ISSN: 2320-5407 Int. J. Adv. Res.

10(03), 411-419

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/14404
DOI URL: http://dx.doi.org/10.21474/IJAR01/14404

RESEARCH ARTICLE
THE ROLE OF PROSTHODONTICS IN VARIOUS CLINICAL SCENARIOS OF MUCORMYCOSIS: A
REVIEW ARTICLE

Dr. Suresh Kamble1, Dr. Pratiksha Somwanshi2, Dr. Ajit Jankar3, Dr. Yogesh Nagargoje4, Dr. Shashi Patil5
and Dr. Sandeep Fere6
1. Principal, Department of Prosthodontics, MIDSR College, Latur, Maharashtra.
2. Post Graduate Student, Department of Prosthodontics, MIDSR College, Latur, Maharashtra.
3. Head of Department, Department of Prosthodontics, MIDSR College, Latur, Maharashtra.
4. Senior Lecturer, Department of Prosthodontics, MIDSR College, Latur, Maharashtra.
5. Assistant Professor, Department of Prosthodontics, MIDSR College, Latur, Maharashtra.
6. Reader, Department of Prosthodontics, MIDSR College, Latur, Maharashtra.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Coronavirus disease 2019 (COVID-19) is a new disease thing caused
Received: 18 January 2022 by a unique coronavirus (SARS-CoV-2) first documented in China in
Final Accepted: 20 February 2022 December 2019 and subsequently causing a worldwide pandemic.
Published: March 2022 COVID-19 caused by severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2), has been sweeping across the globe. During the current
Key words:-
COVID-19, Maxillary Defect, pandemic of COVID-19, acountless of manifestations and
Mandibular Defect, Orbital, Ocular, complications have emerged and are being reported on. There is
Auricular, Nasal Defect anincidence of patients with COVID-19 who are at increased risk of
acute cardiac injury, arrhythmias, thromboembolic complications like
pulmonary embolism and acute stroke), and secondary infection to
name a few.The frequency of fungal infections is increasing due to
immunodeficiency viruses and immunosuppressive drugs. Candidiasis
is the most common fungal infection of the oral cavity.Mucormycosis
is an invasive fungal infection, often acute and extremely severe,
occurring in patients with an underlying condition. Mucormycosis
isproduced by saprophytic fungi of the order Mucorales. The estimated
prevalence of mucormycosis is about70 times greater in India than that
in global data. Diabetes mellitus is the most common risk factor,
followed by hematological malignancy and solid-organ transplant.

Copy Right, IJAR, 2022,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
In December 2019, a cluster of patients with pneumonia of unknownsource was observed in Wuhan, China. A novel
coronavirus was identified the causative pathogen, 1‐ 6 temporarily named as 2019 novel coronavirus
(2019‐ nCoV) by the World Health Organization (WHO). On 11 February 2020, WHO named this novel
coronavirus pneumonia “COVID‐ 19” (coronavirus disease 2019)1. Recently emerged human-to-human
transmission of COVID-19, a novel lethal strain of coronavirus, caused a global pandemic burden, affecting
thousands of individuals, having life-threatening outcomes, not only in medically compromised people but also in
perfectly healthy young individuals with immunocompetent system2. TheCOVID-19 infection caused by the novel

Corresponding Author:-Dr. Pratiksha Somwanshi

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Address:-Post Graduate Student, Department of Prosthodontics, MIDSR College, Latur,
Maharashtra.
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severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) may be related with a wide range of disease
patterns, ranging from mild to life-threatening pneumonia3.

The Covid-19 symptom spectrum has expanded since the first days of the disease’s presentation, which initially
included only a dry cough and high-grade fever, to additionally include various multisystem problems such as
shortness of breath, anosmia, ageusia, diarrhea, generalized malaise, acute cardiac injury, and secondary infections 4.
The most common symptoms are fever and dry cough and in some cases shortness of breath, dysosmia, and
dysgeusia (Guan et al. 2020; Lechien et al. 20205. It is responsible for lower respiratory infection and can cause
Acute Respiratory Distress Syndromes (ARDS) 1. Besides, the diffuse alveolar damage with severe inflammatory
exudation, COVID-19 patients always have immunosuppressionwith a decrease in CD4 + T and CD8 + T cells 6.

