FACIAL R E C O N S T R U C T I O N BY PROSTHETIC M E A N S

A. C. ROBERTS, F.I.B.S.T., F.R.S.H.

Plastic and Maxillo-Facial Unit, St Luke's Hospital, Bradford, 5

INTRODUCTION
FEW people are more severely handicapped than the patients with facial deformities.
The face is the centre point of attention in everyday life and, as such, of particular
importance. A facial deformity subjects the patient to both physical and mental
indignities. The rehabilitation of the patient with a facial defect is of prime
importance in restoring him to his accustomed way of life. Prosthetic recon-
struction of facial defects is now an established practice in the plastic and
maxillo-facial field. Facial prostheses may be constructed to transform con-
genital and acquired defects into natural-appearing reproductions of the missing
parts, providing an acceptable appearance with as much function as possible.
Reconstructive surgery produces satisfactory results in suitable cases. Some-
times there is a long period between the establishment of the deformity and the
commencement of surgical procedures. The provision of a 'temporary' prosthesis
in such cases is of considerable psychological as well as practical value.
There are many inoperable cases for which the provision of a permanent
prosthesis is necessary. In many patients who have suffered extensive burns to
the face and head of a severity requiring skin cover, there is often insufficient
tissue locally available for the reconstruction of a nose or ear. Also the grafted
area may not be suitable for attachment Of pedicle flaps. In malignant disease,
where there has been prolonged radiotherapy, surgery may have to be excluded.
Facial prostheses have always been required for patients in civilian life, but
war, with its casualties, becomes instrumental in calling attention to the problems
and importance of facial reconstruction by prosthetic means. The ravages of
war are not alone responsible for facial defects. Even in peace, other destructive
factors contribute to facial deformity--traumatic road accidents, burns and
malignant disease provide a constant flow of cases.
Radical surgery of the head and neck, so often necessary in cancer cases,
requires the removal of a considerable section of tissue adjacent to the neoplasm.
In many of these cases, a considerable post-operative deformity results. The
provision of a temporary or permanent prosthetic substitute is of considerable
benefit to the patient.
The main indications for the provision of a facial prosthesis may be listed
as follows:
I. As a temporary measure with regard to future surgery.
2. Case unfavourable for surgical procedures due to existing disease.
3. Age and general health of the patient.
4. Insufficient tissue available for surgical reconstruction.
5. Unwillingness of patient to undergo surgery.
6. Financial considerations due to a long stay in hospital.
/vi x57
I58 BRITISH JOURNAL OF ORAL SURGERY
The construction of a facial restoration requires technical skill and artistic
abilities. The qualities involved are those of artist, chemist and engineer. To
combine these specialities requires a person who is trained to use a wide range
of materials and apply them to the problem of facial restoration.
Because of its medical influences, the construction of facial prostheses cannot
be confined to the field of art and sculpture. One may ask who is best qualified
to be responsible for this type of work. The construction of intra-oral prostheses
of many kinds has long been practised in dentistry. In view of the development
of this branch, it is understandable that it should expand to include extra-oral
restoration. Dentistry with its wide knowledge and application of materials for
restorative techniques provides the ideal background for this work. The accurate
impression techniques perfected and the special laboratory facilities available
make the dental surgeon and his technical staff the most qualified persons to be
responsible for facial restoration by prosthetic means.

HISTORY

Prosthetic reconstruction of facial defects is distinctly evident in the history

of mankind. Although it is almost impossible to determine how far back in history
man's attempts to correct by prosthetic means, congenital and acquired defects,
records indicate the use of facial prostheses long before dentistry. Archeological
findings have produced artificial noses, eyes and ears in Egyptian mummies. The
Chinese are known to have constructed facial prostheses from waxes, clay and
wood.
It is logical to assume that the need for prosthetic restoration has existed
since the time when man began to be inflicted with disfigurement, caused by
disease or mutilations of one kind or another, sustained during hunting or tribal
wars. An interesting account of an artificial nose is quoted from an account on
the life history of Tycho Brahe (Bulbulian, 1945):
'Tycho and his enemy agreed to meet in the dead of night and fight it out with
swords. There was no light furnished for the duel, it was pitch dark and the fighters
found each other only by ear. The combat was waged fiercely for some time with no
damage done, then Tycho got his nose in the way of his opponent's sword. At that
instant he lost the fight--and his nose.
'Honour was satisfied and Tycho was led away to a doctor. The great Dane was
not content to go through life without a nose. He set about making himself one, out
of silver and gold, some say copper. Nothing so common would have suited the
aristocratic Tycho. This manufactured nose was cemented in place and his enemies
said it looked better than the old one. Of course, occasionally it would drop off, but
Tycho always replaced it and went about his business undisturbed.'

Ambroise Par6 (151o-9o) can well be called the father of facial prostheses.
His fabrication of these appliances has done much to form the basis of facial
reconstruction by prosthetic means. Ambroise Par6 describes the indications and
appliances used:
'By what means a part of the nose is cut off may be Restored, or How Instead of
the Nose that is cut off Another Counterfeit Nose may be fastened or Placed in the
Stead.
 F A C I A L R E C O N S T R U C T I O N BY P R O S T H E T I C MEANS 159

'When the whole nose is cut off from the face or portion of the nostrils from the
nose, it cannot be restored or joined again for it is not in men as in plants. Instead
of the nose cut away or consumed, it is requisite to substitute another made by art
because that nature cannot supply that defect, this nose so artificially made must be
of Gold, Silver, Paper of Linen cloths glued together; it must be so coloured, counter-
feited and made both of fasion, figure and bigness, that it may as aptly as is possible
resemble the natural nose; it must be bound or staid on with little threads or laces unto
the hinder part of the head of the hat (Fig. I). Also if there be any portion of the upper
lip cut off with the nose, you may shadow it with annexing some such things that is
wanting unto the nose, and cover it with hair on his upper lip that he may not want
anything that may adorn or beautify the face.'

FIG. I
Ambrose Par~ prostheses.

H e goes on to relate the case o f a young m a n of the family of St Thoan, who,

being weary o f an artificially m a d e silver nose which he had worn in the place o f
his nose that was cut off, went to a chirurgeon in Italy and b y means of an
unforesaid practice he recovered a nose o f flesh again, to the great admiration o f
all who knew him before.
Pard also tells o f the treatment of gun-shot wounds:

'It often happens that the face is deformed by a sudden flashing of gunpowder and
pestulent carbuncle for one cannot behold it without greater horror. Some persons
must be so trimmed and ordered that they may come in seemly manner into the company
of others. The lips if they be cut off with a sword or deformed with erosion or eating
16o BRITISH JOURNAL OF ORAL SURGERY

o f a pestulent carbuncle or ulcerated cancer so that the teeth may be seen to lie bare
with great deformity. I f the loss or consumption of the lip be not very great it
may be repaired by that way I have described in the cure o f hare lips or ulcerated
cancer, but if it be great, then there must be a tip o f gold made for it, so shadowed and
counterfeited that it may not be much unlike in colour to that natural lip and it must
be fastened and tied to the hat or cap the patient weareth on his head so that it remains
stable and trim.'

