Fabrication

of

a nose

prosthesis
(DC) USN*

Kenneth E. Brown, Commander Naval Hospital, Great Lakes, Ill.

and lhhe h uman nose, because of its prominence facial character, is a difficult structure to replace. 1 supplying adequate function and esthetics requires skills., 3 This article describes the technical and fabricating a nose prosthesis. IMPRESSION TECHNIQUE

commanding role in establishing Construction of a nose prosthesis both prosthodontic and artistic artistic procedures involved in

I. Place the patient in a supine position and drape the face. 2. Pack moist gauze into the nasal defect to prevent intrusion of impression material into the nasal cavity. 3. Place a wax collar around the face to confine the impression material. A generous encompassment of the face is required to provide a working moulage with sufficient perspective for sculpturing (Fig. 1) . 4. Temper reversible hydrocolloid impression material to a tissue-tolerable range of 11 O F. and paint it generously over the skin surface. 5. Use bent paper clips to provide retention for a subsequent plaster reinforcernent (Fig. 2). 6. Cover the congealed hydrocolloid and imbedded paper clips with a layer of quick-setting plaster. 7. After the plaster has set, remove the entire irnpression and examine it for accuracy of registration. 8. If acceptable, box the impression with wide paper rnasking tape and pour a working cast (Fig. 3). SCULPTURING THE PROSTHESIS 0.001 tinfoil to facilitate

1. Seat the patient where he can be easily observed. 2. Cover the defect site on the working cast with easy removal of the eventual clay-sculptured nose form.
The opinioris and assertions contained not to be construed as official or reflecting at large. *Chief, Dental Service. herein arc the private the views of the Navy

ones of the author and are Department or naval service

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Brown

Fig. 1. This postsurgical defect resulted from treatment in eradicating extensive disease of the nose. The proposed impression area is outlined, giving sufficient registration of tissue to afford good facial perspective in the working moulagc. Fig. 2. This cut-away illustration of the facial boxing shows the confined with paper clips to provide retention of a plaster reinforcement. impression material

3. Using common artists clay, develop the nose form. Patient observation, presurgical moulages, photos, or a sample of classic sculpturing will assist in reconstructuring the defect. 4. Build the clay sculpture to normal contours and end it in a natural line (fold) of the skin of the face. This will provide good peripheral adaptation and allow the edges of the finished prosthesis to be concealed (Fig. 4) .4 5. Personality and character may be incorporated in the sculpture by developing
a prominent arch or a flat nasal bridge. Slight asymmetry given to the aiae, nares;

columella, and lateral slopes of the nose provides a natural appearance. 6. As the sculpture reaches the final stages, it can be removed from the working cast and held against the face of the patient for further evaluation. EXTERNAL DIE CONSTRUCTION

1. Notch the working cast at three equally separated points beyond the margin of the clay sculpture to create aligning keys in the periphery of the dies to be produced.

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545

Fig.

Fig. 4

Fig. 3. The working tate sculpturing. Fig. 4. The tinfoiled

moulage

provides

enough

of the facial clay sculpture

architecture

and features

to facili-

cast shows a proportioned

of the nose.

Fig. 5. The cross section illustrates a boxed sculptured nose poured in refractory investment. The plaster reinforcement is represented by the bottom stippled section. Irreversible hydrocolloid impression material with retentive paper clips is the white center section. The poured refractory investment is the top shaded section.

2. Place a wax collar around the clay sculpture in position on the moulage and extend it outward to include the notches in the cast, 3. Use a free-flowing irreversible hydrocolloid (double the water requirement recommended by the manufacturer for standard dental impression procedures), and duplicate the form of the surface within the boxing. 4. Again reinforce the impression with plaster as previously described. 5. Remove the impression from the working cast and check for accuracy and detail of the registration.
Deelastic, Kerr Manufacturing Co., Detroit, Mich.

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Brown

Fig. 6. Thr refractory below a cut-away

cast is shown view of thr wax

on which the extrrnal surface die will up with spruing (square) and venting

1~11 fabricated
colum~ts (round

and
;.

Fig. 7. The working clips is illustrated.

moulage

is boxed

and

a cut-away

view

of impression

material

with

papel

Fig. 8. A boxed impression of the hydrocolloid impression. Bent paper loops for plaster backing reinforcement

facial defect is registered directly by clips are imbedded in both impressions (shaded layrrs).

a sc:c~nd rrversible to art as retentive

6. Surround the impression with a collar of palmer masking tape. and pour a refractory cast using gray investment* prepared in the proportions recommended b) the manufacturer (Fig. 5). 7. Cover the entire tissue representation of the investment (refractory) rast with three layers of baseplate wax to ,give a castin,q of sufficient thickness For dimensional stability.
*Ransom and Randolph Co., Toledo, Ohio.

