheloide’ was first used by Albert in 1806 to

describe the lateral expansion of an excessive scar into

the surrounding normal tissue.

Ear piercings are often followed by such complicated

wound healing process which firstly extends beyond the

original site and secondly does not show spontaneous

regression. These are the two key features differentiating

them from simple hypertrophic scars. This distinction is

difficult to discern clinically, but it is imperative to do so

as prognosis of hypertrophic scar is spontaneous

softening and flattening whereas keloids maintain their

thickness and remain elevated for years. Also it is more

difficult to achieve total excision and primary closure in

case of keloids as compared to hypertrophic scars.4,5

The best treatment strategy to avoid these complications

is prevention. Patients prone to excessive scar formation

should avoid surgical procedures until absolutely

essential, particularly in high risk locations susceptible to

development of keloids. Clinicians today are presented

with a plethora of treatment options to choose from for

the treatment of hypertrophic scars or keloids which

include radiotherapy, cryosurgery, intra-lesional cortico-

steroids, laser therapy, or a combination of these. All of

them have their own pros and cons and have shown

varying degrees of success. Unfortunately there is no

single treatment modality or a universally accepted

treatment protocol that can guarantee a complete and

permanent amelioration and also prevent recurrence.6

The search for a less aggressive and conservative

management option for scars lead to the development of

pressure therapy. Over the years it has been established as

an effective treatment option, to reduce the amount of

scar tissue. It works on the mechanism of application of

continuous pressure which creates localized hypoxia,

resulting in fibroblast degeneration and cell breakdown.

Constant pressure of 25 mm Hg for minimum six months

has been recommended by various authors. Care should

be taken to avoid prolonged and excessive pressure which

results in localized circulatory disturbances and

eventually forms pressure ulcers.7,8,9,10

Management of keloids always remains is a challenge.

This article describes a case series of young female

patients with auricular keloid, for which simple, logical,

inexpensive therapeutic appliances were fabricated.

Further studies can be performed to evaluate the efficacy

of such appliances on the remission of auricular keloids.

The management of two patients who visited Department

Of Prosthodontics, V.S. Dental College & Hospital with

keloids in the ear pinna is described in this report where

pressure therapy was utilized. The aim was to provide a

conservative and economical treatment option to these

patients, who could not afford more expensive therapy

and still achieve the desired result. Custom made pressure

clips of auto polymerising polymethylmethacrylate were

fabricated which were esthetically acceptable to the

patients for management of keloids.

How to cite this article: Shastry T, Shetty S, Menon N, Bhola M, Satpathy S. Custom made Acrylic Therapeutic Pressure Appliance for Auricular Keloid: A Case Report. Int J Oral Health Med Res 2016;2(5):122-127.

INTRODUCTION

1,3,4,5- Post graduate student, M.D.S., Department of Prosthodontics and Crown and Bridge, V.S. Dental College and Hospital, Bangalore- 560004. 2- M.D.S., Professor and Head, Department of Prosthodontics and Crown and Bridge, V.S. Dental College and Hospital , Bangalore-560004.

ABSTRACT



Case 1

A 32-year-old female patient was referred from the

Department of General Surgery, Kempegowda Institute

of Medical Sciences, Bangalore, Karnataka to the

Department of Prosthodontics, V.S. Dental College and

Hospital, Bangalore for the management of auricular

keloid. Figure 1

The Patient gave a history of infection in both the ears 6

months back which required an incision, surgical

debridement and placement of sutures. The wound healed

in a complicated manner resulting in the appearance of

tissue overgrowth at the site of wound closure 2 months

after removal of the sutures. The swelling increased in

size for the following 2 weeks and was accompanied by

severe pruritis and erythema. In the following weeks, the

pruritis and erythema subsided but the size of the

swelling remained constant.

On examination it revealed a small irregularly shaped

swelling on the superior aspect of the helix involving the

scaphoid fossa, extending 0.5 mm into the crura of

antihelix measuring 2.8 cm anteroposteriorly x 1.9 cm

superoinferiorly and 2.9 cm anteroposteriorly x 1.6 cm

superoinferiorly on the right and left ear respectively. The

skin covering the swelling had a tense and stretched

appearance. On palpation, it was found to be non-tender

and had a rubbery consistency. Figure 2

Case 2

A 30-year-old female patient was referred from the

Department of Surgery, Bowring hospital, Bangalore for

the management of auricular keloid. Figure 3

The chief complaint of the patient was swelling in the

helix of the right and left ears since one month. A history

of ear piercing was given by the patient on both right and

left ears 8 years back which was followed by the first

appearance of swellings bilaterally 3 years back along

with accompanying pain and itching. There was a gradual

increase in the size of the swellings in both the ears.