FIG. 2A
Pard prostheses are indeed ingenious.
His eye prosthesis was made of 'gold and
silver and counterfeited and enamelled so
that it may seem to have brightness or
gemmy decency of the natural eye.' For
those who could not retain an indwelling
eye, he describes one complete with eyelids
and retaining band encircling the head. He
illustrates a similar means of retention for
ear prostheses. The retaining bands in all
Pard's cases were made of gold o r silver
wire, bowed or crooked to the head, so
retaining the prosthesis.
Sir William Whymper, writing in the
London Medical Gazette of I832, describes
the case of the gunner with the silver mask
(Fig. 2):
'Alphonse Louis, aged 22 years, a native of
St Laurent in the Pas de Calais, Private in the
5th Company, 2nd Regiment of artillery who
was wounded in the trenches on the 6th December
FIG. 2C I83Z by the splinter of a I2 inch shell.
 FACIAL RECONSTRUCTION BY PROSTHETIC MEANS I61
'The projectile first attacked the external part of the left jaw carrying away almost
the totality of the maxillary process, of which there only remained the edge of thc
extreme left posterior portion, the coronoid process and condyle. In short, to render
the description more clear, nothing whatever remained of the lower jaw, save four
fractured teeth and injured fragments on the right side, thus the tongue dropped down
to a length of several inches, exposing the cavity of the throat, a horrible and ghastly
sight.
'The patient recovered sufficiently from his apparently hopeless condition for his
physician, Dr Forget, to consider the construction of a prosthetic restoration. Whymper
gives the foUowing description of the construction of the appliance. "On Ioth February,
an exact plaster cast was taken of the face. A cast iron mask was then made; and by the
aid of this the artist was enabled at his leisure to construct a substitute for the lost parts
that might not only render essential services to the eye as to the ravages of the wound.
The mask was made by a skilful artist of antwerp, M. Verchuyler from the designs of
Dr Forget." '
W h y m p e r goes on to say:
'The ability shown by the artist in the construction of this ingenious piece of
mechanism is deserving of much commendation, and we venture to recommend such
of our readers who may have an opportunity of visiting the Invalids at Paris, to enquire
there for the "Gunner with the Silver Mask"; they will then be enabled to inspect the
contrivance and to see and converse with its proprietor. To practical men the visit
will be of deep interest. A short description of the mask itself is necessary, though we
cannot pretend to offer a graphic portrait.
' T h e external part is composed of a lower half-mask, without nose or cheeks.
The anterior edges are in immediate contact with the lower part of the nasal cartilage
and adjacent muscles, and thc angles of the upper jaw. The two sides, or half cheeks,
repose on the parotid borders of the maxillary and the sterno-mastoideum so as to conceal
and enclose the whole extent of the deformity. In the front of its centre, that is the por-
tion occupied by the lips and chin, there is an oblong square plate or trap, opening
with a lateral hinge and spring; this imitates the surface of the chin, two lips, and
middle section of the mouth. This trap being opened by the patient's left hand shows a
second or internal chin, and complete buccal cavity with a regular set of metal teeth.
By the aid of this aperture, of which the mechanism is extremely simple, a communication
is opened between the air and the pharynx, so that he can repose and breathe freely
without taking off his mask. This is not strictly necessary for the process of respiration
as there is an opening between the artificial lips; it is merely done to give greater freedom
to the action of the lungs, and to diminish the heat.
' All the points of contact with the face are skilfully ornamented with mustachios
and whiskers, which entirely cover the edges. The inferior parts are covered by the
cravat; and the posterior part, which reaches behind the ear, hidden by allowing the hair
to grow and fall down over it. At the distance of two or three yards it is impossible
to distinguish the artificial nature of the substitute; the subject having the appearance
of a man of good constitution between 45 and 50 years of age. The mask is painted
in oils, of a tint analogous to his complexion, so that illusion is so strong that, unless
forewarned, he might be steadfastly examined at a short distance without betraying his
misfortune.
'The internal part is divided into two compartments. The upper, or sublingual,
section is furnished with a platform which supports the tongue, retains it in its proper
position and regularly circumscribes its action by a complete alveolar process, set with
gold teeth. This jaw, being adapted with a hinge and spring, can be lowered at will
by the man's left hand, so as to admit food. The lower section forms the cavity of the
inward chin, and is disposed so as to serve as a reservoir for the saliva and mucous
secretions which are incessantly flowing from the remaining parotid and glandular
162 B R I T I S H J O U R N A L OF ORAL SURGERY

integuments of the mucous membrane; these fluids are got rid of through a small orifice,
by merely leaning the head to one side. The different portions of the mask are of silver,
strongly gilt, and so constructed that they can be taken to pieces in order to undergo
cleansing, and can be re-united with the utmost facility. The whole contrivance, an
admirable proof of mechanical skill, is maintained in its proper place by means of Indian
rubber bandages which hook on the occiput and vertex, and are strengthened by means
of a flexible metallic strap, intended to prevent all possibility of derangement. The
weight is about three pounds and the cost of the whole was about £12 sterling.
'The use of the mask is by no means painful or inconvenient, considering the nature
of the wound. It is, above all, of great assistance in arresting in their passage, and
retaining in the cavity of the artificial chin, the salivatory and mucous secretions; it
facilitates the action of the tongue; it has restored a face dreadfully mutilated to a human
form; it has singularly softened the rigour of the sufferer's fate, conduced to his comfort
and rendered his existence not only desirable but comparatively happy. On our last
visit to Alphonse Louis, the day previous to his departure for Lille, he appeared in high
spirits; he walked about with agility; used the stump of the forearm with address; took
off and re-adjusted his mask with his left hand; spoke not only intelligibly but easily;
he was high-coloured and fatter, as he stated, than he had ever been prior to his mis-
fortune. He played at cards and seemed to be as proud of showing the mechanism of
his artificial jaw as he was of the crosses of the Legion of Honour and Leopold that
glittered on his bosom.'

GENERAL CONSIDERATIONS

In cases of facial deformity, each case is an individual problem requiring

special consideration. T h e success of a facial restoration may depend upon careful
examination and evaluation of the defect and surrounding tissues. Preconstruction
planning provides valuable information as to which procedures and materials to
employ. The case history of the patient, together with details of employment,
should be fully documented to provide a detailed reference during subsequent
treatment. Occupation, nature and extent of prosthesis, material used, shade
data, characterisation details, weights, history and any other relevant remarks
should have their headed spaces at the commencement of the departmental
treatment record in the notes. The face should be examined in repose and during
expressive movements. Palpation of the margin of the defect is an important
means of defining supporting tissue and areas of sensitivity. Consideration should
be given as to which form of retention will be suitable to the requirements of
the case. I f spectacles are required, the patient should be examined by an optician
in the primary stage of the treatment programme. This will save time and allow
the treatment to continue while the spectacles are being prepared. The extent
of scar tissue will have particular importance in the design of the prosthesis. In
cases of eye and orbit restoration, the lateral extent of the defect and scar tissue
make any movement of the mandible a displacing factor to the wearing of an orbital
prosthesis. The minimum extent of prosthetic coverage should be defined by a
wax template which is reduced until satisfactory stability is achieved. M a n y
failures of facial restorations result from over-extension. A prosthesis may have
to be contained to avoid mobile tissue and to utilise tissue folds as marginal
masking lines.
It is important that the Plastic Surgeon has an understanding of what may be
achieved by prosthetic reconstruction and, where possible, plan the surgical
 FACIAL R E C O N S T R U C T I O N BY P R O S T H E T I C MEANS 16 3

procedure so as to provide the type of defect that will best aid prosthetic recon-
struction. For example, a total prosthetic ear or nose is more satisfactory than
a partial one. Excision of a section of the lower end of the nasal septum together
with retaining the base of both ala cartilages will assist in the stability of a nasal
prosthesis (Fig. 3). Preservation of the tragus greatly facilitates prosthetic

