Resection prostheses according to Oksman. Facial prostheses - ectoprostheses
Facial defects can form due to a number of factors, such as removal of tumors, especially malignant ones, injury to various parts of the face, burns (thermal, electrical, chemical), congenital defects and deformations of the facial area, consequences of diseases (tuberculous lupus, syphilis), etc. Defects faces can be isolated or combined. Their elimination is possible through plastic surgery and prosthetics. Prosthetics are indicated for large and complex defects of the face (ear, nose). If the patient refuses surgery, prosthetics are also used for small facial defects.
Plastic surgeries give positive results, but they cannot always be performed due to the traumatic nature and duration of treatment, which requires a number of repeated surgical interventions before a satisfactory aesthetic effect is achieved, which is often the reason for patients to refuse this method of treatment.
Contraindications to plastic surgery:
1. weakened general condition of the body;
2. unfavorable conditions for tissue engraftment created after removal of a malignant tumor and a course of radiation and chemotherapy;
3. danger of tumor recurrence;
4. the extent of the defect in a part of the face and its complex shape (auricle, nose);
5. advanced age of the patient.
6. small facial defects if the patient refuses surgery.
In these cases, preference should be given to the orthopedic method of treatment. Prosthetics are aimed at restoring the patient’s appearance and speech, protecting tissues from environmental influences, eliminating drooling and food loss, and preventing mental disorders. Ectoprosthetics completes the complex of measures for the rehabilitation of patients with facial damage.
Facial prostheses are made from soft (orthoplast) or hard plastic based on polymethyl methacrylate - PMMA (AKR-7, -9, -10, EGMASS-12), sometimes a combination of plastics is used. Modern ectoprostheses are made from materials based on silicone and PMMA. To obtain the best aesthetic effect, soft plastics are painted with special dyes that are selected according to color. A facial prosthesis made of rigid plastic is painted in two ways. The best results are obtained by painting the prosthesis with oil paints. The second method is to add dyes to the polymer (ultramarine, crown lead, cadmium red, etc.) The required color of the prosthesis is obtained experimentally.
Mechanical fixation.
Ectoprostheses are strengthened using a spectacle frame, which is either connected to the facial prosthesis monolithically using reinforcement or quick-hardening plastic, or is made removable and connected to the ectoprosthesis using locking devices, for example, magnets. To attach ectoprostheses, special clamps are also used, which are inserted into natural or specially created surgically retention points, clamps (as in a hearing aid), and a rubber band passing under the hair from one temple of the glasses frame to the other. In some cases, the ectoprosthesis is fixed using a screw-shaped implant with a rough surface, which provides the best connection with the bone.
Chemical fixation. As an additional method of fixing ectoprostheses, special adhesives or theater glue are also used, which for small facial prostheses (for example, when replacing a defect in the wing or tip of the nose), where other methods of fastening cannot be used, are the main method of fixation.
Physical fixation. The combination of an implant with magnetic elements simplifies the design of the ectoprosthesis without compromising the quality of fixation and completely avoids the risk of infection of the implant by maintaining the integrity of the skin.
All facial prostheses are prepared using face models(plaster mask). When modeling an ectoprosthesis, they check the patient’s photographs, take into account the shape of the face, anthropometric data, the symmetry of the paired organ, and take into account personal complaints and wishes.
Facial prostheses:
1) prosthesis of the orbit and nose with fixation on the frame of glasses.
2) prosthetic nose (made of hard plastic with a gasket and inserts in the nasal passages made of soft plastic)
3) prosthetic nose with fixation on the frame of glasses
Ear prosthesis, mounted on Filatov stems:
a) Filatov stems made from leather;
b) metal plate;
c) ear prosthesis with magnets.
Replacement prosthesis for soft tissue defects in the perioral area (according to B.K. Kostur and V.A. Minyaeva).
Fixation of the prosthesis is carried out using a solid-cast dental frame with occlusal linings - a splint, with an intact dentition, and a prosthetic splint - with partial absence of teeth. The intraoral part of the ectoprosthesis can be used as a forming apparatus during delayed osteoplasty, and after it as a replacement prosthesis.
