10.14639/0392-100X-N2543
Objective. To describe a new method to improve the exposure of the surgical field and to protect the oral cavity during transoral laser micro-surgery of the larynx. Methods. Dental Impression Silicone Putty (DISP) was employed as an alternative to traditional mouthguards.Results. DISP mouthguards perfectly fit to each patient, reduce encumbrance in the mouth, and reduce pressure on the teeth; disadvantages are minimal. Conclusions. Although clinical studies are necessary to demonstrate the efficacy of the method in reducing the incidence of oral complications, DISP mouthguards represent a significant aid for laryngeal exposure.
text/xml
1827-675X
2543
en
Gianluca Leopardi
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
dental injury
Dental impression silicone putty in transoral laser laryngeal surgery: prevention of oral complications
Text.Serial.Journal
https://www.actaitalica.it/
43
Clinical techniques and technologies
2023-05-23
2023-03-09
2023-09-29
2023-10-02
348-351
1
Gianluca Leopardi
2023/05/23
10.14639/0392-100X-N2543
348
Unit of Otolaryngology, “S. Giuseppe Hospital”, Empoli (FI), Italy
1827-675X
dental injury
en
351
Dental impression silicone putty in transoral laser laryngeal surgery: prevention of oral complications
https://www.actaitalica.it/article/download/2543/1009
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:348-351; doi: 10.14639/0392-100X-N2543




Clinical techniques and technologies


Dental impression silicone putty in transoral laser
laryngeal surgery: prevention of oral complications
Silicone da impronta dentale nella chirurgia laringea laser transorale:
prevenire le complicanze sul cavo orale
Niccolò Cerchiai1, Valentina Mancini1, Miriana Picariello1, Giandomenico Maggiore 2, Luca Muscatello3, Paolo Iannicelli1,
Gianluca Leopardi1
1
 Unit of Otolaryngology, “S. Giuseppe Hospital”, Empoli (FI), Italy; 2 Department of Otorhinolaryngology, Careggi University Hospital,
Florence, Italy; 3 Unit of Otorhinolaryngology, Apuane Hospital, Massa, Italy


SUMMARY
Objective. To describe a new method to improve the exposure of the surgical field and to
protect the oral cavity during transoral laser micro-surgery of the larynx.
Methods. Dental Impression Silicone Putty (DISP) was employed as an alternative to tra-
ditional mouthguards.
Results. DISP mouthguards perfectly fit to each patient, reduce encumbrance in the mouth,
and reduce pressure on the teeth; disadvantages are minimal.
Conclusions. Although clinical studies are necessary to demonstrate the efficacy of the
method in reducing the incidence of oral complications, DISP mouthguards represent a
significant aid for laryngeal exposure.
KEY WORDS: larynx, laser, microsurgery, oral complications, dental injury

RIASSUNTO
Obiettivo. Descrivere una nuova metodica per migliorare l’esposizione del campo operato-
rio e per proteggere il cavo orale durante la Microchirurgia Laser Transorale della laringe.
Metodi. Il mastice siliconico per impronte dentali (DISP) viene utilizzato in alternativa ai   Received: March 9, 2023
paradenti tradizionali.                                                                        Accepted: March 28, 2023
Risultati. I paradenti DISP si adattano perfettamente ad ogni paziente, riducono l’ingom-      Published online: May 23, 2023
bro in bocca e riducono la pressione sui denti; gli svantaggi sono minimi.
Conclusioni. Sebbene siano necessari studi clinici per dimostrare l’efficacia del metodo       Correspondence
nel ridurre statisticamente l’incidenza delle complicanze orali, i paradenti DISP rappre-      Miriana Picariello
sentano un aiuto significativo per l’esposizione laringea.                                     Unit of Otolaryngology, “S. Giuseppe Hospital”,
                                                                                               viale Boccaccio 16, 50053 Empoli (FI), Italy
PAROLE CHIAVE: laringe, laser, microchirurgia, complicanze orali, lesioni dentali              Tel.+39 0571 706918
                                                                                               E-mail: miripicariello@gmail.com