FIG. 3
Base of both ala cartilages retained to assist stability.

reconstruction of an ear. Accessory appendages of cartilage and scar tissue are

best removed from the defect site so as to provide a smooth surface on which to
place the prosthesis. Following exenteration of the orbit, a skin graft to the
orbital area will enable a prosthetic restoration to be extended into the defect
resulting in more satisfactory retention and appearance.
The number of clinical sessions will depend on the prosthesis required. In
all, some five sessions are needed to complete the restoration:
I. Examination and impression.
2 and 3. Wax trial and adaption.
4. Packing and basic colour simulation.
5. Final fitting.
Considerable time is required for a facial prosthesis. Some 3o hours may be
used in the case of an eye and orbit restoration and some 28 hours for an ear or
nose. Wax trial and adaption sessions are time-consuming periods and two hours
each are often needed for this important stage. A number of sessions will prevent
the patient from becoming fatigued.

PROSTHETIC PROCEDURES
T i m e o f C o m m e n c e m e n t . m I t is difficult to define the exact time to
commence facial reconstruction by prosthetic means In some cases a simple
164 BRITISH JOURNAL OF ORAL SURGERY

cover plate will suffice during wound healing and tissue contracture. A prosthesis
which is fitted too early following surgical procedures may have a traumatic
effect on the wound and is seldom tolerated by the patient. The constant tissue
change of the defect area also destroys the aesthetic effect of any prosthesis. Some
cases may require an early restoration in which case the limitations of the pre-
liminary prosthesis should be explained to the patient. These factors should
be considered during the initial examination.
It has been the author's experience that the most suitable time to commence
prosthetic procedures is when the wound has healed and all post-operativedressing
and sutures removed. The patient should be able to tolerate without discomfort
any procedures at the defect site. The use of a simple cover plate also enables
support for surgical dressings and is easily re-made during the preliminary stage
of treatment.

Impression Technique.--In facial reconstruction by prosthetic means,

an accurate impression is an important contribution towards a satisfactory pros-
thesis. The first essential for a satisfactory impression is the position of the
patient. The best results are obtained if the patient is supine. For this a medical
examination couch is ideal. The patient should be made as comfortable as
possible since any movement may ruin the impression. A theatre gown provides
protection for the patient's clothes and towels are placed round the head to
isolate the face. To define further the area for impression, adhesive draft-excluder
tape is placed round the periphery of the area. This tape serves to check the
flow of the impression material and is easily removed without discomfort to the
patient. In most impressions of the frontal area of the face, there is no need to
include the mouth. The adhesive tape is placed across the upper lip preventing
the flow of the impression material and allows the patient to breathe through the
mouth. This has a relaxing effect as most patients are disturbed at the thought
of full coverage of the face. Deep cavities and undercut tissue are packed with
Vaseline gauze. Pendulous tissue is also supported in this way. A thin film of
liquid paraffin is painted over the skin and hair-bearing areas. Alginate is mixed
in a large rubber bowl. Some ~ lb. of material will be required for the average
impression. Water-powder ratio should allow for a fluid mix. The material is
poured over the defect and surrounds and is spread with a broad spatula; the
flow of the material will be checked by the adhesive tape. Further control can
be achieved by dental napkins placed over the impression material, some of which
will flow through the gauze. When gelled, a backing of plaster is applied to
prevent gross distortion during removal of the impression. Pink impression
plaster is ideal for this purpose and sets quickly. A thin mix is spatulated over
the Alginate. The plaster will run into the mesh of the gauze napkins and provide
a bond between the two materials. When the plaster backing has set, the adhesive
tape is peeled from the margins of the impression and the material removed from
the face. Vaseline gauze plugs and packing will be contained in the impression
and left in situ for casting of a plaster model.
There is always distortion in facial impressions. This is due in many cases
to tension in the patient preventing the face from being in full repose. This is
clearly illustrated in wrinkling around the eyes shown in the plaster model.
Further distortion results from the weight of the impression material. A more
accurate wax prosthesis is achieved by adapting and carving on the patient's face.
 FACIAL RECONSTRUCTION BY PROSTHETIC MEANS 165
The wax prosthesis is moulded to the reposed tissue. The plaster model obtained
from the impression is used as a primary base to carve the basic wax form. In
some cases changes in the defect site result during the treatment period, thus to
use the model as a final base for the restoration is not advised.

Wax C a r v i n g a n d A d a p t i o n . - - F r o m the facial impression, a stone plaster

model is cast to the model to which the basic wax pattern of the prosthesis is
modelled. Before construction of the restoration, the recording of facial
measurements will enable a prosthesis to be constructed which is in proportion
and orientated to the rest of the face. Measurements are taken using 8-inch
dividers.
In a restoration of the nose, the vertical distance from the base of the
columella to the glabella is approximately equal to the distance from the base of
the columeUa to the point of the chin, and also to the vertical height of the
forehead (Fig. 4)- I f the nose does not conform to these proportions, it will
appear to be too long or too short. ~ The naso-facial angle (Fig. 5) varies between
3°° and 4 °° in normal individuals. Angles beyond these limits would usually
be associated with a nose out of harmony with the rest of the face. The lip
columella angle (Fig. 6) is approximately 90 ° in most people but varies con-
siderably. I f more than 12o° the nose would be deformed and if much less than

~ b

- - C

FIG. 4 FIG. 5 FIG. 6

Equal distant guide lines Lip columeUa angle. Naso-facial angle.
for facial measurement.

7°° the tip would appear to droop over the upper lip (Peet & Patterson, I963).
Marks and measuring points are marked on the model with an indelible pencil.
Measurement marks and orientation lines may be marked on the face before the
impression is taken. This is particularly useful in providing orientation for
construction of a prosthetic ear or the approximation of the pupil centre in an
orbital prosthesis.
To orientate an ear, a vertical line is drawn from above the helix passing
through the centre of the external auditory meatus and through and beyond the
166 B R I T I S H J O U R N A L OF ORAL SURGERY