In case of extensive facial defects, the presence of scar tissue around the defect, weakening of the patient’s general condition or his refusal of surgical intervention, orthopedic treatment methods are used - facial prostheses. For this production, it is necessary to obtain a cast of the entire face and use wax or plasticine to form the missing part of the face on a cast model (mask).
Method of taking an impression. The patient is placed in a horizontal position, rubber tubes (or a flat tube between the lips) are inserted into the nasal openings and the hairy areas of the face are lubricated with Vaseline. The head and neck are covered with a sheet, leaving the face and chin exposed. The facial defect is filled with gauze, leaving only its edges exposed. Then liquid plaster is poured over the face in a certain sequence (forehead - eyelids - nose - cheeks - lips - chin), creating a layer 1-15 cm thick. After the plaster has hardened, the cast is removed, placed in a soap solution for 15-20 minutes and a mask model is cast .
Manufacturing of a prosthetic nose according to I. M. O k s m a i u. On a plaster mask, the nose is modeled with wax or plasticine, focusing on a photograph of the patient before the formation of the defect and matching the shape and size of the prosthesis with it. Then, a collapsible plaster mold, consisting of 2-3 parts, is removed from the wax reproduction and connected.
and the inner surface is covered with a layer of wax with a thickness of I -!.5 mm, forming a template for the future prosthesis.
To ensure a tighter fit of the edges of the prosthesis to the skin surface, a layer of molten wax 5-10 mm wide is applied to the plaster mask along the edges of the defect with a brush and a wax template of the prosthesis is glued to it. After the necessary correction, the wax reproduction of the prosthetic nose is replaced with elastic and hard plastic.
Reinforcement of a prosthetic nose on the face can be done either by means of a spring inside the nasal openings, or by means of a spectacle frame. To use a spectacle frame, holes or slots are drilled with a bur at the base of the prosthetic nose and the temples of the glasses, into which cotter pins are inserted that are unbent from the inside of the prosthesis.
Production of combined.
maxillofacial prostheses. When there are combinations of facial and jaw defects, combined maxillofacial prostheses are used, connected to each other using springy metal rods in combination with spectacle frames. This type of fastening provides sufficient fixation of the prosthesis and some of its mobility during contraction of the facial muscles.
Manufacturing. First, a jaw prosthesis is made, into which two round couplings with a diameter of 3 mm are welded, and after it is applied to the jaw, a face impression is taken to obtain an imprint of the front surface of the jaw prosthesis. After removing the prosthesis from the mouth and attaching it to the face cast in the desired position, a mask model is cast. The missing parts of the face are modeled on the mask, and stainless steel rods in the form of slightly bent rods, soldered at one end, are inserted into the tubes of the jaw prosthesis. The other ends of the rods are mounted in a facial prosthesis made from elastic or hard plastic using the method described above.
Facial defects can form due to a number of factors, such as removal of tumors, especially malignant ones, injury to various parts of the face, burns (thermal, electrical, chemical), congenital defects and deformations of the facial area, consequences of diseases (tuberculous lupus, syphilis), etc. Defects faces can be isolated or combined. Their elimination is possible through plastic surgery and prosthetics. Prosthetics are indicated for large and complex defects of the face (ear, nose). If the patient refuses surgery, prosthetics are also used for small facial defects.
Plastic surgeries give positive results, but they cannot always be performed due to the traumatic nature and duration of treatment, which requires a number of repeated surgical interventions before a satisfactory aesthetic effect is achieved, which is often the reason for patients to refuse this method of treatment.
Contraindications to plastic surgery:
1. weakened general condition of the body;
2. unfavorable conditions for tissue engraftment created after removal of a malignant tumor and a course of radiation and chemotherapy;
3. danger of tumor recurrence;
4. the extent of the defect in a part of the face and its complex shape (auricle, nose);
5. advanced age of the patient.