Swelling in the right ear was larger in size than the left

ear. Both the swellings were surgically excised one

month back.

On examination, a small, oval non-tender irregularly

surfaced swelling was present on the helix of the right &

left ear, measuring 1.8cm anteroposteriorly x 2cm

superoinferiorly and 1.7cm superoinferiorly x 1.2cm

anteroposteriorly respectively. Figure 4

CASE REPORT

Figure 1

Figure 2

Figure 3



There was no pain, itching or other accompanying

symptoms except that it caused emotional stress due to

impaired esthetics.

A clinical diagnosis of bilateral auricular keloid of the

helix was given for both cases. It was decided to use

pressure therapy to prevent recurrence of keloid on both

right and left ears. Custom made polymethylmethacrylate

passive pressure appliances were planned to be used for

maintaining the pressure for a specific period of time and

to prevent the recurrence in both ears.

Procedure followed for fabrication of passive pressure

appliance: The skin over the right and left ear was

lubricated with petroleum jelly, and the external auditory

meatus was blocked using cotton. Primary impressions

were recorded using a thin mix of irreversible

hydrocolloid impression material (neo colloid tm

,

Zhermack) with the patients’ head tilted to the opposite

side for which impression was being made. The

impression material was loaded into a syringe and

injected over the desired area to ensure recording of the

fine details of the defect. A thin mix of plaster of Paris

was poured over the irreversible hydrocolloid as a

backing, material. Figure 5

Completed impressions were retrieved, and disinfected

following which the impressions were cast in dental stone

and master casts of both ears were obtained. Figure 6 (A)

& (B)

A spring was designed using 8mm diameter stainless

steel wire that was made as a V- shaped loop with a helix

at its apex and adapted over the region of the keloid.

Figure 7

A final trial was done on the patient to make sure of the

fit and extent of the pressure clip to ensure coverage of

the desired area and adjustments were made in the helix

avoidance of excess pressure and ensure comfort for the

patients. Figure 8

Custom made pressure appliances were fabricated

incorporating this loop in clear polymethylmethacrylate

resin (DPI RR Cold cure-clear, DPI, Mumbai, India) and

characterization was done using fabric paints and

artificial ornamental stones to make it resemble auricular

ornament thereby making the appliance more esthetically

acceptable to the patient. Figure 9 A & B

All sharp projections were removed using acrylic

trimming bur and the appliances were finished and

polished. Finally, a clear coat was applied to preserve the

integrity of the characterization. Figure 10 & 11

Figure 4

Figure 5

Figure 6

Figure 7



Instructions were given to the patients to wear the

appliance continuously throughout the day, to maintain

required pressure. It was made sure that appliance did not

apply undue pressure on the swellings on both right and

left ears. The Patients were also instructed to clean the

appliances with spirit for maintenance of hygiene, and put

on periodic recall at every three months intervals.

Although knowledge about the mechanism of wound

healing and physiology of collagen fibre remodelling has

advanced by leaps and bounds in recent years, treatment

of keloids still remains a therapeutic challenge. They may

lead to significant morbidities such as pruritis, pain and

cosmetic disfigurement. There is still no universally

accepted treatment modality that can ensure complete

resolution of a keloid.11

A variety of skin injuries resulting from surgical

procedures, piercings(especially in ears), burns,

lacerations, tattoo placement, vaccine injections, insect

bites, and any inflammatory process such as acne,

varicella zoster infection, or folliculitis, can lead to the

development of keloids. But common to all the above

mentioned causes is wound tension, which has been

implicated as a factor in the development of keloid and

hypertrophic scar formation.12,13,14

The location of the injury and ethnic background may

predispose a patient to the development of keloid or

hypertrophic scars, occurring more frequently in patients

with darker skin photo types. Black and Hispanic

populations have shown an incidence ranging from 4.5%

to 16%.15,16,17

Equal occurrence is seen in both the sexes.