centre of the lobe of the natural ear. A further horizontal line is drawn from the
anti-helix passing through the centre of the external auditory meatus and beyond
the tragus of the natural ear. These same vertical and horizontal lines are traced
on the defect ear side to coincide with the natural ear.
Measurement and orientation of an orbital restoration is achieved by marking
a vertical indelible line through the pupil centre commencing at the supra-orbital
ridge on the unaffected side. A bisecting horizontal line is drawn through the
outer canthus to the inner canthus, terminating at a point on the nose. T h e
distance from the inner canthus to the terminal mark on the nose is also
measured. These markings are duplicated on the defect side. Indelible markings
on the skin are transferred to the alginate impression and the plaster model and
are a useful guide to the initial wax sculpture of the prosthesis.
Wax sculpture and application of the wax pattern to the face is an exacting
stage requiring time and care. Shape and form in the wax pattern determine the
final anatomical effect of the finished prosthesis. The basic wax shape is formed
in the laboratory. Undercuts and cavities not required in the restoration are
blanked out with red base wax and the surface of the model coated with a release
agent? The sculpture wax used is carving wax of an off-white colour. This
neutral shade allows apprec-
: : , iation of size as red dental
- waxes present the illusion
•; of the pattern being large.
T h e basic wax shape of
. . . . ~0 the prosthesis is carved in
;~~:~. -~ relation to the measurement
and orientationmarks. Dup-
.... : ..................... i lication of the anatomical
~ 1 features of a total ear pros-
~•y, d~'~• thesis are achieved by carv-
" ' ing the wax from a basic
,d ~
:" : ,- "~'~ " ~
~k
form or by utilising a wax
• ~° stock ear shape. A number
- ;..~.., :?~ of wax ears may be kept
i ~,~ ::.* for this purpose; from this
' ~ ~ : ?:i?~ ~ stock a shape may be found
. ~ .~ . :..!~~ which can be adapted to the
&~c.,,. -:,~:! ~ ' ;'"~"":''" : model.
?. -, .~.. : The more exacting
.;. o.~ i:~:" , ~ ........ . technique of carving the
:: ~ complete wax pattern can
•: . ~ J be simplified by using a re-
...~ .- ~ verse image mirror (Fig. 7).
' " : This instrument provides
Fro. 7 the user with a reference
Reverse image mirror, image of the size, shape and
contour of the restoration
required. The plaster model of the unaffected ear is placed on the adjustable
platform and focused to the mirror which has horizontal and vertical measurement
Xyon.
 FACIAL R E C O N S T R U C T I O N BY P R O S T H E T I C MEANS 16 7

graduations. A right ear is shown as a left in the mirror when attempting to

simulate a left ear; the image provides a constant reference.
Following the initial wax sculpture of the prosthesis in the laboratory, the
wax pattern is positioned on the patient's face. Measurement and orientation
are checked and detailed sculpture completed. Ideal instruments for this
procedure are a periosteal elevator, Lecron carver, clay modelling instruments
and a soft brush. During this stage, attention is given to the fit of the prosthesis.
Margins are tapered and moulded to gain full contact with the tissue. To
facilitate moulding and adaption, the wax pattern is immersed in warm water.
Margins may be adapted with wet pellets of cotton-wool. To ensure marginal
contact of the wax pattern, the skin in contact is lubricated with Glycerine, and
wet plaster is painted over the margin between the wax and skin. When set,
the wax prosthesis is removed and tasked immediately. The position of the wax
prosthesis in the plaster should minimise the angle of undercuts.
When an acrylic eye is to be incorporated in an orbital prosthesis, there is
a danger of the eye moving during tasking. This is avoided by heating a pin
formed from post wire, some I inch long, inserting it into the back of the eye to
such a depth that it forms a rigid locating pin. To protect the polished sclera
of the eye which may become damaged through contact with flash from the
prosthesis when packing, it is painted with a liquid skin preparation 1 which peels
off when processing is complete. Flasking of the wax prosthesis is completed and
the wax flushed out. The eye remains in its location retained by the pin which is
now embedded in the plaster mass. To achieve further stabilisation, some clear
self-curing acrylic is run under the eye providing a firm base which will withstand
the pressure of packing. The pin is easily removed at the finishing stage.
An alternative method is to remove the eye from the wax prosthesis prior to
packing. If the eye is lubricated with a Silicone grease at the time of forming
the wax prosthesis, it can be removed from the wax leaving a socket. Shape and
detail of this socket are retained by the plaster during the tasking. The eye is
fitted back into its final position and sealed with a self-curing acrylic in the
finished prosthesis. Eyelashes and eyebrows ~ are fixed to the finished prosthesis
by adhesive. If the prosthesis is constructed of resilient material, the eyelashes
are attached by splitting the upper lid and coating the split with adhesive. A
satisfactory fluid adhesive can be made from 3 parts Methyl Methacrylate Monimer
and I part Evostick. The eyelashes are inserted into the prepared surface and the
eyelid gently compressed. Eyelashes are attached to rigid materials by preparing
a groove in the upper lid. The groove must be of sufficient depth to mask the
fitting edge of the eyelashes. If lower lashes are required, they can be simulated,
using a solution of graphite and matt varnish.

MATERIALS
One of the main difficulties of constructing a facial prosthesis is the selection
of the material. The colouring of the face and skin is not uniform and is subject
to constant variations due to temperature, emotion and general health, presenting
individual problems. It is at present impossible to expect a prosthesis material
1 Wildfoil, W. Germany. ~ R. H. Smith & Sons Ltd., Gainsborough, Lincs.
168 BRITISH JOURNAL OF ORAL SURGERY

to fulfil all the demands made upon it and, unfortunately, a material that combines
every requirement does not exist. The properties of the ideal material may be
listed as follows:
I. Non-irritant. The material must not irritate the tissues with which it
comes in contact.
2. Pliability. The material must be soft and pliable and be capable of
adapting to facial movement.
3. Weight. The material must be light in weight so that it may be supported
without fear of detachment during wear.
4. Colour. The material must be of a basic skin colour, blending as much
as possible.
5. Hygiene. The material must be hygienic and non-porous and be capable
of being washed and disinfected in approved solutions.
6. Durability. The material must have an indefinite life and keep its texture
without being affected by sun, moisture and chemicals in the atmosphere.
7. Thermal Conductivity. The material must be a poor conductor of heat.
8. Manipulation. The material must be easy to manipulate and require no
complicated or extensive equipment.
9. Texture. The surface of the material must be able to retain cosmetics
and adhesives applied for characterisation and retention.
Io. Availability. The material must be easy to obtain and inexpensive.
It can be appreciated from this list of requirements that a most exacting
material is necessary for facial prostheses. A number of materials are available
at the present time each with its own merits. They can be placed in two main
groups--Flexible and Rigid.

FLEXIBLE MATERIALS
Flexible materials, if able to conform to the physical characterisation required
of a facial prosthesis, are more acceptable to this field of work. A flexible material
has the following general properties:
I. Comfort in contact with the tissues.
2. More readily adapts itself to folds and contours at the periphery of the
deformity.
3. Some facial expressions are reciprocated by the material.
4. Undercut areas may be utilised for retention.
5. Surface texture more readily takes cosmetics.
6. Psychologically more acceptable to the patient than rigid materials.
7. If carefully used, more than one prosthesis can be made in the same
mould.
Various flexible materials have been adapted to meet the requirements of a
facial prosthesis material. Two main materials are produced commercially for
facial restorations--Palamed 1 and Dicor ~.
Palamed, Kulzer, W. Germany. ~ Dicor, Vernon-Benshoff Co. Inc., U.S.A.
 FACIAL RECONSTRUCTION BY PROSTHETIC MEANS 169

