A TE OF M XILLOFA ITU CI ST AL IN TH E
Advancement & knowledge for the benefits of patients.
WINTER 2011 VOLUME 11 ISSUE 1 | ISSN 1366-4697 | www.impt.co.uk
OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
ISTS & TECHN OL HET ST OG RO
Note from the editor
Editorial team & IMPT Council 2012 Featured articles
Analysis of lecturing patterns at IMPT scientific congresses 1963 â€“ 2011. Mr Adrian Kearns MIMPT, DPS Caroline Reed AIMPT, BSc (Hons), DPS
Fabrication of a hollow and a foam filled breast prostheses - a case study. Sally Lane MIMPT
Survey about attitudes, opinions, and experience of maxillofacial prosthetists and technologists in the UK towards maxillofacial silicone prostheses. Muhanad M. Hatamleh AIMPT, PhD, MPhil, DPS, MSc Colin Haylock FIMPT, MBE Jason Watson MIMPT, B Med Sc David C. Watts BSc, PhD, DSc
Custom made nasal septum obturator. Carmen Orbaneja Botija MIMPT
A review of current MPT practice in the provision of the prosthetic nipple areola complex. Dianne Bowers, Maxillofacial Prosthetist Chris Maryan FIMPT, Principal Lecturer Peter Gough, Senior Lecturer
A modification to prevent vertical compression in intermediate silicone wafers for orthognathic surgery. Gavin J Carmichael MIMPT, FOTA, LBIDST, RDT
Technical note. Profile dressings: the first restorative approach for head and neck external resections. Carmen Orbaneja Botija MIMPT
33. Articles of interest 34. 2012 Congress abstracts
46. Instructions for authors 50. Ian Kenneth MacLeod â€“ an obituary
IMPT WINTER 2011 3
Note from the editor
Welcome all IMPT members to the new IPMT e-journal! As the new journal editor I sincerely hope you will be in favour of the updated journal format, which I believe is a step forward for the development of the journal and makes the publication more accessible to members. We are far from alone as a profession in adopting an e-journal format, and it is easy to see why as there are many benefits to be had from adapting to this change. The cost implications to the membership regarding production of the journal are greatly reduced. There is the potential for authors to reach a far wider audience using this format via search engines so your work is more widely recognised. The website also allows each member to download and print the journal if a hard copy is desired. It is considerably easier for authors to submit articles directly to the editor in an electronic format and the e-journal is also more interactive for the reader. The contents and abstracts of each journal issued are available to non IMPT members in the Journal area of the website. Whole articles or journals will be available upon subscription request in PDF format. I trust the authors agree their work is presented in a visually appealing and professional manner. Changes to the journal include the new “articles of interest” section. This is designed for members input and is open to the prodigious variety of publications available to our profession. Please also take note of the new authors instructions for all those wishing to be included in the next issue, due out in Spring 2012. As editor I would like to point out that papers do not always have to be research projects or brilliant new ideas, welcome as those always are. As highlighted at the conference journal update, most other peer journals routinely have several literature reviews in every edition, and yet I cannot recall one literature review in the history of our journal. This is definitely an area which requires expansion, so if there is an area of particular interest, or a subject you are considering researching, please consider writing a literature review and submitting it to your journal.
Mr Barry Edwards MIMPT, MSc Editor Barry has served on council before as minutes secretary and applied to rejoin after completing his MSc. After being successfully voted onto council he has recently been elected as the new journal editor.
“I would urge the membership to consider putting forward articles for submission to your journal” Furthermore, most maxillofacial prosthetists will invariably have a moment when they make a device which delivers a successful outcome and think “that worked well”. If so, that is what the journal is for, a sharing of ideas and information. For first time writers, and indeed any article submission, every effort will be made by the journal team to ensure publication is achieved. To conclude, I would urge the membership to consider putting forward articles for submission to your journal. While this is something which currently sits nicely on someone’s personal CV, I envisage a time quite soon where this becomes increasingly desirable and eventually essential for those seeking new employment or promotion. It is worth remembering the author is the biggest benefactor of all. Acknowledgements The editor would like to thank the journal team for their combined efforts in producing this latest edition of the IMPT journal, however, particular acknowledgement must go Jason Watson, Muhaned Hatamalah, Caroline Reed and Naimesha Patel for their contribution, frequently outside of work hours, to ensure production of this journal. Barry Edwards MIMPT, MSc Editor
IMPT WINTER 2011 5
Editorial team & IMPT Council 2012 Design & Publication Hampson & Partners
Subscriptions Willwell Cottage, Wilford Road, Ruddington, Nottingham NG11 6NA T. 01159 215 848 www.handpdesign.co.uk
Advertising Sales Barbara Anne Thomson MIMPT Pg Cert, BSc, Dip (Eng)
Membership of the IMPT is required to view the journal on the IMPT website. The contents page and abstracts will be accessible to non members and should access to the journal or individual articles be requested these can be supplied for a fee of £3.00 per article or £20.00 for the journal complete. Requests should be made directly to the editor at the address below.
Maxillofacial Laboratory, Neurology Building, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF
Mr. Barry Edwards MIMPT, MSc
Queen Victoria Hospital, Maxillofacial Department, Holtye Road, East Grinstead, West Sussex RH19 3DZ firstname.lastname@example.org
ISSN 1366-4697 © The Institute of Maxillofacial Prosthetists and Technologists 2006. No part of this publication may be reproduced without the permission of the editor. Permission is not required to copy abstracts on condition that a full reference to the source is shown.