                                                                                                 How to cite this article: Cerchiai N, Mancini
Introduction                                                                                     V, Picariello M, et al. Dental impression sili-
                                                                                                 cone putty in transoral laser laryngeal surgery:
Laser-assisted surgery is a well-established method to treat both benign and                     prevention of oral complications. Acta Otorhi-
malignant lesions of the upper aero-digestive tract. The most employed tech-                     nolaryngol Ital 2023;43:348-351. https://doi.
nique for the treatment of laryngeal lesions, according with the new nomen-                      org/10.14639/0392-100X-N2543
clature proposed by the European Laryngological Society, is defined as CO2
                                                                                               © Società Italiana di Otorinolaringoiatria
transoral laser microsurgery (CO2 TOLMS) 1. Many types of innovative and                       e Chirurgia Cervico-Facciale
better performing instruments have been proposed and successfully employed
over the years, in order to ensure the best exposure of the laryngeal surgical                                OPEN ACCESS

field. With the same purpose, an important study by Piazza and colleagues                      This is an open access article distributed in accordance with
                                                                                               the CC-BY-NC-ND (Creative Commons Attribution-Non-
showed the importance of standardised pre-operative assessment 2. However,                     Commercial-NoDerivatives 4.0 International) license. The
a transoral approach to the larynx still mandates the employment of rigid steel                article can be used by giving appropriate credit and mentio-
                                                                                               ning the license, but only for non-commercial purposes and
operating laryngoscopes. Therefore, despite the use of standard dental guards,                 only in the original version. For further information: https://
the possibility to cause minor or major lesions to teeth or to the alveolar ridge              creativecommons.org/licenses/by-nc-nd/4.0/deed.en




348
                                                      Avoiding gum and dental injuries in transoral laser laryngeal surgery with dental silicone putty




during these procedures must be concretely considered.
The literature documents only few studies reporting the
incidence of surgical complications in the oral cavity dur-
ing transoral laryngeal surgery, especially when laser tech-
niques are employed 3,4.
Our centre performs about 30 laser-assisted laryngeal pro-
cedures per year. Many types of precautions have been
adopted over the years to prevent dental and gum injuries
(silicone or stainless-steel mouthguards, pre-operative den-
tal evaluation). However, we recently developed a very
promising method to protect both dental and periodontal
apparatus, employing a dental impression silicone putty
(DISP).
The primary aims of this paper is to present this technique
and then to analyse the advantages and disadvantages of
the method.

Technique
The material employed for this study is a nanotechnolo-
gy-based silicone (“Elite HD+ Putty Soft” – Zhermack
SpA – Badia Polesine, Italy), composed of a base (orange
putty) and a catalyst (white putty) (Fig. 1). The set is stored
in a dry and cool locker in our operating block.
When the patient is under general anaesthesia, with the en-
dotracheal tube correctly in place and cuffed, the surgeon
opens both the plastic jars of the set (base and catalyst) and         Figure 1. Set of nanotechnology-based dental impression silicone putty.
takes about 4 cc of both putties with a dedicated plastic
spoon (Fig. 2a). The surgeon should wear clean and sterile
surgical gloves to prevent dust, dirt, or organic material from        plications were more frequent in therapeutic procedures,
contacting with the putty. The surgeon uses fingers to knead           and there was a significant correlation between dental in-
the impression material mixing base and catalyst, until the            jury rate and pre-operative dental and periodontal disease 3.
material assumes a uniform color (it takes about 2 minutes).           One recent retrospective study by Larner et al. 4 reported 1
The surgeon rolls the putty into the shape of a small log              dental injury out of 174 cases.
(Fig. 2b), and then distributes the DISP up to cover the teeth         Even if the incidence of oral complications is relatively
of the maxillary dental arcade, paying attention to leave a            low and not life-threatening, the percentage of refunding
sufficiently thick layer on the incisal edge. In order to achieve      requests in consequence to dental lesions is generally high.
the maximum hardness, the material should now remain in                A recent study by Feng and colleagues showed the advan-
place for at least 5’30’’ at 23°C, according with the specifi-         tages of employing a laryngeal force sensor for suspension
cations given by the manufacturer; however, the higher tem-            microlaryngoscopy in mitigating maximum forces and pre-
perature of patients’ mouth usually shortens the time needed.          venting post-operative complications 5.
A “patient-shaped” DISP mouthguard is now ready, and the               Although our new technique has been successfully em-
operating laryngoscope can be safely positioned (Fig. 3).              ployed in our hospital for the past two years without re-
                                                                       porting any case of gum or dental injury, the main purpose
                                                                       of this paper is merely to illustrate the procedure in detail;
Discussion                                                             specific case-control studies will be necessary to compare
The literature reports different percentages of oral compli-           the efficacy of the method compared to employment of tra-
cations after TOLMS. An important study on a large series              ditional mouth guards.
of patients reported that minor mucosal lesions can occur              The advantages of the employment of DISP in TOLMS are
in 75% of patients; dental injuries are much less frequent,            the following. The material is low-cost; with a single set of
occurring in 6.5%; the study also reported that these com-             silicone putty it is possible to treat up to 60 patients; tradi-



                                                                                                                                                349
N. Cerchiai et al.




                                                                              Figure 3. The silicone putty is distributed on teeth and gums of the upper
                                                                              maxillary bone; next, the operative laryngoscope is placed.