Palamed.--The chemical composition of this material is based on esters of

acrylic and methacrylic acid. The esters in the monomer state are in liquid form
and are converted into the polymeric form on processing. The resilience of the
processed mass results from plasticisation formed by a special molecular structure.
This material has a chemical bond to hard acrylic. One of the main properties
of this material is that it produces a soft resilient skin with a spongy central mass
which results in a skin-like prosthesis that is light in weight. A wide range of
basic colour polimers enables the user to provide a satisfactory basic shade.
Colour modifiers provide further means of characterisation. Manipulation of
this material can be completed with normal dental laboratory apparatus. To
obtain satisfactory results, weighing the material is essential. Expansion of the
centre mass is obtained by the inclusion of a foaming agent in the material. The
manufacturers recommend that the material is packed to 9o per cent. in the
plaster mould. During the processing under pressure and heat, the material
expands to produce the outer skin with its spongy centre mass. Present difficulties
with this material are:
I. Colour loss after a period of wear.
2. Attraction to dirt and dust.
3. Difficulty in maintaining stability of form.
Over Ioo restorations have been completed in this Unit using the material
Palamed. Resilience of the material has been maintained in all cases, some of
four years duration. Colour stability in most cases has not been satisfactory
following a period of wear, the degree of colour loss depending to a great extent
on the environment of the patient. It has been found that considerable improve-
ment to the colour stability of Palamed can be achieved by the addition of
Tinuvin P., a new type of ultra-violet light absorber for plastic materials, which
protects the substrait from yellowing and shields the colouring compounds
from the deteriorating effects of ultra-violet light. In recent cases, 0"5 per cent.
Tinuvin P. has been incorporated in the polymer. Considerable improvement
has resulted from this addition. Tinuvin P. may also be used in a suspension
of monomer during tinting at the final stage.
Attraction to dirt is a problem with Palamed. This has particular im-
portance in relation to a patient's employment. Patients who work in contact
with dust and dirt are unsuitable for a prosthesis constructed of Palamed.
Magnified examination of the outer skin reveals the surface to consist of pore-like
voids, consistant with expanded and plasticised materials which would account
for the material's affinity to dirt, as the pores fill with debris and dust. The use
of the non-expanding Palamed 1 has resulted in a surface texture which remains
clean and does not have the 'pick-up' of the standard material.
Because of its unique resilience, difficulty is experience in maintaining
stability of form. To overcome this, thin sections can be laminated using a
nylon mesh. This technique is useful in reinforcing the margins of a prosthesis.
Palamed has a chemical bond with hard acrylic and may be used as a com-
bination to stabilise a prosthesis. Palamed can be successfully used to produce
prosthetic restorations which fulfil most of the requirements of the ideal material.
Variations of laboratory techniques are required to overcome disadvantages of the
material.
1 P a l a m e d B.
I7 o BRITISH JOURNAL OF ORAL SURGERY
Dicor.--Dicor is a copolymer resin with suitable plasticising agents which
combine to produce a resilient material with elastic properties. It is supplied in
the standard form of powder and liquid; pigments are supplied in red, yellow and
blue from which the user may obtain shade variations.
The laboratory technique for Dicor is similar to Palamed. It is packed in
normal plaster moulds; IO gr. of powder to 9 ml. liquid or equivalent mixing ratio
produces a satisfactory resilient prosthesis. Because of the fluffy nature of the
powder, the liquid should be added to the powder and be mixed in a glass pestle
until a uniform consistency is obtained. Time of mixing depends upon room
temperature. The resulting mix should be a soft paste. Dicor is processed in
water under pressure. The time required will depend on the size of the flasked
restoration. Standard denture flasks require one hour boiling; large flasks eight
hours boiling. The water bath may reach boiling point quickly as no slow heat
up is required. Flasks must be cold before deflasking. The prosthesis may be
trimmed with fine scissors and any small imperfections removed with abrasive
bands. Care should be exercised to ensure a perfect surface during the waxing
and flasking stages as the material is difficult to modify when processed. A hot
stainless-steel spatula will smooth out superficial irregularities after deflasking.
Should a split occur during the deflasking procedure, an adhesive is available
for repair of the material. Retention to spectacles and hard acrylic is only a
mechanical bond. Undercut retentions should be provided and the two surfaces
bonded together with self-cure acrylic.
A number of resilient materials have been successfully adapted for facial
prostheses.

Silicone R u b b e r . This relatively new synthetic material is now firmly

established in the medical and industrial fields. Of all the resilient materials that
have been applied to facial restoration, silicone rubber may provide the ideal
material. There are a few disadvantages which may be overcome as knowledge
of this material progresses.
Medical-grade elastomers do not contain plasticisers, anti-oxidents or any
additions which are injurious to the body. Silicone elastomers for medical use
are manufactured by the Dowcorning Corporation of the United States and trade
marked 'Silastic'. 1 Two grades are available--Room Temperature Vulcanising
(R.T.V.) and Heat Vulcanising.
The room temperature vulcanising Silastic Medical Grade 382 is supplied
as a thick but easily pourable fuid. When a catalyst is added, the fluid sets to
become a silicone rubber in some IO minutes. The action of the material is such
that it vulcanises without heat or pressure. R.T.V. Silastic can be used in
applications where heat cannot be tolerated. In its liquid form it can be poured
into moulds to form shapes or injected into body cavities where it solidifies
neither requiring nor giving off heat during this reaction. Setting time may be
varied from 2 to 3o minutes at room temperature by varying the quantity of the
catalyst. The catalyst used is a medical grade stannous octoate. It is mixed
with medical grade Silastic 382 elastomer just before using. The recommended
proportion is 0"5 part catalyst to Ioo parts Silastic by weight. After the stannous
octoate has been added, Silastic 382 remains workable for about Io minutes.
Setting is completed in about 30 minutes.
1 Down Bros., Mayer & Phelps Ltd., England.
 FACIAL RECONSTRUCTION BY PROSTHETIC MEANS 171
Heat vulcanising silicone rubber used for medical purposes is composed of
Silastic 37o, 372 and 373 medical grade elastomers. The Silastic 37 ° is a soft
rubber, Silasfic 372 is a medium hardness rubber and Silastic 373 is a hard rubber.
With this group of silicone rubber, heat is required to complete vulcanisation
using a conventional oven. Silastic 373 and 372 require no pressure. Heat
vulcanising Silastic brand silicone rubber is a putty-like material before vulcanisa-
don, is easily handled and suitable for moulding techniques. With Silastic 37°
pressure is required. The material is packed into dental flasks, the plaster should
be cold. It is recommended to overpack the material and maintain pressure
using a spring clamp. The clamped moulds are placed in a cold electric oven
and the temperature raised to I4o°C. This temperature is maintained for one
hour. After this time the prosthesis is cooled and removed from the mould and
allowed to stand on a glass slab for a further hour at I4o°C. This allows for the
volatile byproducts of the vulcanising agent to be driven off and completes the
cure. Silastic 37 ° may also be vulcanised in an autoclave at 20 p.s.i, for IO to
2o minutes depending upon the thickness of the prosthesis and the mass of the
mould used. Silasfic 372 and 373 can also be autoclaved or heat press cured at
i2o°C; again a concluding period cure is required with the prosthesis removed
from the mould.
To colour silicone rubber, various shades of concentrated silicone colours
are available. These colours are in the form of R.T.V. silicone pastes1: Titamox,
BI27I , 65 per cent.; Orange, B2643, 66 per cent.; Mapico Red, Bio73 , 75 per cent.;
Black, B622, 75 per cent. The pastes are mixed on a glass slab using shades of
pinks, blues, browns, greys and purples. The tinting procedures are best com-
pleted with the prosthesis on the patient for more exact results. Preparation of
the surface is important. Tetrachloroethylene is wiped over the area to be tinted
and allowed to dry. Colours are applied to the surface using cotton-wool buds.
Dark shades are applied first, leading to a gradual development of the skin tones,
using lighter shades until satisfactory simulation is achieved. Over-application
of colours can be rectified at this stage by simply wiping with a dry cotton pad.
To fix the final colour simulation, stannous octoate is sprayed over the surface.
This makes the colours permanent. The prosthesis is then placed in an oven at
I4o°C for 20 minutes to cure the catalyst. Special characterisafion may be
achieved by a suspension of R.T.V. colour pastes in xylene and applied with a
fine paint-brush, colours being finally fixed by the catalyst. Intrinsic colouring of
silicone may be achieved by mixing powder dyes 2 into the material before
vulcanisation. These dyes are concentrated and only small amounts are required.
Silicone Powder Dyes.
Tan, F.W. 1135 Yellow, F.W. 1935 Orange, F.W. 1533
Blue, F.W. 1238 Red, F.W. 154° White, F.W. IOOO
Silastic brand silicone rubber can be bonded to metal and plastic surfaces
during vulcanisation. The bond is promoted by first priming the metal or plastic
using Dow Corning A.4o94 primer or Chemlok 6073. Before priming, the surface
must be well cleaned with a solvent such as Acetone. Unvulcanised silicone
rubber can be bonded to pieces of vulcanised Silicone rubber with no preparation
1 Ware Chemical Corp., Westport, Connecticut, U.S.A.
2 Ferro Corp., Cleveland, Ohio, U.S.A.
Hudson Chemical Co. Erie, Pennsylvania, U.S.A.
 172 i[BRITISH JOURNAL OF ORAL SURGERY
other than cleaning the vulcanised part by roughening followed by wiping the
surface with a solvent. Vulcanised pieces of silicone rubber can be bonded
together by using Silastic medical adhesive Silicone Type A.
Silastic 386 R.T.V. rubber foams to seven times its volume during vulcanisa-
tion. This material has proved useful for direct application to cavities and
undercut areas to obtain lightweight volume in facial prostheses. In orbital
restorations, the sponge enables deep undercut areas to be engaged for retention.
Silastic 386 has an approximate working time of I½ minutes and a set-up time of
5 minutes. Heat vulcanising silicone rubber sponge is made from stocks to
which a blowing agent is added. During vulcanisation, the blowing agent releases
nitrogen bubbles which cause the sponging. The cells in this type of sponge do
not intercommunicate.
Medical grade elastomers have proved ideal materials for general prosthetic
application. Experimental work with these materials may further their use in
the construction of facial prostheses.