Ginny Kingsmill BDS, PhD, FDS, RCS (Rest Dent)
Clinical Lecturer, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London E1 2AD
Pauline E Paul MIMPT, MSc
Principal Maxillofacial Prosthetist, Maxillofacial Laboratory, Neurology Building, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF
Muhanad Hatamleh AIMPT, BSc, Mphil, MSc, Dip (Max Fac), PhD
School of Dentistry, University of Manchester, Higher Cambridge Street, Manchester M15 6FH
Peter Ward Booth FDS FRCS
Maxillofacial Surgeon, Howbourne Oast, Buxted TN22 4QD
Jason Watson MIMPT, BmeD, Sci
Consultant MPT Healthcare Scientist, Maxillofacial Laboratory, Nottingham University Hospitals Trust, West Block B Floor, Derby Road, Nottingham
Membership and change of address All correspondence relating to membership of The IMPT should be sent via post or email to: Adrian Kearns Honorary Registrar IMPT Department of Maxillofacial Prosthetics
Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guilford, Surrey GU2 7XX email@example.com
6 WINTER 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
A TE OF M XILLOFA ITU CI T S AL IN
ISTS & TEC H N OL HET ST OG RO
Editorial Advisory Board
Steven Dover FDSRCS (Eng), FRCS (Eng)
Sarah Parkinson FIMPT, BSC (Hons)
Fraser Walker FIMPT, MSc, LCGI
Mrs Paramjit Kaur Sandhu MIMPT, BSc (Hons), DPS, Pg Cert
Richard Eggleton FIMPT
Liz Gill MIMPT, BSc (Hons)
Mark Cutler FIMPT, MBE
Barry Edwards MIMPT, MSc
Website Editor and Communications Officer
Jason Watson MIMPT, BMed, Sci
NHS Liaison Officer
David Allen FIMPT
Adrian Kearns MIMPT, DPS
Dr Mohamed Bamber FIMPT, Phd
Carol Winter MIMPT
David Thompson MIMPT
Karen Boyd-Glen MIMPT, GCGI
Stefan Edmonson MIMPT, BSc (Hons), DPS
Barbara Anne Thompson MIMPT, BSC, DPS, PgCert
Contacting The IMPT
Co opted Council Member
Naimesha Patel MIMPT, MSc
All correspondence to The IMPT should be sent via our website or email:
Co opted Council Member
Steven Hutchinson MIMPT, MSc, DPS
Fraser Macnamara MIMPT (Hons)
Dr Harry Reintsema
Mark Cutler MBE
East Grinstead, UK
Colin Haylock MBE
East Grinstead, UK
East Grinstead, UK
Dr Trevor Coward
K.F. Moos OBE
East Grinstead, UK
Proof Readers Naimesha Patel MIMPT, MSc
Caroline Reed AIMPT, BSc (Hons), DPS
Dr Richard Bibb
IMPT WINTER 2011 7
Analysis of lecturing patterns at IMPT scientific congresses 1963 – 2011 Mr Adrian Kearns MIMPT DPS, Consultant Maxillofacial Prosthetist Maxillofacial Laboratory, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7XX Caroline Reed AIMPT, BSc (Hons) DPS, Maxillofacial Prosthetist Maxillofacial Laboratory, The Queen Victoria Hospital NHS Foundation Trust, Holtye Road, East Grinstead, West Sussex RH19 3DZ
Abstract Since the first Maxillofacial Technicians conference held at the Queen Victoria Hospital, East Grinstead, in 1963, hundreds of lectures have been delivered by Maxillofacial Prosthetists and other professionals involved in rehabilitation of patients. This paper reviews the lectures and the lecturers who have contributed to the Institute of Maxillofacial Prosthetists & Technologists (IMPT) scientific congresses, and the changes in lecturing patterns over the years. Keywords IMPT, scientific congress, history
Introduction The first Maxillofacial Prosthetics scientific congress was held in 1963 at the Queen Victoria Hospital, East Grinstead. Over the years, there have been hundreds of lectures given by Maxillofacial Prosthetists (MfPs) from all over the world on a wide range of topics. This paper outlines the variety of topics lectured upon and how working and lecturing patterns have evolved into the 21st century. The paper highlights individuals who have significantly contributed to the IMPT scientific congress lecture programmes over the years and describes the influence they have had on others.
Method Programmes from each conference since 1963 to 2011 were obtained from IMPT members and the lecturing timetables analysed to obtain data relating to MfPs’ lectures. This included the number of lectures, lecture topic, time of lectures, individual presenter and their respective unit. Only information printed in each conference programme was used. Last minute alterations to lecture content
8 AUTUMN 2011 IMPT
and individuals lecturing that were not included in the programme could not be taken into consideration for this study. Lectures given at IMPT seminars were not included. Lecture categories The lecture topics were divided into the following ten categories: • • • • • • • • • • •
Prostheses Materials Orthognathic Computer technology Overviews Oro-facial/intra-oral Trauma Implants Education and administration Miscellaneous Data analysis
“There have been 25 IMPT scientific congresses since 1965, 477 lectures have been delivered, totalling over 145 hours” The total numbers of lectures given for each category, throughout the entire history of IMPT conferences, were ascertained to see which topics have been lectured on more frequently. Comparisons were made between lectures given in the first ten conferences and the last ten to see how lecture patterns have evolved over the years. The individual lecturers, and their respective units, were recorded to see which MfPs have significantly contributed to the IMPT lecture programme and whether their input has influenced others.
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Results and discussion There have been 25 IMPT scientific congresses since 1963. Twenty were held in England, three in Scotland, one in Ireland and one in Sweden. In total, 477 lectures have been delivered by MfPs, totalling over 145 hours. The total number of lectures presented on each topic is given Figure 1, and shows that prostheses total almost one third of all lectures. Excluding miscellaneous, all other topics range between 4% and 12%, showing a fairly even spread. Computer technology is an emerging topic and did not appear on the lecture programme in the first fifteen congresses, which explains its low overall figure. The first ten IMPT scientific congresses (Figure 2) totalled 99 lectures. Prostheses and oro-facial/intra-oral figure quite highly, making up almost half (47%) of the total lectures. The two main differences between Figure 1 and Figure 2 are, oro-facial/intra-oral lectures, which have a big contribution to the first ten lectures but show a lower input to the overall lecture content, and computer technology, which did not feature at all in the lecture programme in the first ten conferences. Figure 3 shows how the IMPT scientific congress has changed in recent times. The last ten congresses comprised 269 lectures â€“ just over 56% of all lectures and more than two and a half times the total for the first ten congresses.
The 16th scientific conference in 1993 was the first to include a lecture on computer technology, the second being in 1999, and from then till 2011, the lecture rates rose from 0% to 7%. As Maxillofacial Prosthetists encounter more formalised training, regulation and changes to the Health Service, education and administration has doubled to 12% in the last ten conferences. Overviews have more than doubled from 7% to 15%, possibly reflecting the professions growing involvement in research and development of services and increased audit. In the first ten conferences, prostheses and oro-facial/ intra-oral lectures accounted for 47% (26% and 21% respectively) of the total lecture content. In the last ten conferences, prostheses lectures have stayed at a similar level (27%) while oro-facial/intra-oral lectures show a drop of 28%, accounting for only 6% of the lecture content over the last ten years. This explains the lower percentage of total oro-facial/intra-oral lectures appearing in Figure 1 (Total congress lectures) when compared to Figure 2 (First ten congresses). All other fields show limited fluctuation in comparison to Figure 2.
12% 21 57 12%
Education and Administration 8%
Education and Administration 6%
Computer Technology 4%
Computer Technology 0%
Figure 1. Total congress lectures 1963 - 2011.
Figure 2. First ten congresses 1963 - 1981.
IMPT AUTUMN 2011 9
Individual lectures Table 1 shows the leading lecture contributors and the total time of their combined presentations.
31 75 9% 23
Computer Technology 7%
Education and Administration 12%
Figure 3. Last ten congresses 1993 - 2011.
Lecturing Specific centres have significantly contributed to the lecture programme over the years. Units such as Roehampton (39 lectures), East Grinstead (36), Swansea (24) and Birmingham (21) have contributed to just over a quarter of all lectures since 1963. MfPs from outside the UK have also had a significant input, with 106 of the total lectures coming from Australia (2), Austria (1), Canada (9), Germany (11), Holland (20), India (7), New Zealand (2), Norway (4), Saudi Arabia (1), South Africa (1), Spain (3), Sweden (23), Switzerland (2), USA (18) and Yugoslavia (2). Hopefully this is a trend that continues, with knowledge and practices shared between MfPs all over the world. Number of lectures
14 13 13 11 10 10 10 10 9 9 9 9 8 8 8
C.Haylock B.Conroy M.Pilley P.Smith M.Cutler P.Evans D.Allen J.Watson A.Roberts G.Pratt C.Maryan K.Page A.Bamber A.Bocca M.Townend
260 360 250 235 270 165 140 120 195 190 185 150 195 165 145
Roehampton Professor Brian Conroy MBE presented 13 lectures while head of the Maxillofacial Laboratory in Roehampton. Professor Conroy was also one of the people involved in the inception of the Maxillofacial Technicians Association (later to become the Institute of Maxillofacial Prosthetists & Technologists), and the IMPT scientific congress. His enthusiasm and drive appeared infectious. Numerous people who worked in Roehampton moved on to other centres but continued contributing to congress programmes. In some cases these units had little or no previous lecturing history (Table 2). Name
Lectures since arrival at unit
Lectures by MfPs before arrival
Lectures by other MfPs since arrival
Kevin Page Mark Townend Mark Cutler Colin Haylock
Bristol Poole East Grinstead Charing Cross
7 7 8 5
3 0 6 0
0* 6 22 7 *Bristol employs one MfP
Table 2. Lectures and influences of ex-Roehampton MfPs.