6. small facial defects if the patient refuses surgery.
In these cases, preference should be given to the orthopedic method of treatment. Prosthetics are aimed at restoring the patient’s appearance and speech, protecting tissues from environmental influences, eliminating drooling and food loss, and preventing mental disorders. Ectoprosthetics completes the complex of measures for the rehabilitation of patients with facial damage.
Facial prostheses are made of soft (orthoplast) or hard plastic based on polymethyl methacrylate - PMMA (AKR-7, -9, -10, EGMASS-12), sometimes a combination of plastics is used. Modern ectoprostheses are made from materials based on silicone and PMMA. To obtain the best aesthetic effect, soft plastics are painted with special dyes that are selected according to color. A facial prosthesis made of rigid plastic is painted in two ways. The best results are obtained by painting the prosthesis with oil paints. The second method is to add dyes to the polymer (ultramarine, crown lead, cadmium red, etc.) The required color of the prosthesis is obtained experimentally.
Mechanical fixation.
Ectoprostheses are strengthened using a spectacle frame, which is either connected to the facial prosthesis monolithically using reinforcement or quick-hardening plastic, or is made removable and connected to the ectoprosthesis using locking devices, for example, magnets. To attach ectoprostheses, special clamps are also used, which are inserted into natural or specially created surgically retention points, clamps (as in a hearing aid), and a rubber band passing under the hair from one temple of the glasses frame to the other. In some cases, the ectoprosthesis is fixed using a screw-shaped implant with a rough surface, which provides the best connection with the bone.
Chemical fixation. As an additional method of fixing ectoprostheses, special adhesives or theater glue are also used, which for small facial prostheses (for example, when replacing a defect in the wing or tip of the nose), where other methods of fastening cannot be used, are the main method of fixation.
Physical fixation. The combination of an implant with magnetic elements simplifies the design of the ectoprosthesis without compromising the quality of fixation and completely avoids the risk of infection of the implant by maintaining the integrity of the skin.
All facial prostheses are prepared using face models(plaster mask). When modeling an ectoprosthesis, they check the patient’s photographs, take into account the shape of the face, anthropometric data, the symmetry of the paired organ, and take into account personal complaints and wishes.
Facial prostheses:
1) prosthesis of the orbit and nose with fixation on the frame of glasses.
2) prosthetic nose (made of hard plastic with a gasket and inserts in the nasal passages made of soft plastic)
3) prosthetic nose with fixation on the frame of glasses
Ear prosthesis, mounted on Filatov stems:
a) Filatov stems made from leather;
b) metal plate;
c) ear prosthesis with magnets.
Replacement prosthesis for soft tissue defects in the perioral area (according to B.K. Kostur and V.A. Minyaeva).
Fixation of the prosthesis is carried out using a solid-cast dental frame with occlusal linings - a splint, with an intact dentition, and a prosthetic splint - with partial absence of teeth. The intraoral part of the ectoprosthesis can be used as a forming apparatus during delayed osteoplasty, and after it as a replacement prosthesis.
When making ectoprostheses in the case of a unilateral combined defect of the upper and lower lip and the corner of the mouth, they are made separately and secured to the dentures, each independently. Taking into account the fact that when the mouth is opened, the defect in the area of the corner of the mouth increases, a special protrusion is modeled on the distal edge of the ectoprosthesis of the upper and lower lips, extending to the ectoprosthesis of the lower lip.
Combined maxillofacial prostheses are a combination of an ectoprosthesis with jaw prostheses. They can be fixed to each other using hinges or magnets, locks of various designs, springs, couplings, tubes and pins, or rigid connections. The choice of fixation method is individual in each specific case.
Combined maxillofacial prosthesis (according to I.M. Oksman). The facial prosthesis is fixed using a spectacle frame and rods that fit into the sleeves of the upper jaw replacement prosthesis.