This kind of complicated wound healing may occur at

any age, but patients between the age group of 10 years to

30 years are at a higher risk.18,19

The size of a keloid ranges from a few millimetres to

several centimetres in diameter or even larger and the

consistency may be soft and doughy or firm and banded.

Figure 8

Figure 9

Figure 10

Figure 11

DISCUSSION



Areas particularly prone to keloid formation include the

ears, cheeks, shoulders, chest, upper arms, and upper

back.20

The greater chance of occurrence can be attributed

to the fact that there is increased skin tension in these

areas.21

The cosmetic disfigurement caused by keloids and

hypertrophic scars subject the patients to a great amount

of psychological stress. They are further complicated by

accompanying pain, itching, burning sensation, secondary

infections, and ulceration which together lead to a

restricted movement of the affected area .22,23

As mentioned earlier, the best way to avoid keloid and

hypertrophic scars is to take all necessary precautions to

prevent them from occurring in the first place. A clinician

should avoid surgical procedures in high risk patients as

far as possible and resort to more conservative options.

Other modalities of treatment include surgery, radiation,

silicone gel sheeting and other dressings, cryotherapy,

intralesional corticosteroids, most commonly used being

triamcinolone acetonide, interferons and fluorouracil.

Laser therapy can also be employed. The most commonly

used lasers are Carbon dioxide laser and Nd: YAG laser.6

Despite the variety of treatment options available the

search for the ultimate treatment protocol for keloid

management is still on.

Compression therapy as a conservative treatment option

for keloids was first reported in the 1960s.24

The

continuous pressure delivered through some form of an

appliance exerts its effect by producing tissue ischemia,

decreasing tissue metabolism and increasing collagenase

activity.25,26,27

while other authors believe there is a

release of metalloproteinase 28

or prostaglandin E2 29

in

response to the applied pressure that induces extracellular

matrix remodelling and gradually leads to decrease in

size and softening of the scar.

Pressure therapy is an excellent conservative therapeutic

option for keloids and offers several advantages over the

aggressive treatment modalities but it also has its own set

of drawbacks. The success greatly depends upon a

cooperative and motivated patient as the pressure

dressing must be worn for at least 6 months for a

minimum of 18 hours a day, requires meticulous hygiene

maintenance and frequent recalls to adjust the appliance

to ensure that only the required amount of pressure is

delivered. All this is difficult to achieve with

uncooperative and indifferent patients and limits their

compliance to the prescribed regimen leaving the

treatment unsuccessful despite of meticulous construction

and adjustment of the appliance. Response shown by

older scars which have been present for a year or longer

is poor. Also the excess skin mobility makes it difficult to

achieve the required amount of constant pressure (24–

40mm Hg) if the keloid is located over a joint.21,30

. Hence

the patients need to be motivated about continuous usage

and maintenance of the appliance and put on regular

recall visits to monitor the formation of pressure ulcers

and make adjustments in the u-loop to tighten or loosen

the appliance if necessary.

Management of keloids always remains as a challenge.

This article describes a case series of young female

patients with auricular keloid, for which simple, logical,

inexpensive therapeutic appliances were fabricated.

Further studies can be performed to evaluate the efficacy

of such appliances on the remission of auricular keloids.

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hypertrophic scars: review and treatment strategies. Semin

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2. Muir IFK. On the nature of keloidal scars and hypertrophic

scars. Br J Plast Surg 1990; 43: 61-9

3. Alibert JLM. Quelques recherches sur la cheloide. Mem

Soc Medicale d’Emulation 1917 8: 744-52

4. Chrisostomidis C, Konofaos P, Chrisotomidis G,

Vasilopoulou A, Dimitroulis D, Frangoulis M, et al.

Management of external ear keloids using form-pressure

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and Keloids Etiology and Management, Am J Clin

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various methods of treating keloids and hypertrophic scars:

A 10-year follow-up study. Br J Plast Surg 1992 ;45:374-9

11. Breasted HG. The Edwin Smith surgical papyrus:

hieroglyphic translation and commentary. Chicago:

University of Chicago Press 1930

12. Stegman SL, Tromovitch TA, Glogan RG. Treatment of

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Surg A 1896; 14: 483-5

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CONCLUSION

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781-7

Source of Support: Nil

Conflict of Interest: Nil

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