Conclusion The IMPT congress has grown from six lectures in 1963 to a bi-annual international scientific event which regularly consists of more than 20 lectures, as well as submitted or invited lectures from other professionals. Lecture topics show a shift in recent years away from the subject of oro-facial/intra-oral to computer technology and education and administration. The influence of leading lecturers continues to supply the congress with willing participants. These stimulating and inspiring speeches affirm the professional and technical progression of Maxillofacial Prosthetics.
Acknowledgements Many thanks go to everyone who supplied IMPT congress programmes for this study, all of which have been scanned and are available to view on the IMPT website www.impt.co.uk
Table 1. Most lectures at congress.
10 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Fabrication of a hollow and a foam-filled breast prostheses - a case study Sally Lane MIMPT, Maxillofacial Laboratory, Russells Hall Hospital, Dudley Group of Hospitals NHS Trust, West Midlands DY1 2HQ
Abstract This paper describes the method and construction of both a hollow and a foam-filled custom made breast prosthesis. Its purpose is to emphasise the importance of providing a lightweight, contoured and colour matched alternative to a stock gel-filled breast prosthesis. Keywords Lightweight, silicone foam, breast prosthesis
Introduction Many women choose to have reconstructive surgery following a mastectomy to rebuild the contour of the breast.1 Reconstruction can start as the mastectomy is taking place, but it is also possible and sometimes necessary to wait until months or even years after the mastectomy.1 This can be because of a number of reasons, one simply being a patient’s unwillingness to undergo further surgery.1 The decision to delay breast reconstruction is not always based on a woman’s preferences. Some women, for example, may not be suitable surgical candidates because they are having radiation therapy after a mastectomy.1 As well as additional surgery, reconstructing the breast involves more recovery time, more scars, the possible risk of disfigurement, infection and failure.1,2 It is for these reasons that choosing to restore the breast through the application of a prosthesis remains as valid as ever.4-6 A stock silicone gel-filled breast prosthesis may possess various features that attempt to provide an acceptable level of comfort, form, feel, weight distribution, fullness and softness of the natural breast, and, for some patients, they are an adequate alternative to a custom made prosthesis. There are limitations, however, in the standard sizes, shapes and colours available. They can
be heavy, ill-fitting and shapeless, having a tendency to relax under their own weight within the bra, as well as lacking both anatomical detail and realistic appearance.5,6 Many mastectomy patients struggle to cope with a stock external prosthesis, resulting in the requirement of custom made external breast prostheses.5,6 A custom made prosthesis is unique and designed to fit the individual. The aesthetic, functional and psychological needs of the patient are all considered in the construction of such a prosthesis.2 - 6
“The weight of the prosthesis was 675g and this was the patient’s main concern. It caused discomfort and back pain” Case study A patient presented with a mastectomy of the right breast. Following surgery she had been wearing a stock silicone gel-filled breast and was referred to the maxillofacial laboratory for a custom made prosthesis. The weight of the prosthesis was 675g (1lb 7oz) and this was the patient’s main concern. It caused discomfort and back pain, making her an ideal candidate for a hollow custom made prosthesis. During the consultation with the patient, assessments were made to greatly improve the contour, shape and size of the prosthesis.
Methods and materials Hollow box prosthesis Stock breast prostheses are supplied in individual boxes within moulded plastic trays. The tray provided an appropriate size guide on which to base the final prosthesis. Vaseline was applied and plaster poured into the tray, producing a similar shape and size to that of the prosthetic breast, therefore giving a suitable template
IMPT AUTUMN 2011 11
to work on. Sheets of softened wax were then added to the plaster to create a more contoured and realistic breast shape. This was then duplicated in wax, and positioned inside the patientâ€™s bra.
Once set, the wax was removed with boiling water. The mould was left to cool and a separator, Isolant (Dentsply, Addlestone, Surrey UK), was applied to both halves with a brush.
The underside of the pattern (the part in contact with the skin) was modified by softening and removing wax to achieve a more natural, slightly concave fit to rest against the chest wall and also to help reflect changes that will occur with bodily movements. The pattern was then sculpted to simulate the contours of the natural breast. The pattern was removed and the wax made smooth. An impression of the patientâ€™s existing nipple areola was taken using a silicone-based material (Exafast injection type, GC Ltd, Newport, Buckinghamshire, UK) and filled with wax to produce a nipple areola. It was then softened to gain a slight curvature for easy positioning onto the wax pattern within the bra.
Fifty grams of maxillofacial silicone M511, shore hardness 25-30, were mixed with 10% M513 softening agent and 10% M514 anti-slump agent (Technovent Ltd, Principality House, Western Valley Road, Rogerstone, Newport, UK) and applied in a very thin layer to both halves of the mould, taking care to eliminate any air bubbles. The application was extended slightly beyond the edges and also thickened to ensure a seal of the two halves. A thicker layer was applied to the areola.
The existing prosthesis provided only a very basic outline of a nipple areola with no visible protrusion. Once the wax nipple was in position it highlighted the importance of regaining some symmetrical projection. At the end of the appointment, a skin shade match was recorded. Before investing the pattern, a plaster model was cast to the fitting surface of the wax pattern to provide a base, and to record the fit surface for the foam-filled prosthesis later on. This model was then put aside. An Alginate (Heraus, Kulzer, GmbH, Gruner Weg 11, 63450, Germany) two-part mould of the wax pattern, backed with impression composition (Kemdent, ADP Ltd, Purton, Swindon, UK) was then made. This was separated and placed in water to prevent shrinkage of the alginate for later use (Figure 1).
Figure 1. Alginate two-part mould.
The wax pattern was invested in a two-part mould, using Crystacal R (British Gypsum) and sprayed with Aurofilm (Bego, Bremen, Germany), to relieve surface tension.
12 AUTUMN 2011 IMPT
Figure 2a. Application of silicone in a two-part mould.
Figure 2b. The addition of gauze for stability.