Plastisols and Organosols (Vinatex)

These are dispersions of Polyvinyl Chloride resins in plasticisers and oare
modified with other materials to give a range of pastes with widely varying
properties. The pastes vary in viscosity from mobile to viscous liquids. When
cured by simple heat treatment they are converted into solids which vary from
soft to very flexible. The cured pastes are tough, durable, waterproof, virtually
odourless, colour-stable and resistant to chemicals in the air. Vinatex P.V.C.
pastes have a shelf life of some six months or longer if stored correctly at tempera-
tures of I7-22°C. Some pastes are thixotropic and may show an increase in
viscosity if stored for long periods. Gentle stirring is required to bring the
viscosity back to normal.
This group of materials has a wide application in industry. Experiments in
their application to facial prostheses are progressing, the main difficulty is the
preparation and equipment. Successful application of the material depends on
the use of split metal moulds. Copper plating to a depth of some 3 ram. enables
the Vinatex P.V.C. pastes to be heated evenly, completing gelation of the paste.
Linotype split metal moulds are more easily constructed to a prosthesis pattern.
The prepared moulds are initially heated for a few minutes in an oven set at a
temperature of I7O-I85°C. Higher pre-heating temperatures can be used in order
to reduce the pre-heating time, but this is only practicable provided two ovens
are used, eliminating the necessity for continual temperature adjustment between
pre-heating and curing cycles. The mould is removed from the oven and filled
immediately with the Vinatex P.V.C. paste and left for two minutes. During this
period, the heat of the moulds gets the paste in contact with the mould wall to
form a coating some 3 mm. thick. The surplus paste which has not been affected
is poured back into the paste container for future use. The mould is then returned
to the oven for IO minutes, to allow gelation to be completed. When cool, the
mould is opened and the prosthesis removed. Little or no trimming is required
due to the mould form. This technique is termed as 'slush moulding' and is
useful in constructing hollow, lightweight prostheses.
A second technique is to fill the mould and plug the pour hole. The pre-
heating and gelation timing is the same as for slush moulding.
There is little to choose between the two techniques. The first offers an
 FACIAL RECONSTRUCTION BY PROSTHETIC MEANS 173
accurate control of wall thickness in the pre-gel stage, while the second eliminates
the entrapment of air bubbles which are encountered when a hot mould is used.
Vinatex P.V.C. pastes are obtainable in various shades from which a basic
skin shade can be dispensed. Further tinting is achieved by stains and dyes.

RIGID MATERIALS
The majority of facial prostheses constructed in this country are of rigid
materials in the form of Methyl Methacrylate. This is mainly due to its satis-
factory basic colour which can be varied with accuracy. The early failures of
Vinyl r~sins have left a feeling of no confidence in flexible materials, resulting
in preference being given to rigid materials.
Advantages of rigid materials are:
I. Stability of form and colour.
2. Satisfactory basic skin shade.
3. Colour easily variable by stains and dyes.
4. Easily cleaned.
5. Bonds readily with allied plastics.
6. Less expensive than flexible materials.
The disadvantages of rigid materials are in the main clinical and may be
listed as follows:
i. Possible discomfort at the site and surrounding areas of the defect.
2. Lack of movement during facial expression.
3. Shining of the material surface after a period of wear.
4. Surface texture unsuitable for cosmetics.
5- Limited use in undercut areas utilised for retention.
6. Psychologically less acceptable by the patient than flexible materials.
7. Moulds destroyed in deflasking the prosthesis.
At the present time, flexible materials have not reached a sufficient stage of
development to exclude rigid materials from a prominent place in facial restora-
tion by prosthetic means. From the standard Methyl Methacrylate denture base
resins a satisfactory basic skin shade can be achieved (Roberts & Penny, 1964).
Parts by weight:
4 ml. Stellon Pin.
8 ml. Stellon Veined.
5 ml. Stellon Clear.
4 ml. Stellon C. No. z--Light Yellow.
4 ml. Stellon C. No. 4--Dark Yellow.
2 ml. Stellon C. No. 6--Light Grey.
I ml. Dentine StainmYellow.
i ml. Dentine Stain--Orange.
I ml. Dentine Stain--Grey.
I ml. Dentine Stain--Light Brown.
All powders to be incorporated together.
N
174 BRITISH JOURNAL OF ORAL SURGERY
A wide colour variance and simulation of special skin tone characteristics
may be achieved using high concentrate acrylic stains. 1
Intense Red M.7o9 Intense Red M.7o8. Intense Red M.7IO.
A.S. Grey. A.S. Yellow. A.S. Ivory Dense White. A.S. Blue. A.S. Brown.
These are used at the packing stage in the form of selective tinting on the
surface of the pressed basic skin dough to the above formula.
To simulate vascular areas, nylon filaments in shades of red, burgandy and
purple can be used. Acrylic paints dispensed in Methyl Methacrylate monomer
also provide a means of accurate skin colour reproduction. The acrylic paints
may be used in concentrated form to provide high colour contrast and definition.
The only true colour chart is the patient's own skin. To achieve the maximum
colour simulation from the materials used, the presence of the patient is required
during the packing stage. The patient is seated adjacent to the packing bench
and is available for constant reference throughout the packing procedures. Final
tinting of the polymerised material can be satisfactorily achieved using these
paints.
The problem of surface sheen with rigid materials can be overcome by sand
blasting the surface at 4° lb. p.s.i, using an acrylic blasting grade of sand. Thus
surface texturing may be repeated at intervals throughout the life of a prosthesis.
The physical structure of Methyl Methacrylate resin allows for ease of cleaning
and its stability of form enables a restoration to be worn for a considerable time
before being remade.
A prosthetic restoration which requires frequent renewal causes considerable
inconvenience to a patient. The psychological effect of constant maintenance and
renewal prevents the patient from establishing confidence in the prosthesis.