PROSTHESES THAT REPLACE FACIAL DEFECTS
Defects in the soft tissues of the face are usually restored through plastic surgery with local tissue or transplantation of a Filatov stem. However, in some cases, when surgical restoration is contraindicated or the preparation of the stem is significantly delayed, restoration with a prosthesis is resorted to. The difficulties of such replacement of defects in the soft tissues of the face lie in the fact that it is necessary to create missing parts of the face in the absence of sufficient landmarks.
Facial prostheses are made of plastic.
Methods for strengthening prostheses depend on the nature of the defect, its size and location. Prosthetic noses with an upper lip or part of the adjacent cheek are in most cases strengthened with glasses. If there are no teeth bordering the facial defect, a denture is made, to which various devices are soldered for connection with the facial prosthesis (hooks, tubes with rods, rings, mouth guards, etc.). Tubes and rods are made of stainless steel according to the previously described method. If the prosthesis will be fixed on one rod, the rod and tube should be tetrahedral; when using two rods they can be round. The necessary devices are soldered to the prosthesis and the finished denture is put on the patient.
To make a facial prosthesis, the mask is removed with plaster and a plaster model is cast. If the facial prosthesis will be attached to a dental prosthesis, then during the removal of the mask it is necessary to obtain an impression of this prosthesis in order to insert it into the mask and cast a general plaster model. The strengthening parts for the facial prosthesis are put on the fixing devices of the denture and the formation of the facial prosthesis from modeling wax begins. If an eye is missing, a prosthetic eye is simultaneously selected according to the color of the remaining one and installed in a wax model. During modeling, it is useful to use photographs of the patient. After modeling, the wax prosthesis is checked on the patient and appropriate corrections are made. To avoid displacement when pressing devices for fixing the prosthesis, special attention should be paid to securing them in the plaster of the ditch. To do this, the free end of the tube or hook is tied with wire, which secures the device in plaster. Then the prosthesis is plastered, molded from plastic, finished, sanded with sandpaper and tested on the patient.
There are two ways to stain a prosthesis:
- 1) oil.paint,
- 2) by introducing dyes into plastic.
Painting with oil paints is done to match the color of the skin surrounding the defect. It is better to introduce dye into plastic according to the following recipes:
- 1) 100 g of powder, 0.1 g of ultramarine, 40 g of powder, 0.1 g of crown lead;
- 2) 30 g of powder, 0.1 g of cadmium red sulphide;
- 3) 200 g of powder, 2 g of ocher. Diluted dyes are mixed with powder and pure monomer in appropriate proportions. Polymerized plates of various color numbers are prepared, which are selected according to the color of the areas of the face.
To strengthen the prosthesis with the help of glasses, select glasses with ordinary glasses and strengthen them in the area of the bridge of the nose on the prosthesis; To do this, two holes are cut into the prosthesis with a thin spherical bur and a ligature wire is threaded through them to secure the prosthesis to the frame of the glasses (Fig. 126a and 126b). For free nasal breathing, holes are cut out in the prosthesis corresponding to the external nasal openings.
Most facial defects are now corrected by well-developed plastic surgeries. However, in cases where patients are weakened, exhausted, or have undergone surgery to remove a malignant tumor, facial prostheses are made.
There are prosthetics for lips, cheeks, chin, nose, ear, and eyes. Facial prostheses can be used either permanently or temporarily, i.e. before plastic surgery. They are often called ectoprostheses.
The following requirements apply to facial prostheses:
- must restore the shape and contours of that part of the face for which the prosthesis is intended to replace, and the shape of the prosthesis must correspond to the patient’s face as a whole,
- the coloring of the prosthesis must match the tissues of the given area of the patient’s face,
- the prosthesis must fit snugly to the edge of the defect at rest and during function,
- fixation of the prosthesis must be reliable.
Liquid plaster is initially applied to the forehead, eyes, nose, applying it 1-1.5 cm thick, then to the cheeks and chin. When the plaster hardens, the impression of the face is removed forward and slightly downward to avoid hematoma on the bridge of the nose.