Two hundred and fifty grams of silicone M4408 (Abacus, 7 Oxford place, Bradford, U.K), with a shore hardness of 8 was mixed with A-302 thixotropic agent (Factor 2, Lakeside, USA), for ease of application. It was then added to the mould directly on top of the M511 in a uniform layer approximately 5-10mm thick, and to the nipple area, filling it completely (Figure 2a). Strips of gauze were placed within the silicone layers on the fitting surface half of the mould to provide stability against the chest wall (Figure 2b). The mould was placed in a clamp and bench-cured for 48 hours, after which time the mould was opened and the prosthesis trimmed and finished. Foam-filled prosthesis The composition-backed alginate mould (Figure 1) was retrieved from the water and the two halves held together with thick elastic bands. Using a scalpel, a large hole was cut in the top between the two alginate halves. Molten wax was poured into the mould and immediately poured back out (Figure 3a). The mould was immersed into very cold water and this process was repeated two more times, each time the layer of wax thickening to produce a shell of approximately 3mm thick. The wax shell will determine the thickness of the silicone layer, which will cover the foam for the finished prosthesis.
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
The wax within the mould was left to cool naturally, removed, and the alginate disposed of, leaving the hollow wax pattern. The hole in the top was sealed and the pattern replaced onto the plaster model to check for any distortion (Figure 3b). The pattern was turned over with the nipple areola facing downwards and, using a hot wax knife, the fitting surface was cut away approximately half an inch from the edge. At this point, the wax pattern was carefully held and filled with water which was measured to determine the approximate amount of silicone foam needed for the prosthesis. It held 250ml of water which equates to 250g of silicone foam.7
â€œThe hollow prosthesis weighed 247g, a difference of 428g... reducing the weight by almost two thirdsâ€? The pattern was then dried off, returned to the model and the nipple areola removed by carefully cutting around the periphery with a scalpel. A funnel was then formed by curving a sheet of wax into the shape of a cylinder to the same diameter as the nipple areola. This was then sealed into the hole to allow any excess foam to escape without the risk of contacting the outside of the wax pattern. A two-part platinum self-skinning foam M3240 (Abacus, 7 Oxford Place, Bradford, U.K) with the expansion rate of five times the overall volume was stirred and poured through the wax sheet funnel. As the foam expanded up through the funnel (Figure 4a), it also filled the inside of the wax pattern against the model creating the fitting surface (Figure 4b). The pattern was held down onto the plaster base for approximately three minutes until expansion was complete. All of the wax surrounding the foam, including the funnel, was taken away and the excess foam removed with a scalpel. A separator was applied to the original Crystacal mould and 250g of M511 maxillofacial silicone was mixed with 10%M513 softening agent; 10% M14 anti-slump was colour matched as before and applied to the concave half of the mould (containing the nipple areola) in an even layer. M4408 silicone was again used in the nipple area. The foam was positioned onto the other half of the mould and coated with silicone extending the material down onto the plaster base. The flask was pressed together and left in a clamp to bench cure overnight. Once cured, the prosthesis was removed
from the mould, the flash trimmed away and cleaned with an alcoholic wipe. A one-part silicone dispersion sealant ME10 â€“ 6607 (NuSil USA) was then applied using a brush to the exposed foam on the underside of the prosthesis and left to dry for approximately one hour.
Results and discussion Both finished prostheses (Figures 5a and 5b) were weighed. The hollow prosthesis weighed 247g, a difference of 428g when compared to the manufactured prosthesis, reducing the weight by almost two thirds. The foam-filled prosthesis weighed 398g, a difference of 277g. Although more than the hollow prosthesis, it was still significantly less than the stock prosthesis, reducing the weight by over one third. Both the hollow and the foam-filled custom made prostheses were fitted. The hollow prosthesis naturally responds to pressure and once positioned inside the bra became self-supporting. The softness of the prosthesis helped it to mould against the skin on the chest wall, distributing the weight evenly and deflecting it away from
Figure 3a. Pouring the hollow wax pattern.
Figure 3b. Wax template taken from the mould and replaced back on to the plaster model.
Figure 4a. Expansion of the silicone foam within the wax pattern becoming visible as it travels up through the funnel.
Figure 4b. The exposed foam on the underside of the pattern.
IMPT AUTUMN 2011 13
available and should be considered as a treatment modality for patients in these circumstances.
Acknowledgements I would like to thank Mr. David Heath, Senior Chief Maxillofacial Prosthetist, Russells Hall Hospital, for his continued support.
Figure 5a. The definitive hollow prosthesis.
Figure 5b. The definative foamfilled prosthesis.
References 1. Ananthakrishman P, Lucas A. Options and considerations in the timing of breast reconstruction after mastectomy. Cleveland Clinical Journal of Medicine, Volume 75, Supplement 1, 2008, 75 (1): 30-33.
the shoulder, improving the functional fit. The patient experienced an almost immediate relief in her shoulder due to this reduction in weight and also an improvement in posture.
2. Roberts S, Livingston P, White V, Gibbs A. External breast prosthesis use: experiences and views of women with breast cancer, breast care nurses, and prosthesis fitters. Cancer Nursing, 2003, 26 (3):179-86. 3. Hart S, Meyerrowitz BE, Apolone G, Mosconi P, Liberati A. Quality of life among mastectomy patients using external breast prostheses. Journal of experimental and clinical oncology. 1997, 83 (2):581-6.
The foam-filled prosthesis, although heavier and firmer than the hollow prosthesis, provided the patient with a unique and possibly preferable alternative. Both prostheses provided the patient with a combination of comfort and customized shape, enhancing the overall fit.
4. Reaby L L, Hort LK. Post mastectomy attitudes in women who wear external breast prostheses compared to those who have undergone reconstructions. Journal of behavioural medicine. 1995 18, (1): 55-67.
The weight of a custom made breast prosthesis is one of the most important areas to consider and will often determine its success or failure. It needs to be designed to accommodate an individual’s movement, correctly fitting the torso, whilst maintaining the balance of the body and reducing stress on the spine, making it comfortable to wear.
7. Collins Pocket Reference – Ready Reference. 2nd revised edition, 7th April 1994.
5. Healey I. External Breast Prostheses - Misinformation and False Beliefs. Can we do better to help women after mastectomy? Medscape General Medicine. Sept 2003:5 (3). 6. Healey I. Art Applied to Medicine: Reconfiguring the Body. 10th Annual Subtle Technologies Festival, Summary of article May 24th - 27th 2007. University of Toronto, Canada.