Many studies of hospitalized patients with COVID-19 note the empiric use of antibiotics in a majority of patients 7;
however, there is evidence that the inflammatory serological markers that are usually associated with bacterial
infection, such as raised procalcitonin and CRP, may appear in patients with COVID-19 without a conforming
bacterial co-infection occurring8.The patients who were admitted to the intensive care unit (ICU) and required
mechanical ventilation, or had a lengthier duration of hospital stays, even as long as 50 days, were more probable to
develop fungal co-infections9. Henceforth, it is significant to notice that COVID-19 patients can develop encourage
fungal infections during the middle and latter stages of this disease, mainly severely ill ones 10.

Mucorales infections are emerging as a matter of concern in COVID-1911. Recently, mucormycosis, also recognized
as black fungus, made severe chaos in India during the second wave of the tragical COVID-19 epidemic by its
sudden12. It is associated with angio-invasion and high mortality. The infection is increasingly reported in patients
with diabetes mellitus, hematological malignancy, solid organ transplants, and corticosteroid therapy. Due to the
aggressive and invasive nature of the disease, extensive surgical resection is required which results in large complex
maxillofacial defects13.

The spores of the fungus are inhaled through the mouth and nose, but infection infrequently occurs in a person with
an intact immune system because macrophages phagocytize the spores. However, an immunocompromised
individual is unable to mount an effective immune response against the inhaled spores; thus, germination and
hyphae formation occurs and infection develops, most commonly in the sinuses and lungs 14.

When the fungus invades the paranasal sinus mucosa, it may spread directly to the orbital apex and, from there, gain
intracerebral access. Mucormycosis is difficult to diagnose early, as patients often present with nonspecific
symptoms. By the time signs of orbital apex involvement develop, it is often too late to save the patient’s vision, or
even the patient’s eye or life. The presentation is typically a rapidly progressive infection, and the disease is
associated with a high mortality rate14.

This article will briefly describe the possible treatment options available, according to the area affected (i.e.
maxillary, facial, orbital).

Incidence of Mucormycosis:
The incidence of mucormycosis is rising globally15but the rise is very high in India and China among patients with
uncontrolled diabetes mellitus16.

Risk Factors:
Not all people who have contracted coronavirus infection and are on treatment for COVID-19 obtain mucormycosis.
Certain individuals are more prone to getting affected by the fungal infection, such as
1. People with uncontrolled diabetes mellitus are the major risk factor in 54-76% 17
2. Hematological malignancy (HM) is a risk factor in 1–9% of mucormycosis patients in India17,18
3. Persons with comorbid conditions taking immunosuppressant steroid medications to manage pre-existing
illnesses as well as COVID-19, over an extended length of time7
4. Being treated in the Intensive Care Unit i.e. ICU wing of hospitals for a prolonged interval of time8
5. Solid-organ transplantation (SOT) is a risk factor in 2.6–11% of mucormycosis cases from
Indianprocedures19,20,21
6. Already taking prescription antifungal drugs to combat infections

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7. Other predisposing factors associated with mucormycosis in India are chronic kidney disease (CKD),
pulmonary tuberculosis, and chronic obstructive pulmonary disease (COPD) 22

Role of prosthodontics in India:

Fig. 1:- Maxillofacial defects and related prosthesis.

Small maxillary defects

In small defects (Fig.2 a)with adjacent teeth or adequate supporting alveolar ridges, one-piece maxillary obturator
prosthesis is often all that is needed. Retention and comfort are superior by making it lightweight, hollowing out the
obturator section, and extending it only a few millimeters into the defect(Fig.2 b). Full extension is not advocated as
the tissues neighboring the defect often lack bone and can be tender and friable, providing no further support or
retention for the prosthesis, but adding to the potential complications of tissue irritation. It is crucial to ensure a good
seal around the opening of the defect by taking a functional impression or using a tissue conditioner to record fine
details and tissue movement 23.

Fig. 2:- a. Small maxillary.

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Fig. 3:- b. Small maxillary.

Large maxillary defect

Larger maxillary defects require to be obturated to address the various complications. This usually includes a two-
part prosthesis consisting of a hollow, flexible glove/ bulb obturator attached to a solid denture base (Fig.3). The
glove section is made from a rubber material, which can be compressed to permit for easy insertion and removal
(these patients often have trismus which makes it difficult to insert large appliances). The denture clips into the bulb
for additional retention and to confirm a complete seal. The complete prosthesis is easy to insert and remove for oral
hygiene purposes and to permit the clinician to examine the defect intermittently for any signs of tumor recurrence
or other complications23.

