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Doctors share reconstruction story from the heart

July 02, 2019

By Jennifer Garvin

Drs. Brett Shirley, Joseph Massad, George Purifoy and Paul Gunderson
Connection: Drs. Brett Shirley, left, and Joseph Massad share a moment with patients George Purifoy and Paul Gunderson. Both patients are Vietnam veterans who were treated by the doctors. Photo courtesy of Dr. Brett Shirley.

Dr. Joseph Massad calls it “the gift of a challenge.”

Four years ago, the Tulsa, Oklahoma-based dentist received a call from the Oklahoma Veteran Affairs and oral and maxillofacial surgeon Dr. Brett Shirley. They were looking for a dentist who could help reconstruct the nose and jaw/teeth of a Vietnam veteran. The patient, George Purifoy, had received radiation therapy and undergone multiple surgeries for a nasal squamous cell carcinoma that resulted in a total rhinectomy and the loss of his front teeth. He was also in terrible pain from the after-effects of the radiation.

“I was literally living without a nose, and had to wear a surgical mask everywhere I went to avoid all the pointing and whispers,” said Mr. Purifoy, who at the time was traveling between parts of Oklahoma, Arkansas, Louisiana and Texas for various medical and dental treatments.

It had been a long journey for Mr. Purifoy. Some initial misdiagnoses delayed his treatment — which were documented in a 2015 article in USA Today. Dr. Massad wanted to help.

“I felt like I could do this, but I would need to work with his oncologist and oral surgeon,” Dr. Massad said.

The story of how Dr. Joseph Massad and Dr. Brett Shirley teamed up to reconstruct Mr. Purifoy will be featured as part of the Live-Patient Series continuing education courses at the ADA FDI World Dental Congress in San Francisco. The course, Oral Facial Reconstruction of Complete Nose and Maxilla, will take place from 1:30-4pm, Thursday, Sept. 5.

“When I saw him, he had pretty advanced osteonecrosis, as advanced as it gets in his maxilla,” said Dr. Shirley, a Maxillofacial Oncology and Reconstructive Surgeon, who began treating Mr. Purifoy in 2015 when he worked a VA facility in Shreveport, Louisiana. “There were no other options besides removing all of the dead bone— you can't save that. And unfortunately, the teeth are encased within that, so they had to go too. Essentially all of his upper teeth were affected.”

“The trickiest thing was figuring out how we can rebuild what had to be removed given the complexity of the defect.  George had some medical problems that prevented us from being able to use microvascular tissue transfer,” Dr. Shirley continued. “What makes this so complex is normally when you lose your upper teeth and a portion of your maxilla, you can make a denture or implants for a denture. But if you don’t have any remaining maxilla or nose to support a prosthesis, then you don’t have many options. [Mr. Purifoy] did have a prosthetic nose but it needed to have some support from the upper jaw or it would just fall off.”

George Purifoy
Facial reconstruction: George Purifoy smiles after receiving his nose prosthesis from Dr. Joseph Massad. Dr. Massad and oral surgeon Dr. Brett Shirley will discuss Mr. Purifoy’s case Sept. 5 at the ADA FDI World Dental Congress in San Francisco. Photo courtesy of Dr. Joseph Massad.
Dr. Shirley proceeded with removing the dead bone. During the six weeks after, as Mr. Purifoy worked on healing, he relied on a temporary partial denture (flipper).

For about a year following the surgery, Dr. Shirley continued removing diseased teeth and replacing them with implants in the posterior maxilla where possible. It was around this time, that he was introduced to Dr. Massad.

“Dr. Massad and I talked, and I told him my plan was to sequentially remove the rest of George’s upper teeth and place as many dental implants as I could and then have a full upper denture/obturator made that would be retained by these locators.  The tricky thing is it needed an arm that would stick up into his nasal fossa for the nose to snap onto. This would give nasal prosthesis something to attach onto by the use of a magnet.”

For his part, Dr. Massad envisioned creating a prosthetic nose that would attach to a stem.

“This was new territory for me. It wasn’t a matter of simply getting a pre-made nose and gluing it on; it had to be a highly custom job,” said Dr. Massad. “I thought I might be able to use the dental prosthetic device to support the nose and, with the entire nasal cavity gone, I knew I’d need some sort of internal piece attaching the nose to the much lower dental prosthetic. Everything would need to connect precisely and perfectly.”

He started by making a provisional denture. “[Mr. Purifoy] was still without a nose but we had to do things one at a time,” Dr. Massad said. “I made the impressions, poured the model, articulated the jaw to ensure we had the correct space, and all the while made certain to ask him what he wanted and to involve him in the process.”

“By the second visit he was already taking impressions and working on a denture so I’d be able to eat,” Mr. Purifoy said, “I’ll always remember Dr. Massad telling me, ‘we’re going to make it work.’”

The next step was to send Mr. Purifoy — along with his provisional prosthesis — back to Dr. Shirley to finish extracting the remainder of his teeth and insert the provisional denture, which would hold his jaw in position.

Along the way, Mr. Purifoy continued to experience health problems. He had bypass surgery on his legs and also was diagnosed with lung cancer, which prompted chemotherapy and radiation—in addition to what he’d already received for the nasal carcinoma.

During the process of integration, Dr. Massad began making renditions of prosthetic noses.

“I knew from talking to [Mr. Purifoy] and looking at old photos that his nose had been quite small, and the challenge became making a nose of a suitable size that would still cover what was a significant scar line,” he said. “It was a learning process from start to finish. I learned what he wanted, learned what would and wouldn’t work and, more often than not, went back to the drawing board to make everything as perfect as possible.”

Dr. Massad said he initially built the stem with an acrylic material and had a metal casting made to serve as a framework that would be inside the denture but would then come out of the denture like a stem, using two magnets. He first tested this model after Mr. Purifoy had five of the implants in place. But because Mr. Purifoy had only back teeth and implants and no premaxillary, he had trouble eating with the new prosthesis. In the end, Dr. Massad decided to use a single snap and magnet. It would take four trials until he got this right.

The next challenge was ensuring the stem was sufficiently hollow so that Mr. Purifoy could breathe properly and feel comfortable. For the final design, Dr. Massad used silicone attached to a metal frame which housed a retention magnet and locator that would snap onto Mr. Purifoy’s denture prosthesis.

That was the functionality part. Next came making the nose look as realistic as possible. Dr. Massad made several prostheses for Mr. Purifoy in different skin tones that he could use depending on the situation. Thinking outside the box, Dr. Massad decided to consult with a make-up artist, Elizabeth Bender-Bey, whom his son knew from working in the film industry.

He and Ms. Bender-Bey spent hours matching tones and getting it just right.

A self-described perfectionist, Dr. Massad knew he wouldn’t be satisfied until the nose looked and felt natural, in and out of various types of lighting.

“I was a pariah and I had resigned myself to wearing a mask for the rest of my life,” he said.  “My wife and I never went anywhere, and all my old friends disappeared from my life. Today, I have a nose, I can eat, I can communicate, and my wife and I have already gone out to dinner 5 or 6 times. I just put on my nose and away I go.”

Dr. Shirley called Mr. Purifoy a “once in a lifetime” patient.

“Sometimes in cases like this, you can get burned out,” he said. “But George was so happy to have someone willing to give him a shot it helped give us perseverance and Dr. Massad was a true blessing to work with that seems to never tire or lose his enthusiasm for a difficult case.”

Editor's note: Mr. Purifoy’s comments in this story were part of an interview he did with Dr. Massad’s staff for educational purposes.