Aesthetics are also a very important part of the finished prosthesis. When fabricating a custom made prosthesis, a number of colour swatches are used to create the patient’s unique shade match. Additionally, thoughtful silicone selection resulted in soft and flexible prostheses. Whether the loss of a breast is partial or complete, any change to a woman’s body image can be a traumatic event.2,6 Many mastectomy patients who require a prosthetic replacement do not want to be reminded that they are wearing a breast prosthesis; they want to return to the lifestyle they had prior to their diagnosis. Both of the prostheses described above allow the patient to feel more whole, as well as presenting a normal appearance beneath clothing. This contributes greatly to a patient’s body image, self worth and emotional well being.2-6
Conclusion The production of both hollow and foam-filled custom made breast prostheses provide considerable improvements when compared to the stock items
14 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Survey about attitudes, opinions, and experience of maxillofacial prosthetists and technologists in the UK towards maxillofacial silicone prostheses Muhanad M. Hatamleh AIMPT, PhD, MPhil, DPS, MSc, Author for correspondence School of Dentistry, University of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK Colin Haylock FIMPT, MBE | Jason Watson MIMPT, BMedSc | David C. Watts BSc, PhD, DSc
Abstract The aim of this study was to investigate attitudes, opinions, and experience of maxillofacial prosthetists and technologists (MPTs) in the UK towards several aspects related to maxillofacial silicone prostheses. A ’closed and partial-closed ended questions’ questionnaire was carried out and distributed to 220 MPTs in the UK. The following areas were investigated: airbubbles in silicone elastomers, effects and how to eliminate them, silicone elastomers, commercial types and colouring techniques, challenges of fabricating maxillofacial prostheses, and nonprofessional information. The overall response rate was 43.6%. Cosmesil and Technovent silicones were the most commonly used
silicones in the UK. MPTs affirmed that airbubbles within silicone mixtures affected aesthetics, strength, and hygiene of silicone prostheses. However, the majority (71.4%) employed pressure packing to minimize airbubbles. Aspects of prosthesis maintenance (longevity 59.2%, and colour change 57.1%) were the significant challenges that MPTs face. During the last year, the majority of MPTs who responded attended at least one hands-on training course. Keywords Silicone elastomers, maxillofacial prostheses, questionnaire, survey
Introduction While facial prostheses are in use, several factors contribute to their deterioration. Degradation in mechanical and physical properties and discoloration are the most common problems reported. Several studies have investigated these problems, employing different types of silicones, and exposing them to severe conditions, which affect silicone while in service.1-3 These studies have utilised different test standards, and concluded recommendations based on the criteria selected for their testing environments. Also, different types of silicone elastomers have been compared. The process of silicone discolouration was investigated and ’colour stable’ pigment silicone combinations were passed fit to use in practice.4,5 Despite all of these theoretically significant alternatives, MPTs still face problems with serviceability of maxillofacial prostheses.6, 7 MPT techniques and experience have not been investigated and evaluated regarding the process of enhancing the serviceability of maxillofacial prostheses.
Furthermore, MPTs during their daily work have developed their own techniques to create long-time serviceable prostheses based on variations in health market, patients’ attitudes, and environment among different parts of country.
“Ninety-six IMPT members responded to the questionnaire, indicating an overall response rate of 43.6%” It is important to investigate MPTs’ professional practice, and direct experimental studies to investigate clinically related situations in order to make conclusions, as more problem solving is connected to what is faced in daily practice. The aim of this study was to investigate MPTs’ opinions, attitudes, and experience regarding
IMPT AUTUMN 2011 15
starting from the fabrication process, silicone materials used, challenges they face, and continuous professional development. This paper is part two of a larger study.9
Materials and methods A self-administrated pilot questionnaire was first carried out on eight experienced MPTs in a variety of maxillofacial units in the UK to enhance the layout and format of questions, and ensure that the questions were easily understood. The National Research Ethics Service (NRES) of the regional ethics committee was supplied with a copy of the aims of the study and the questionnaire asking for approval, but the information sought from participants was not deemed to be sensitive so approval was not required (Appendix A). Closed and partial-closed ended questions were included in following areas: silicone elastomers (commercial types and colouring techniques), silicone elastomers used, challenges of fabricating maxillofacial prostheses, record keeping and hands-on training courses attended (CPD). It was distributed via the Institute of Maxillofacial Prosthetists & Technologists (IMPT) to all MPTs (220) working in the UK. The questionnaire was accompanied by a covering letter explaining the aims and objectives of the study and indicated that all information would remain confidential and anonymous.
were AIMPT (Associate in the Institute of Maxillofacial Prosthetists & Technologists). Air bubbles A key question in the survey asked whether it is important in your work to have prostheses free of air bubbles. Respondents were asked two further questions to specify possible effects of air bubbles, and their techniques to minimise them. Multiple responses were available in each question. The majority of respondents (76.6%) indicated it was very important to fabricate silicone prostheses free from air bubbles (Table 1). Four possible effects of air bubbles in the maxillofacial silicone prostheses were indicated in a closed-end question (Table 2). The most frequently used technique to eliminate air bubbles was packing silicone mixtures under pressure (71.4%) (Table 3).
Very important Important
36 (76.6%) 9 (19.2%)
*Number of respondents for this question was 47.
Table 1. Most of MPTs indicated it is very important to have maxillofacial prostheses free of air bubbles.
Possible effect Aesthetics compromised Bacterial colonisation of porous fitting surfaces Effects on prosthesis colour Difficulty in finishing margins
*Number (%) 41 33 28 23
(83.7%) (67.3%) (57.1%) (46.9%)
*Number of respondents for this question was 49.
Table 2. Effects of air bubbles on maxillofacial silicone prostheses.
A prepaid envelope was included with the address of the main investigator. The IMPT council did not approve follow up reminders. After collecting the responses, data was entered into SPSS windows software (release 16, SPSS Inc., Chicago, IL, USA), and analysed.
Results Response rate details Ninety-six IMPT members responded to the questionnaire, indicating an overall response rate of 43.6%. Of the original sample size (220), 32 proved to be non-usable (10 returned cover letters only, 22 returned blank questionnaires), and 15 returned mail. Accordingly, 47 were not considered when the data was analysed.8 Membership in maxillofacial-related associations: 89% were members of the IMPT. Of them, 53.7% were MIMPT (Member in the Institute of Maxillofacial Prosthetists & Technologists), 36.6% were FIMPT (Fellow of the Institute of Maxillofacial Prosthetists & Technologists), and 9.8%
16 AUTUMN 2011 IMPT
Step Packing silicone under pressure Other (own technique) Degassing silicone mixture in a vacuum chamber Leaving silicone in fridge to let air escape Mixing silicone mechanically under vacuum Injecting silicone mixture into mould Two steps including pressure packing
*Number (%) 35 (71.4%) 12 (24.5%) 11 (22.4%) 10 (20.4%) 5 (10.2%) 1 (2.0%) 24 (68.6%)
*Number of respondents for this question was 49.
Table 3. Steps utilized in minimising porosity within silicone prostheses.
Silicone materials used Participants were asked to mention the four common silicone materials they use in fabricating maxillofacial prostheses in descending order (most commonly to least commonly used) (Table 4). Silicones made by Principality Medical and Technovent were the most commonly used materials in the UK. Colouring Respondents were asked about techniques used in
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
colouring silicone mixtures. Overall, 89.4.1 % of respondents used both internal and external stains to colour silicone prostheses, and 10.6 % used internal stains only. Challenges Respondents were asked to indicate possible challenges faced in fabricating maxillofacial prostheses. Factors related to prosthesis maintenance (longevity) (59.2%) and colour changes (57.1%) were considered as the most significant challenges (Table 5).
Manufacturer (brand series)
Cosmesil (*only, M511, Z004 or Gel Technovent (*only, Elastomer 42, TechSil only or 25) Factor II (*only, FX 502, VST 50, A-2000, VST 30 or PSE 70) Matrix (M3428 or M3040) Nusil (*only, LSR2-5830 or 4920) Realistic Abacus (*only, shore 8, shore 24 or shore 40) Molloplast B Promax plastic (Gel or 10 R) Microflex Silorrm 20/20 Dow Corning (RTV or MDX) Premium 2 TSE B455STA Dragon Skin
27% 21% 10% 8% 8% 5% 5% 3% 3% 2% 2% 2% 2% 1% 1%
Total number of silicone/materials mentioned was 100.