M E T H O D S OF R E T E N T I O N
There are two main categories of retention for facial prostheses--external
retention and internal retention.
E x t e r n a l Retention. When using external retention, spectacles are the
most satisfactory means of retaining a prosthesis in position. It is generally
found that most patients who require a facial restoration wear or require
spectacles. If the patient's sight is perfect, plain glass lenses can be fitted which
will not affect the eyesight. A nose prosthesis is attached to the spectacle flame at
the bridge. At the wax carving and adaption stage of the wax prosthesis, the
area at the bridge is softened and the previously selected spectacles positioned.
When the correct position has been established, the wax is cooled and the
spectacles removed leaving a bed in the wax to aid the repositioning of the spectacles
at the final stage. Spectacles used should be of the library frame type--frames
of thin design tend to attract attention to the prosthesis. The library frame has
the feature of making itself noticed before the restoration. Consideration Should
be given to the material of the spectacle frame. Acrylic resin frames enable a
chemical bond with most of the materials used for facial prostheses. An opaque
material is preferred to a translucent, to prevent retention marks from being
visible. The use of self-cure acrylic has proved satisfactory in bonding
1 Metrodent, Huddersfield, Yorkshire.
 FACIAL RECONSTRUCTION BY PROSTHETIC MEANS 175

spectacles to prostheses. Silicone rubber requires its own fixative. A prosthetic

ear may be retained by a flexible steel band worn across the crown of the head.
The band is covered by the hair.
An alternative means of retaining a prosthesis can be achieved by adhesives.
By this means, retention is obtained by painting spirit gum on the periphery of
the prosthesis. A surgical adhesive may be dispensed to the following formula:
Compound Mastic Paint B.P.C.
Mastic, 40 per cent.
Castor Oil, 1.25 per cent.
Benzole, Nitration grade of commerce to IOO per cent.
Latex based adhesives have superseded spirit gum in recent years. This type
of adhesive has the advantages of ease of application and removal. The preparation
is applied from a tube and removed from the skin and prosthesis by peeling away
the adhesive which has the form of a flexible film. Two adhesives of this group
used for facial prostheses are Duo 1 and DavoP.
A satisfactory method of retention has been found in the form of a double-
sided adhesive tape z (Roberts & Penney, 1964). This type is hygienic in use and
it is recommended in cases where fluid adhesives are contra-indicated. The tape
is available in various widths. Its adhesive properties will support a prosthesis
with confidence. When this method of retention is used, a space maker in the
form of tin-foil is used to allow for the thickness of tape behind the prosthesis.
Patients find this tape retention simple and clean in use. The use of adhesives
in conjunction with mechanical retention is useful in preventing lifting of thin
sections and margins. Surgically constructed skin bridges may be used to provide
retention for an ear prosthesis. The base of the prosthetic ear or separate base
section are located under the skin bridges.
I n t e r n a l Retention. In many cases of facial prostheses, it is found that the
patient wears full or partial dentures. If a section of the palate has been surgically
removed and the defects communicate, it is possible to combine both facial
prosthesis and denture. The retention point of fixation is provided by means of
two pins on the fitting surface of the facial prosthesis which fit into tubes on the
denture.
Alternative retention may be achieved by a stud clip. This is cast in chrome
cobalt and designed to provide for the socket section of the stud to be part of
the denture while the plug section is located in the facial prosthesis. With this
type of retention, the patient need not have spectacles attached to the prosthesis.
Although a firm fixation is provided between denture and prosthesis, some move-
ment results during mastication.
Retention by ufilising undercut areas in the defect is usually confined to
prostheses constructed from resilient materials.

FITTING THE PROSTHESIS

The fitting of the prosthesis is the final stage of treatment and some time
must be given to the procedures involved.
1 Johnson & Johnson, Gt. Britain. 2 F. & H. Baxters Ltd., Bradford, Yorkshire.
3 Fassaon Double-Faced Mylar Tape 33o, Sydney Beaumont Ltd., Leeds, Yorkshire.
176 B R I T I S H JOURNAL OB ORAL SURGERY

The prosthesis is positioned on the face and the margins examined for contact.
Any area causing discomfort is corrected. When satisfactory, the chosen method
of retention is applied. Any tinting or final characterising is completed. The
patient should be instructed how to fit and remove the prosthesis. Consideration
as to the use of cosmetics can be discussed with the patient. Co-operation by
the patient in the use of cosmetics can do much to enhance the appearance of the
prosthesis. After some simple instruction, the patient can achieve sufficiently
satisfactory results for everyday requirements. In many cases, the prosthesis has
to blend with discoloured tissue. For grafted areas a fluid rouge is used to bring
up skin tone followed by a base colour preparation. The make-up is applied to
the skin first working towards and on to the prosthesis. The problem of the
marginal contact line can be blended out with a masking compound1. This
material has the properties of being plastic yet firm 'and is unaffected by tempera-
ture, moisture or chemicals. Normal facial movement will not break the marginal
seal. Its colour is of a basic skin shade which can be modified by cosmetic
colouring. A small amount of compound is worked into the junction between
the appliance and the skin and removed with a sponge when not required. The
compound remains as applied and does not harden. Cosmetics can be applied
to the surface if required.
In cases where considerable scar tissue is present, the provision of a scar-free
prosthesis may not achieve the correct aesthetic result. Scars can be simulated
by the use of Flexible Collodion and tinted with cosmetics or acrylic paints.
Flexible Collodion B.P.
Pyroxylin 1.6 per cent.
Colophony 3 per cent.
Castor Oil 2 per cent.
Alcohol (90 per cent.) 24 per cent.
Solvent Ether to IOO per cent.
When the prosthesis is constructed of a hard material, a liquid polyvinyl
plastic is painted over the surface. The liquid imparts a flexible skin to the
acrylic surface which will take cosmetic foundations more easily. A solvent
facilitates removal of the preparation.
A full colour range of cosmetics is available which are not perfumed. Advice
is given to the patient as to the care and maintenance of the prosthesis. This
can best take the form of a small card providing advice and foUow-up appointments.
The advice we give is as follows:
Care of the Prosthesis
Your facial restoration, or prosthesis as it is called, is made of a plastic
material which should present no difficulties if you observe the following
simple instructions concerning its care and maintenance.
Cleaning
This is important. The prosthesis should be cleaned each day before
use in a bowl of lukewarm water which contains one drop of liquid
detergent or antiseptic soap. Brush over all the surfaces, paying particular
attention to crevices. If any special adhesives are used, peel these off or
1 Natro-Plasto No. 2, Max Factor.
 FACIAL RECONSTRUCTION BY P R O S T H E T I C MEANS I77
use the cleaning solution provided. Rinse in cold water and pat dry with
a paper tissue.
If the prosthesis is kept dean, it will last much longer, be more
hygienic and its appearance will be greatly enhanced.
When fitting the prosthesis, use a mirror, If adhesive preparations are
required, follow the instructions given you.
Sleeping
It is advisable to remove the prosthesis at night to avoid damage. If
you prefer, you may wear the cover plate provided. Keep the prosthesis
in a safe place ready for use next day.
Note
Some minor sore points may develop during the initial period of wear.
Report these when you visit the clinic so that they can be corrected. If
you break the prosthesis, do not attempt to repair it yourself but come to
the hospital and you will be seen without an appointment.
It is important that you keep your follow-up appointments listed on
the back of this card.