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Fabrication

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Fig. 9. The refractory cast is created registration of the primary impression wax-up with its sprue and venting duplication of the defect site. 8. facilitate Strategically complete place and a sprue accurate

from the double-impression procedure made by a direct of the working moulage. A cut-away view of the casts column show that the resulting surface die is an exact

of casting

adequate (Fig. 6).

size,

and

sufficient

escape

vents

to

9. Place a sheet-metal collar around the waxed wax sprue column a half inch from the surrounding
investment in the sprue area is created to allow greater

refractory cast, positioning the metal collar. The less insulative

access for heat concentration.

10. Fill the metal band enclosure containing the positioned waxed cast with properly prepared refractory investment, totally investing the cast, sprue, and venting columns. 11. After the manufacturers recommended setting time has elapsed (generally requiring overnight), take the investment mold to the boil-out tank and eliminate the wax. 12. Place the mold in an oven and bring it up to a casting temperature of 300 F., and allow sufficient heat soaking to insure total heat penetration. The total heating time is approximately 90 minutes. 13. Cast the die by slowly pouring molten linotype metal into the sprue until the venting columns show complete filling. Accurate casting is insured by directing a blowpipe flame on the inventment in the sprue area to maintain a molten reservoir upon which the solidifying casting can draw. 14. After casting, retrieve the metal die, clean it, and examine it for possible surface defects. TISSUE-CONTACTING DIE CONSTRUCTION

1. Remove the clay sculpturing from the working moulage. 2. Using a wax collar, surround the defect area, again including the marginal surface notching created for aligning keys. 3. Make an impression of the boxed area, again using free-flowing irreversible hydrocolloid material and reinforcing it in the fast-setting plaster (Fig. 7) .

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Brom

Fig. 10. Cross-sectional illustration shows thr rstcrnal surface inetal die fclr nose prosthesis. The arrow indicates depressions and prominence which will require npplicatiljn of 1icrhtc.r tone and darker shadow coloring, respectively.

4. Retrieve the impression and, if satisfactory, surround its pcriphcry with paper masking tape. the surface. 5. Coat the impression with a thin film of glycerin to luhticatc 6. Register the contours of this prepared impression by pouring anothrr mix of irreversible hydrocolloid directly over its surface and reinforce it with fast setting plaster (Fig. 8). 7. Separate the two reinforced impressions and examine for accuracy of registnttion. 8. If this irreversible hydrocolloid registration is satisfactory, box and pour ZL Ihis cast, made from the double-impression refractory cast with gray investment. surface die in a manner similarprocedure, is used to create the tissue-contacting to that described for fabricating the external surfact: die (Fig. 9) . 9. Prim and smooth the borders of the two dies to insure their accuratc al)proximation.
PAINTING 1. Seat the patient in good illumination for ac,curatc evaluation of skin tone and highlights. 2. Pour a generous amount of a closely matching stock skin-colored vinyl resin on a large glass mixing slab. 3. Place small pools of base color vinyl resin ted, yellovv, brown and blue around the perimeter of the mixing arca on the glass slab. color *Realastic Industries, 1000 Forty
Street, Oakland, Calif

Fabrication

of

nose prosthesis

549

Fig. 11. External and tissue contacting sembled mold (below) is held together columns are left on dies to act as handles

surface dies are properly aligned (above). The aswith common spring clamps. Sprues and venting for their manipulation.

4. Develop the desired intrinsic skin color by slowly incorporating small amounts of various base colors into the major pool of the selected stock color vinyl resin. 5. Small pools of slightly varying color from that of the major color blending are made up to supply contrastin g hues and color highlights to the prosthesis. PROCESSING 1. Preheat the dies in a dry-heat oven held at a temperature of 195 C. for 1 hour, allowing complete heat saturation. 2. Kemove the external surface die from the oven first and place it on an electric hot plate to maintain its ternperature during application of the colored

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Brown

I. l,-o&et. Sovembrr.

Dent 1971

Fig. 12. The

free respiratory

completed exchange.

prosthesis

is shown

in

various

aspects.

The

nares

are

trimmed

for

vinyl resin. The use of asbestos and mitten and pliers is required to manipulate the heated die. 3. Apply a thin coating of clear vinyl resin to the heated die to give the outer surface of the finished prosthesis a slight translucent effect. 4. Dust red nylon fiber flocking onto the translucent layer to simulate skin vascularity. 5. Return the die to the oven for 5 minutes to congeal the primary coating by heat. 6. Develop the color characterization by applying the separately blended colors to the die surface. Keep in mind during the paint-on application of the various color shades that the high contours of the die surface are the rescessed and shadowed areas of the finished prosthesis and should receive the dark colors, while the low valleys and depressions in the prosthesis are prominences needing lighter toned treatment (Fig. 10). 7. After each application of colored resin, return the die to the oven for 5 minutes to allow the resin to set.