Record keeping Overall, 78.7% of respondents reported keeping records of prostheses which required replacement. Of them, 94.6% thought it was useful to keep such a record, whereas the remaining 5.4% of respondents were either not sure (2.7%) or thought it is not useful (2.7%) (Table 6). Hands-on training courses Overall, 93.5% of respondents had attended training courses (Table 7). Moreover, the majority of respondents (53.8%) attended at least one course and 30.8% of respondents attended six to ten courses. Moreover, all respondents (100%) agreed that such courses were beneficial.
* Please note the â€˜onlyâ€™ indicates the silicone manufacturer without specifying the brand name.
Table 4. Brands of silicone elastomers used by MPTs .
Prosthesis maintenance (longevity) Prosthesis maintenance (colour change) Prosthesis construction (colouring) Prosthesis design (sculpture) Prosthesis construction (bonding) Prosthesis design (material) Communication Patient dissatisfaction Others
29 (59.2%) 28 (57.1%) 27 (55.1%) 14 (28.6%) 9 (18.4%) 6 (12.2%) 5 (10.2%) 2 (4.1%) 1 (2.0%)
* Mutli answer question of 49 respondents per each answer.
Table 5. Challenges that MPTs face during fabricating maxillofacial prostheses.
Whether it is helpful to keep such record?
Discussion It is important to analyse the opinions and attitudes of MPTs toward enhancing serviceability of maxillofacial prostheses. Earlier, we published part one of this study.9 This is part two of the study. Most of MPTs were members of the IMPT (89.8%), and 53.7% of them were MIMPT, 36.6% were FIMPT, and 9.8% were AIMPT.
Yes Do you keep record of cases required remake?
The IMPT levels of membership are: associate level of membership (AIMPT), which accounts for all new members with limited experience; the member level (MIMPT), which includes experienced prosthetists with a specialised qualification; and the fellow level (FIMPT), which is the highest level of membership and is where members are experienced prosthetists, often with a postgraduate qualification, and the majority of them are maxillofacial unit managers. Although environmental and patient factors that diminish silicone prostheses functionality have been investigated thoroughly in the literature, the effect of operator relatedfactors, including air bubble formation during mixing, are
Table 6. Record of prostheses requiring remake.
Number of courses attended 1-5 6-10 11-15 16-20 Over 20
*Number (%) 21 12 2 2 2
(53.9%) (30.8%) (5.1%) (5.1%) (5.1%)
*Number of respondents for this question was 39.
Table 7. Percentages of hands-on training courses that MPTs attended during the last year.
IMPT AUTUMN 2011 17
not known. Air bubbles within silicone mixtures adversely affect the elasticity of silicone prostheses, elongation, tear resistance, and appearance.10,11 Moreover, silicone porous fitting surfaces enhance ’candida albicans’ bacterial colonisation.12,13 Most of the MPTs (76.6%) stressed the importance of air bubble-free prostheses. Moreover, they indicated deterioration in prosthesis aesthetics as the most detrimental effect of air bubbles (83.7%), followed by increased chances of bacterial colonisation (67.3%). An effect on prosthesis colour was third (57.1%), whereas problems in finishing margins of prostheses were the fourth effect (46.9%). Air bubbles are likely to be trapped while silicone ingredients (rubber, hardener, and pigments) are mixed.10 Packing silicone mixtures under pressure (71.4%) was the most used technique by MPTs to minimise air bubbles. However, 24.5% suggested other methods such as careful and skilful manual spatulations; stretching silicone out manually on slabs with a spatula; leaving a silicone mixture to stand; packing silicone slowly to allow air bubbles to surface; and keeping a mould with the fitting surface uppermost during curing. A large proportion of MPTs (68.6%) carried out additional steps along-side pressure packing (i.e. degassing silicone mixture in a vacuum chamber; leaving silicone in fridge to let air escape; or mixing silicone mechanically under vacuum). Other factors that contribute to prosthesis functionality are type of materials used. There is wide range of commercial silicone materials available in the market, and little is known about the most commonly used silicone utilized in the UK. This study showed that silicone elastomers produced by Principality Medical (Newport, UK), including the Cosmesil series of silicones, were the most commonly used (27%), followed by silicones produced by Technovent (Leeds, UK), including TechSil silicones (21%), and, finally, silicones produced by Factor II (Lakeside, USA) (10%). Cosmesil and TechSil silicones are manufactured in the UK. Their properties include being readily available, nationally promoted and easy to use, which made them commonly used materials. Furthermore, the availability of different hardeners to be used with Cosmesil made it a suitable material to produce prostheses with varying Shore A hardness which can be tailored to simulate the elasticity of skin tissues where the defects site is being restored. Techniques for fabricating prostheses with a life-like appearance included a hybrid technique for both external and internal colouring, with 89.4.1% of MPTs using both
18 AUTUMN 2011 IMPT
internal and external stains, and 10.6% using internal stains only to colour silicone prostheses. Extrinsic colouration included painting the outer surface of the prosthesis, and intrinsic colouration involved applying various colours in multiple layers into the textured surface of the mould. However, intrinsic colouration is mostly preferred as it does not affect the translucency of the prosthesis.
“Prosthesis maintenance (longevity) (59.2%) and colour changes (57.1%) were considered the most significant challenges” MPTs faced different challenges in fabricating maxillofacial prostheses. Difficulty associated with prosthesis maintenance (longevity and colour change) was considered the most significant challenge (59.2%, and 57.1% respectively). The second were issues related to prosthesis construction, including colouring of prosthesis and bonding of silicone to the retentive plate (55.1%, and 18.4% respectively). Challenges related to prosthesis design (i.e. sculpting the prosthesis and finding a suitable fabrication material) were considered of moderate importance (28.6%, and 12.2% respectively). Team communication and patient dissatisfaction were considered as the lesser challenges. MPTs were asked whether they kept a record of history of prostheses replacement and whether it was beneficial. Such records might include information such as case type, date of fabrication, causes of remake, retention method, and other relevant information. A high proportion of MPTs (78.7%) kept such records. Of them, 94.6% thought it was useful, whereas the remaining 5.4% were either not sure (2.7%) or thought it not useful (2.7%). During the last year, the majority of MPTs had attended at least one hands-on training course (53.8%) and 30.8% of respondents attended between six and ten courses as part of their continuous professional development (CPD).
Conclusions Within the limitations of this study, and based on the attitudes and opinions of MPTs sought, it was concluded that: 1. Air bubbles within silicone prostheses adversely affected prosthesis aesthetics and colour and enhanced
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
bacterial colonisation. Packing silicone under pressure was the most common technique to reduce inclusion of air bubbles.
Appendix A The questionnaire distributed to MPTs.
2. Cosmesil and TechSil series silicones were the most commonly used silicone elastomers in the UK. 3. The longevity of facial prostheses and colour changes were the most challenging factors that maxillofacial prosthetists and technologists faced.
Acknowledgement “DCW gratefully acknowledges the support of the Alexander von Humboldt Foundation, Bonn, by a Humboldt Research Award.”