Figure 2. About 4 cc of both base and catalyst are mixed in order to obtain
a small log of putty with an orange uniform colour.


tional silicone mouthguards are generally more expensive,
and their performance can decrease after several sterilisation                Figure 4. The silicone putty can prevent excessive pressure on a bad tooth,
procedures. The DISP can also be positioned only where                        distributing the pressure on neighbouring teeth, gums, and bone structures.
necessary; this aspect is a clear advantage in order to reduce
the encumbrance of instruments (i.e., steel mouthguards) in-
                                                                              on the bone); this may cause injuries to the mesial or dis-
side the mouth. The material perfectly follows the profile of                 tal faces of the crown and/or the neck of neighbouring teeth
the dental ridge; therefore, once hardened, the putty never                   (Fig. 5a); in these cases, the DISP can fill the space deter-
moves. The DISP also prevents excessive pressure on rot-                      mined by missing teeth, keeping the laryngoscope in an opti-
ten teeth: optimal positioning of the material also allows to                 mal position (Fig. 5b). Finally, the surgeon can also prepare
distribute the pressure on neighbouring teeth, but mostly on                  the DISP mouthguards before inducing general anesthesia,
gum and bone structures (Fig. 4). Furthermore, there are cas-                 preventing dental injuries during oro-tracheal intubation.
es in which the operating laryngoscope, due to lack of teeth,                 However, the procedure has also the following disadvan-
is forced to lie directly on the bone of the maxillary alveolar               tages. Firstly, operating time increases by about 10-15
ridge (even when correctly positioned, it risks slipping down                 minutes, because the surgeon needs two separate scrubbing



350
                                                                Avoiding gum and dental injuries in transoral laser laryngeal surgery with dental silicone putty




Figure 5. The silicone putty avoids the laryngoscope sliding down on the bone of the maxillary alveolar ridge when one or more teeth are missing; this reduces
the risk of injuring the mesial or distal faces of the crown and/or the neck of neighbouring teeth.


sessions. Secondly, it is necessary to pay attention to apply                    Ethical consideration
the material as a single block to avoid the risk of dispersing                   The research was conducted ethically, with all study proce-
silicone fragments in the oral cavity or in the oropharynx.                      dures being performed in accordance with the requirements
Furthermore, some skill is required in order to not make the                     of the World Medical Association’s Declaration of Helsin-
DISP mouthguard too thick or too thin.
                                                                                 ki. Written informed consent was obtained from each par-
Due to its advantages, we believe that these mouthguards
made of DISP represent a significant aid for CO2 TOLMS,                          ticipant patient for surgical procedure and data publication.
facilitating laryngeal exposure and reducing encumbrance
inside the oral cavity. Consequently, we can hypothesise                         References
that this technique could also be applied in all types of
laryngeal microsurgery. Further studies are necessary to
demonstrate the superiority of the method in reducing the                        1
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Conflict of interest statement                                                       s00405-017-4708-3
The authors declare no conflict of interest.                                     2
                                                                                     Piazza C, Mangili S, Bon FD, et al. Pre-operative clinical predictors of
                                                                                     difficult laryngeal exposure for microlaryngoscopy: the laryngoscore.
Funding                                                                              Laryngoscope 2014;124:2561-2567. https://doi.org/10.1002/lary.24803
This research did not receive any specific grant from fund-                      3
                                                                                     Klussmann JP, Knoedgen R, Damm M, et al. Complications of sus-
ing agencies in the public, commercial, or not-for-profit                            pension laryngoscopy. Ann Otol Rhinol Laryngol 2002;111:972-976.
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                                                                                 4
                                                                                     Larner SP, Fornelli RA, Griffith SD. Consistent technique limits
Author contributions                                                                 suspension laryngoscopy complications. Int Arch Otorhinolaryngol
NC: manuscript redaction, figure drawing; VM: clinical                               2019;23:E305-E310. https://doi.org/10.1055/s-0039-1684036
data collection, critical revision; MP: submission of the                        5
                                                                                     Feng AL, Puka E, Ciaramella A, et al. Laryngeal force sensor
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