The plaster face print is kept for 15-20 minutes. in a soap or glue solution or soak in water for about half an hour. For a simple mask, wire fastening devices (loops) are prepared so that the mask can be stored hanging on the wall.
If it is necessary to connect the ectoprosthesis with the jaw prosthesis, prepare a collapsible model. For this purpose, a rod is bent from wire. One end of it is strengthened with a prosthesis, and the other is immersed in plaster poured onto the patient’s forehead. After the plaster has hardened, the imprint from the forehead, along with the rod and the prosthesis, is transferred to a face mask, thereby obtaining a spatial position in relation to the ectoprosthesis.
The plaster of the cast is separated in parts using a plaster knife and a hammer. The fingers of the left hand should hold the knife by the cheeks of the blade, thereby preventing it from plunging deeply when the hammer strikes. Particular care should be taken when removing plaster from the nose, chin and other areas of the face.
On the resulting mask, the missing parts are modeled with wax or plasticine, focusing on the opposite side of the photograph taken before the facial lesion. Then, from this part, generously greased with Vaseline, a plaster mold is obtained, the inner surface of which is covered with a layer of molten wax 1-1.5 mm thick. The wax composition is tried on, carefully adjusting it to the defect.
In the laboratory, the wax is replaced with the appropriate plastic. Red lead, soot, carmine, ultramarine, cadmium red, etc. are used as dyes. The best results are obtained by applying theatrical makeup and then covering it with quick-hardening transparent plastic. This way you can make a prosthetic nose, zygomatic arch, cheek, and chin.
Fastening of the prosthesis is ensured by connection with the jaw prosthesis (endoprosthesis) or with a spectacle frame using plates covering the arches and the ends fixed in the ectoprosthesis.
A lightweight prosthetic nose can be obtained using the following techniques: a nose is modeled in wax on a mask. A plaster imprint is made sequentially from each half of the nose. Both parts of the print are assembled, tied together and dipped several times into molten wax so that the inner surface is covered with a thin layer of wax. The inner surface of the prints is filled with plaster, i.e. a stamp and a counter-stamp are prepared from plaster. The wax composition is removed, plastered into a ditch and replaced with plastic. The plaster form is preserved. The prosthesis is fixed with a spectacle frame (Fig. 179).
Rice. 179. Strengthening a prosthetic nose using a spectacle frame: a - without a prosthesis; b - with prosthesis
When making an orbital prosthesis, a wax model of the prosthesis is created on the mask. A prosthetic eye is attached to the inner surface behind the eyelids, then it is carefully separated. Eyebrows and eyelashes from hair matched to the patient's hair color are glued to the wax. The wax composition of the orbital prosthesis is plastered into a ditch and replaced with plastic of the appropriate color. The prosthesis is processed. An ocular prosthesis is glued to the back of the orbit. Fixed on the face with brackets and spectacle frames.
In the absence of the auricle, a wax blank is modeled using a plaster mask and photographs. However, it is very difficult to reproduce all the irregularities in a mirror image. It is more advisable to take an impression of the auricle of the corresponding side from one of the same-sex close relatives of the patient with the closest shape of the auricle.
The model with the wax ear is plastered into a ditch. Taking into account the complex shape of the wax composition, counter cuvettes are cast in parts with the application of an insulating layer. This allows you to obtain a collapsible shape, which makes it easier to remove the prosthesis from the cuvette. The form is stored for many years.
In the complete absence of ear tissue, the opening of the ear canal is used to attach the prosthesis.
If there is an ear stump, the prosthesis can be made of two halves in the form of a chest
When replacing the upper part of the ear with a prosthesis, the prosthesis is secured by means of a spring thrown over the opposite side of the head. The spring is disguised as the color of the hair.
In case of severe injuries to the face, there is a need for simultaneous prosthetics of the jaws and facial tissues. Specialists take all possible measures to ensure reliable fixation of jaw prostheses, and facial prostheses are connected on one side with the help of hinges or magnets to the jaw prostheses, and on the other - on the spectacle frame.