References 1. Hatamleh MM, Polyzois GL, Silikas N, Watts DC. Effect of extra oral aging conditions on mechanical properties of maxillofacial silicone elastomer. J Prosthodont 2011;20:439-446. 2. Eleni PN, KrokidaM K, FrangouM J, Polyzois GL, Maroulis ZB, Marinos-Kouris D. Structural damages of maxillofacial biopolymers under solar aging. J Mater Sci Mater Med 2007;18:16751681. 3. Mohite UH, Sandrik JL, Land MF, Byrne G. Environmental factors affecting mechanical properties of facial prosthetic elastomers. Int J Prosthodont 1994;7:479-486. 4. Hatamleh MM, Watts DC. Effect of extra oral aging conditionings on color stability of maxillofacial silicone elastomer. J Prosthodont 2010;19:536-543. 5. Kiat-Amnuay S, Mekayarajjananonth T, Powers JM, Chambers MS, Lemon JC. Interactions of pigments and opacifiers on color stability of MDX4-4210/type A maxillofacial elastomers subjected to artificial aging. J Prosthet Dent 2006;95:249-257. 6. Huber H, Studer SP. Materials and techniques in maxillofacial prosthodontic rehabilitation. Oral Maxillofac Surg Clin North Am 2002;14:73-93.
7. Lemon JC, Kiat-amnuay S, Gettleman L, Martin JW, Chambers MS. Facial prosthetic rehabilitation: preprosthetic surgical techniques and biomaterials. Curr Opin Otolaryngol Head Neck Surg 2005;13:255-262. 8. Locker D. Response and nonresponse bias in oral health surveys. J Public Health Dent 2000;60:72-81. 9. Hatamleh MM, Haylock C, Watson J, Watts DC. Maxillofacial prosthetic rehabilitation in the UK: a survey of maxillofacial prosthetists’ and technologists’ attitudes and opinions. Int J Oral Maxillofac Surg 2010;39:1186-1192. 10. Hatamleh MM, Watts DC. Porosities and bonding of maxillofacial silicone elastomer with embedded glass fibre-bundles. Int J Anaplast 2008;2:15-23. 11. Kent K, Zeigel RF, Kent K, Frost AL, Schaaf NG. Controlling the porosity and density of silicone rubber prosthetic materials. J Prosthet Dent 1983;50:230-236. 12. Nikawa H, Chen J, Hamada T, Nishimura M, Polyzois G. Candida albicans colonization on thermal cycled maxillofacial polymeric materials in vitro. J Oral Rehabil 2001;28:526-533. 13. Shi Y, Song W, Feng ZH, et al. Disinfection of maxillofacial silicone elastomer using a novel antimicrobial agent: recombinant human beta-defensin-3. Eur J Clin Microbiol Infect Dis 200928:415-420.
IMPT AUTUMN 2011 19
Custom-made nasal septum obturators Carmen Orbaneja Botija, MIMPT, Maxillofacial Prosthetist Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset BH15 2JB
Abstract The construction of a highly accurate, comfortable, long lasting and economical custom-made silicone nasal septum obturator is described. This is achieved by utilising computer tomography imaging, stereolithographic modelling, and a dimensionally stable soft silicone to construct the device. The technique was first utilised by the author at Birmingham University Hospital and introduced to Poole Hospital. Keywords Nasal septum obturator, septal button, computer tomography, steriolithographic model
shape of defect that is encountered. This device may then be fitted to the patient under local or general aneasthetic. It may require replacement with a new obturator in the future if the contour of the anatomy changes.
Materials and methods A CT scan of the patientâ€™s defect area is required to obtain accurate data (Figure 1). This data is processed using computer software into images which are examined to determine the morphology and extent of the 3D model required, before interfacing with the stereolithography apparatus to build the replica model (Figure 2).4 A 3D medical model is then constructed in an epoxybased resin which is solid enough to withstand the laboratory techniques required for the methodology described in this paper (Figure 3). The high accuracy of these reproductions makes them an ideal tool to avoid discrepancies in the final prosthetic obturator.4
Introduction Septal perforation is an uncommon and very uncomfortable condition and treatment is difficult especially when confronted with large defects.1 The condition is mainly caused by surgery, nasal steroids, decongestive sprays, trauma, cautery, self induced injuries (i.e. digital manipulation), and cocaine usage.1,2 Patients can experience pain, whistling when breathing, crusting, bleeding, discharge, a distorted sense of smell and neuralgia.1-3 These patients are usually referred to ear, nose and throat (ENT) units where treatment can be symptomatic (local application of ointments), prosthetic or surgical to relieve symptoms.
Figure 1. CT image of the sinuses.
Figure 2. Image obtained from a scan of the defect area.
Large and irregular perforations remain a challenge to close surgically, and prefabricated obturators have limited appeal due to imprecise fit.2 By using computed tomography (CT) and stereolithographic modelling, an accurate close-fitting septal obturator can be custom-made for any size or
20 AUTUMN 2011 IMPT
Figure 3. Medical model of defect area.
Figure 4. Silicone impression of working area.
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
The models can also be sterilised for reference purposes in theatre.5
against tearing, obtain maximum clasping and a smooth finish.
Prior to duplicating the working area of the resin model, the extension of the prospective obturator is marked in pencil to ensure full coverage with impression material.
Nasal septum obturators tend to have an oval/circular shape which makes it difficult to determine the exact position on models/patients. For this reason, a small indentation is created in the wax carving (in this case at the right anterior superior aspect). A dot is also marked on the model with indelible pen parallel to the wax indentation. This will be a guide when fitting the final device on either the model or the patient (Figure 7).2
High definition flexible silicone impression material (Epiform Flex, Claude Hill Dental and Plaster Supplies, West Midlands) is spread slightly beyond the pencil demarcation line with the nozzle of a mixing tip (Figure 4). The impression is cast in dental stone to enhance its resistance to breakage, and creates a doughnut shaped mould (Figure 5). The working area is slightly sandpapered to eliminate layers made from the stereolithography machine on the resin model, which have been replicated in dental stone.
A three-part mould is constructed, part one being the doughnut shaped model (Figure 8). The wax is removed from the mould with boiling water, and left to cool. The author recommends using a metal flask to avoid breakage of the dental stone during the packing process. Separating fluid is applied to the three-part mould and room temperature vulcanising silicone (Ufi Gel SC, Voco, Zahn Laboratory, Gillingham, Kent) is injected through the nozzle of a cartridge dispensing gun, ensuring the mixture of the two silicone components within the cartridge is bubble-free when entering the mould.
Figure 5. Doughnut shaped model.
Figure 7. Location mark on obturator and model.
After mixing, Ufi Gel SC which has a working time of one minute forty-five seconds will be fully vulcanised and ready to be deflasked after 15 minutes at room temperature. To extend the working time the cartridge may be cooled in a fridge prior to use. Any excess material can be removed with sharp scissors or with silicone trimming disks. The finished obturator can be fitted on the stereolithographic model to confirm a precision fit has been achieved (Figure 9).
Figure 6. Contour shown for nasal obturator, sagittal view.
The obturator is carved in modelling wax to reconstruct the morphology of the septum. The width and length of the flanges used to support and retain the obturator are important because, although the obturator will be flexible once fabricated in silicone, it should also be robust to avoid tearing and elongated enough to prevent dislodgment without compromising comfort, breathing, and path of insertion.
Figure 8. Three-part mould.
Figure 9. Final result on 3D resin model.