Fig. 4 Large maxillary Obturator

Orbital defect
Orbital rehabilitation is a complex process that needs specificity in a technique according to a certain patient. An
orbital prosthesis is made to reconstruct a more typical anatomical structure and cosmetic defect produced by these
circumstances in a person. The prosthesis is generally fabricated after complete healing (usually 2 to 4 months). The
orbital prosthesis comprises artificial eyes, lids, lashes, and skin24(Fig.4).

Fig. 5:- Orbital Prosthesis.

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Ocular defect
A effective ocular prosthesis depends on the patient having a deep, healthy socket with proficient functioning
eyelids. Final adjustments and polishing is done at the chair side to perfect the eye position, contour, lid support and
to optimize movement 23.A prosthetic eye (Fig.5) is beneficial in patients with scleral defects and helps reestablish
esthetics. It also goes a long way in effecting psychological rehabilitation in conditions where the loss of visio n is
permanent25. The success of an ocular prosthesis depends largely on the precise orientation of the iris disk
assembly26.

Fig. 6:- Ocular prosthesis.

Orbital defect with maxillectomy

The success of rehabilitative treatment in a patient with widespread resections involving the hard palate, soft palate,
and orbital exenteration is directly related to the quality of the prosthesis. 10 One of the significant problems
professionals encounter when constructing these prostheses is the absence of retention. 3 In addition, the edges of
the facial prosthesis do not always adapt perfectly to the patient’s face because of the movement of bordering
tissues. Retentive elements, apart from conventional adhesives, are normally required. The use of magnets in
multiple/sectional maxillofacial prostheses is an excellent means to bond them together (Fig.6). However, to assure
proper retention and effective stability of the prosthesis each section should be sufficiently extended and the
magnets positioned properly27.

Fig. 7:- Palatal obturator attached with facial extension using magnet.

Facial defect
Facial transplantation is becoming an option for the reconstruction of facial defects following severe facial injury
including burns. The face is the unique identifier, providing both familial characteristics and information about
identities. The reconstruction of the donor's face post-operatively is of some importance (Fig.7), due to

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recommendations that the donor body should be restored to an acceptable aesthetic appearance following organ
harvesting28.

Fig. 8:- Facial prosthesis.

Mandibular defect
Discontinuity of the mandible after surgical excision disturbs the equilibrium and symmetry of mandibular
functions, which leads to altered mandibular movements and deviation of the residual segment towards the defect
side, resulting in loss of occlusion on the unresected side. The deviation of the mandible is secondary to muscle
imbalance and compromised proprioception, and is easily resolved with mandibular guidance therapy29. Once the
continuity of the mandible can be restored surgically, prosthodontic rehabilitation (Fig.8) can be the same as that for
the continuity defect 30.

Fig. 9 Mandibular Prosthesis

Nasal defect
Nasal defects (Fig. 9a) are difficult to treat surgically and usually necessitate the fabrication of a prosthesis. This
involves taking a moulage impression of the affected site as well as of the contra-lateral facial structure. The latter is
copied (in a mirror image) to fabricate a closely matched wax replica. This is carved de nova using casts, old
photographs, and a general knowledge of anatomy and facial dimensions as a guide (Fig.9b). Alternatively, a
“donor- nose” may be used23.

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Fig.9:- a. Nasal Defect.

Fig. 9:- b. Nasal Peosthesis.

Auricular defect
Auricular defects (Fig.10a) are challenging to treat surgically and usually necessitate the fabrication of prosthesis.
This consist of taking a moulage impression of the affected site as well as of the contra-lateral facial structure. The
latter is copied (in a mirror image) to construct a closely matched wax replica. This is carved de nova using casts,
old photographs, and general knowledge of anatomy and facial dimensions as a guide (Fig.10b). Alternatively, a
“donor-ear” may be used23.

Fig.10:- a. Auricular Defect.

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Fig. 10:- b. Auricular prosthesis.

Conclusion:-
Successful prosthodontic rehabilitation of patients with head and neck defects depends on a multidisciplinary
approach where members from all the associated disciplines work in close consultation and cooperation with each
other and with the patient during all the stages of treatment. This remains an area of dentistry that is often neglected,
not only in under and postgraduate training, but also in private practice. As a profession we owe these patients our
full involvement and commitment. We, therefore, need to become involved with our medical and dental colleagues
who treat oral cancer and other patients requiring such rehabilitation, to improve the quality of life, not only of the
patients themselves but of the immediate family members as well.

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