Review appointments every four months enable the prosthesis to be main-

tained in good condition. At these appointments, the prosthesis is thoroughly
cleaned, an ultrasonic cleaning bath being ideal for this purpose. I f required,
re-tinting and minor repairs are completed.

CASE H I S T O R I E S
Case A. Nose. Retired school-teacher, aged 67. Extensive defect following
excision of malignant melanoma. Excision included the tip of the nose and total right
side of nasal septum. Prosthesis constructed of Palamed and Methyl Methacrylate.
Sub-structure of rigid material covered with foamed Palamed. Prosthesis covered both
defect and remaining nasal remnants. The pendulous tissue was supported and con-
tained. Restoration retained by spectacles. Prosthesis worn for I8 months. Defect
finally repaired by forehead rhinoplasty and post-nasal inlay. Throughout the period
of wear, the prosthesis remained resilient and colour stable. The patient kept the
prosthesis clean with a detergent. Some staining of the prosthesis occurred due to
cigarette smoke. This was easily removed during the cleaning procedures. Patient
pleased with restoration and experienced no difficulty or discomfort from ~the
prosthesis (Fig. 8).
Case B. Ear. Lady, aged 76. Defect of two-thirds of the right ear following
excision of epithelioma. Prosthesis constructed of Silastic 382 medical grade elastomer.
Fitting area reinforced by Dacron mesh. Colouring by metallic oxide catalysed silicone
dispersions. Prosthesis retained by Duo adhesive with additional support provided by
spectacles, also an extension into the external auditory meatus. Shape, fit and colour
satisfactory. Patient apprehensive about the prosthesis in initial period of wear but now
very, pleased with result (Fig. 9).
Case C. Nose. Male, aged 72. Defect following near total excision for a tumour.
Base of alar cartilages retained to assist stability. Prosthesis constructed of Methyl
Methacrylate with extension into defect. This extension covered by Silastic 386.
Prosthesis retained by spectacles. Shape, fit and colour satisfactory. Patient delighted
178 B R I T I S H J O U R N A L OF ORAL SURGERY

with result. Some minor discomfort at lateral margins due to over-extension. No

further discomfort following correction. Enthusiastic reception of the prosthesis by the
patient's family and friends have provided him with additional confidence (Fig. IO).

FIG. 8
Case A. Palamed Nose.

FIG. 9
Case B. Silastic Ear.

C a s e D. Eye a n d O r b i t . Textile worker, aged 49. Extensive full thickness

burns of left side of face and scalp following a fall into a coal-fire during a fit of uncon-
sciousness. Plastic repair effected by excision of burned tissue and a series of skin
 FIG. I O
Case C. Methyl Methacrylate Nose.

FIG. I I
Case O. Eye, Orbit and Ear.
FIG. I2A FIG. I2B

F i c . i2c

FIG. 12
Gase E. Eye and Orbit Combination
appliance,
A. Defect.
B. Denture Stud Component in
position.
c. Gomponents of prosthesis.
D. Restoration completed.
 F A C I A L R E C O N S T R U C T I O N BY P R O S T H E T I C MEANS 181

grafts. Prosthesis constructed of Methyl Methacrylate. The patient had already been
provided with a prosthetic ear at another centre. This was now unsatisfactory due to
the patient cleaning it in a caustic solution. This prosthesis was re-made. The pros-
thetic reconstruction was planned in two stages--Stage I, orbital prosthesis; Stage II, ear.
Ring side arm spectacles provided good retention. The ear prosthesis was retained by
double-sided adhesive tape. Stability of both prostheses satisfactory. Colour simulated
to blend with grafted skin areas. Patient pleased with the result and quickly became
confident with the restoration and later returned to his employment (Fig. II).
Case E. Eye a n d Orbit (Combination prosthesis). Retired railway engineer,
aged 69. Extensive defect following excision of cancer of antrum and right cheek.
The defect involved the total orbital area extending down to the angle of the mouth.
Patient had worn a number of prostheses since his operation 12 years previous. Patient
experienced headaches and facial pain due to the weight of the previous restorations
which were combined with his upper denture by means of robust rods and tubes with
additional retention by spectacles attached at the bridge of the nose. New two-piece
restoration constructed of Methyl Methacrylate. The design concentrated on lightness
in weight. The total external prosthesis was formed to restore contour by means of a
thin acrylic shell containing the eye. Retention was achieved by means of a cast chrome
cobalt stud. The plug component of this stud was designed to connect to the socket
section in the buccal flange of the obturator denture. Further stability was achieved
by means of the patient's spectacles which were not attached to the prosthesis. The
patient was delighted with the result and is able to wear the prosthesis for a full day
without discomfort or pain. Hc is able easily to assemble the components of the pros-
thesis and has resumed his hobby of sailing (Fig. 12).

DISCUSSION
The construction of a facial prosthesis is an exacting challenge. Future
progress in this field will depend on the development of new materials.
In the search for the ideal material we must be prepared to look further
than the confines of dentistry. The recent advances in industrial plastics have
greatly enhanced the chances of providing materials which can be utilised to
construct facial prostheses. The wide range of physical properties available
in these industrial plastics make many of them attractive candidates for such uses.
However, even though a material may possess the desired physical properties,
there is no assurance that it may be utilised on the human body. A great deal of
research will have to be completed to determine the relationship between molecular
structure and tissue receptivity. M a n y of the materials used successfully in
industrial applications contain toxic compounds. In these formulae, such toxic
elements may be replaced in many materials without affecting their structure or
properties.
Research towards the solution of such problems will require the combined
knowledge of the polymer chemist, engineer and surgeon. T h r o u g h the efforts
of such multidisciplined groups, a material of outstanding long-term physical
and mechanical properties will be developed, studied, evaluated and made
available to the patient.

SUMMARY
The basic clinical and laboratory procedures for the construction of facial
prostheses are described, together with methods of simulating skin colour using
resilient and rigid materials.
182 BRITISH JOURNAL OF ORAL S U R G E R Y

ACKNOWLED CEMENT S
I wish to express my thanks to M r H. D. Penney, F.D.S., R.C.S., Consultant Dental
Surgeon, Leeds Regional Hospital Board, to M r T. L. Barclay, F.R,C.S., and M r D. J.
Crockett, F.R.C.S., Consultant Plastic Surgeons, for permission to illustrate their cases and
for their continual encouragement and advice. Also to M r P. Harrison, M . S . R . , and M r D.
Harvey for providing the illustrations.

REFERENCES
BULBULIAN,A. H. (1945). Facial Prosthesis. Philadelphia: W. B. Saunders Co.
ROBERTS, A. C. • PENNEY, H. D. (1964). Dent. Pract. 15, 7.
PEET, E. W. & PATTERSON,T. J. S. (1963). Essentials of Plastic Surgery. Oxford: Blackwell
Scientific Publications.