Volume Numbrr

26 5

Fabrication

of a nose prosthesis

551

Fig.

13. The

adaptation

of the

appliance

to the facial

contours

adequately

covers

the

defect.

8. Apply the blended stock color vinyl resin in a generous layer over the entire surface of both dies. (The tissue-contacting die need not be color characterized since this surface is not visible when appliance is worn). 9. Assemble the dies according to the keyed margins, making sure that there is no congealed vinyl resin adhering to the peripheral margins to prevent complete closure of the mold. 10. Secure the assembled mold with large spring jaw clamps and place in the oven to cure for 15 minutes at temperature of 195 C. (Fig. 11). 11. Occasionally rotate the mold in the oven during curing to prevent pooling of the resin within the mold. 12. Kemove the mold from the oven after curing and immerse it in ice water. 13. Disassemble the cooled mold and carefully retrieve the prosthesis. 14. Inspect the prosthesis closely for air bubbles, thin areas, and accurate duplication of color. 1.5. Trim the orifices of the nares and internal surfaces to allow free respiratory exchange (Fig. 12). 16. Hold the processed appliance gently against the patients face and check the peripheral adaptation (Fig. 13 ) . EXTRINSIC COLORING AND ATTACHMENT base pigments to the external

1. Apply small surface for additional

amounts of xylene-suspended color enhancement.

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Brown

The right lateral aspect Fig ;. 14. (A) sur gical resection in cancer ireatmcnt. the sis in place re-establishes the bridge of the nose. (I)) ten tive adaptation.

of the fact has a clinical defect rmulting from cxtrrl (R) The right lateral aspect of thr lacr> with thP I tissue contours. (C) Ihe lrft lateral aspect shows :L clc~fici~ncThe left latmal aspect shows adequate rrcontrmrillg anal gym!

2. Tone down excessive extrinsic coloring by wiping the surfacxb \\ith syk mt:ma listened gaux. 3. Warn the patient against the USC of c.osrnctics on the prosthesis since the uil arc dclcterious to the vinyl resin resiliency. ba: ;cs used in their compounding 4. Instruct the patient to keep the skin area receiving the appliance clean ;IYld

Volume Sumber

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Fabrication

of a nose prosthesis

553

Fig. 15. (A) A nasal defect has resulted from surgical treatment of an extensive basal carcinoma. (B) The nasal prosthesis covers the surgical defect and provides a satisfactory metic restoration. Kate the slight deviation given to the bridge of the prosthesis to simulate original form of the patients nose which had previously been broken.

cell costhe

free of natural oil secretions to improve adhesive retention. This can be done by wiping the skin in the attachment area with ethyl alcohol before the prosthesis is applied. 5. Rehearse the patient in the technique of skin-adhesive application and the correct placement of the appliance (Pigs. 14 and 15). 6. Instruct the patient in the routine cleansing of the prosthesis and warn against the halard of color change associated with smoking.
SUMMARY

This article presents an outline of the steps involved in constructing a nose prosthesis. A two-piece metal mold is made for processing thermally cured vinyl resin. Pertinent considerations in executing the impression procedures, sculpturing, coloring, and processing are presented to insure an esthetically acceptable prosthetic replacement.
The author gratefully USN, Head, Oral Surgery editing the text. References 1. 2. Miglani, D. C., and Drane, J. B.: Maxillofacial Prosthesis and Its Role as a Healing Art, J. PaosrrrEr. DEST. 9: 159-168, 1959. Bulbulian, A. H.: Maxillofacial Prosthetics; Evaluation and Practical Application in Patient Rehabilitation, J. PROSTHET. DEST. 15: 554-569, 1965. acknowledges Division, the assistance Naval Iiospital, of Commander Great Lakes, J. III., S. Lindsay, in reviewing DC, and

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3. 4. 5.

Brown
Strain, J. C., Maxillofacial Prosthetics, J. PROSTHET. DENT. 11: 790-793, 1961. Fonseca, E. P., The Importance of Form Characterization and Retention in Facial thesis, J. PROSTHET. DENT. 16: 338-343, 1966. Tashma, J., Coloring Somatoprosthescs, J. PROSTHET. DENT. 17: 303-305, 1967. NAVAL FORCES AIIVISORY GROUP VIETNAM MAXILLOFACIAL TEAM F.P.O. SAN FRAX~IS~O, CALIF. 96626

Pro,-