Figure 6 (below) shows the standard contour from a sagittal view. The edges are rounded to protect them
IMPT AUTUMN 2011 21
Method of insertion The surgeon may carry out insertion of the obturator using local or general anaesthesia. Utilising the orientation provided by the indentation created in the silicone, the obturator is coated in antibiotic ointment or lubricating jelly and inserted with bayonet forceps.2 After intranasal insertion, an endoscopic view can verify its precise positioning and fitting.
Discussion Properties of Ufi Gel SC This permanently soft material has a shore hardness of 26 and it is dimensionally stable. Due to its high elastic recovery, it returns readily to its original shape. Ufi Gel SC is thixotropic and it can be applied using light pressure or directly with an injecting gun and a mixing tip to be spread bubble-free over an entire surface as required.6 A study carried out by VOCO® showed a water uptake of this silicone of 0.1% after nine months’ storage at 37°C / 98.6°F. This type of silicone has a vastly reduced toxicological and allergenic effects previously associated with other silicones, which is one of the factors that makes Ufi Gel SC an ideal implant material.6 Ufi Gel SC is also being tested in the medical field of orthopaedics as a disc implant used in the lumber section of the vertebrae with positive results recorded regarding biocompatibility and biomechanics.6
“Nasal obturators constructed following the technique described are an accurate and inexpensive treatment option” Treatment options Surgical intervention alone may not resolve nasal septum perforation. Surgery is also costly and exposes the patient to further risks and complications e.g. general anaesthesia, infections.1,2 Custom-made nasal septum obturators constructed following the technique described are an accurate and inexpensive treatment option. Patients should not experience major discomfort when positioning the obturator and do not require hospitalisation or further reviews in the short-term. In the long-term, they may feel the obturator loosen if the defect area changes contour. In this case, a new CT scan and 3D model would be
22 AUTUMN 2011 IMPT
required to construct a new obturator.
Conclusion The technique described to construct a custom-made prosthetic obturator for nasal septal perforation is an accurate, comfortable, rapid and inexpensive method of treatment. Overall costs are reduced as interventions can be performed in outpatient clinics with minimal complications and follow up.
Acknowledgements I would like to thank the following people: Mr. Steve Worrollo, FIMPT, Consultant Maxillofacial Prosthetist, University Hospital, Birmingham, for his valuable support while training at his department. Mr. David Ellis, MIMPT, Consultant Maxillofacial Prosthetist, New Cross Hospital, Wolverhampton, for instructing the author in the described technique. Mr. Mark Townend, FIMPT Maxillofacial Prosthetist Head of Service, and Mrs. Heidi Silk, MIMPT, Principal Maxillofacial Prosthetist, Poole Hospital NHS Foundation Trust for their help in this technical note. Mrs. Becky Ward, Senior Medical Photographer, Poole Hospital NHS Foundation Trust, for her effort in the provision of the enclosed images. Dr. Richard Bibb, Department of Design and Technology, Loughborough University, for his assistance in the 3D modelling of this case. Dr. Dominic Eggbeer, The National Centre for Product Design and Development Research (PDR), Cardiff, for his assistance in the 3D modelling of this case.
References 1. LK Dosen, R Haye. Nasal septal perforation 1981-2005: Changes in aetiology, gender and size. BMC ENT Disorders 2007 7:1 http://www.biomedcentral.com/1472-6815/7/1 2. DL Price, DA Sharris, EB Kern. Computed tomography for constructing custom nasal septal buttons. Arch Otolaryngol Head Neck Sug Nov 2003 129 Full text http://archotol.ama-assn.org/ cgi/reprint/129/11/1236.pdf 3. JP Barraclough, D Ellis, DW Proops. A new method of construction of obturators for nasal septal perforations and evidence of outcomes. Clinic Otolaryng 2007,32:1 51-4 http:// onlinelibrary.wiley.com/doi/10.1111/j.1365-2273.2007.01305.x/abstract © 1999-2009 4. J F Bouyssié, S Bouyssié, P Sharrock, D Duran. Stereolithographic models derived from X-ray computed tomography reproduction accuracy. Surg and Read Anat. May 1997: 19:3 193-9 http:// www.springerlink.com/content/q8r61420x5l2n327 © Springer. Part of Springer Science+Business Media © Copyright Information 5. The National Centre for Product Design and Development Research (PDR), Cardiff. Customer Guidelines for Handling Medical Models. 6. Scientific Product Information Ufi Gel SC, pages 6,7,8,9. http://www.vocoamerica.com/praeparate/gb/html/prodinfo/wi/WP%20Ufi%20Gel%20en.pdf
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
A review of current MPT practice in the provision of the prosthetic nipple areola complex Dianne Bowers, Maxillofacial Prosthetist, Maxillofacial Laboratory, St Lukeâ€™s Hospital, Bradford UK Chris Maryan FIMPT, Principal Lecturer, School of Biology Chemistry & Health Science, Manchester Metroploitan University, Manchester UK Peter Gough, Senior Lecturer, School of Biology Chemistry & Health Science, Manchester Metroploitan University, Manchester UK
Abstract Statement of problem: Due to the increased level of breast cancer incidence and the decrease in mortality rate, it would be expected that more women will require prosthetic rehabilitation. Purpose of study: To identify the scope of practice of nipple areola prostheses provided by members of the Institute of Maxillofacial Prosthetists &Technologists (IMPT). Materials and methods: A web-based self-reporting questionnaire was utilised.
Conclusion: The study identified significant variation in techniques used, a lack of consistency in patient management, particularly in continuing care and recall, and a lack of audit to identify best practice. The low rate of patients returning after two years, or for replacement prostheses, suggests the need for formal recall systems and regular audit of patient outcomes. Clinical implications: Members should be aware of applicable guidelines to ensure that patients provided with nipple areola complex prostheses should be offered regular recall appointments and their use of the prostheses audited.
Results: The results built a comprehensive picture of current practice.
Introduction Early detection and improved treatment has meant that survival of breast cancer patients has increased significantly.1 Approximately 40% of women diagnosed with breast cancer undergo a mastectomy. The options for a woman to restore her appearance post mastectomy are breast reconstruction or external breast prosthesis.2 The absence of a nipple areola or bilateral nipples can be rectified by surgical nipple reconstruction or the use of a nipple areola prosthesis. The uses of external nipple areola prostheses following reconstruction of a breast mound after mastectomy have been described by a number of workers.3-13 The prosthesis may be used temporarily to assist in determining the position of the reconstruction or as an alternative to reconstruction.3-5 The prosthetic nipple can be commercially available in different sizes and skin colours, or may be custom made.6 Custom made nipple prostheses offer a much more realistic and natural
looking alternative to the stock commercial prostheses available and can provide a considerable psychological boost to the patient.7, 8 The production of a custom made prosthetic nipple areola complex was first published by Roberts et al in 1988, who identified the importance of providing this treatment for patients following breast reconstruction.9 Since then, variations of the original technique and their use have been published to produce high quality realistic nipple areola prostheses.10-13 The prosthetic treatment is non invasive and, as such, requires no surgery, which is why this treatment might appeal to many patients. The prosthetic nipple areola complex may be bilateral, or unilateral, in which case the prosthesis is made identical to the contralateral nipple. Nipple prosthetics are offered by many maxillofacial prosthetic units in UK hospitals. Parkinson7 and Janes8 identified that the majority of patients were satisfied
IMPT AUTUMN 2011 23
or very satisfied. No multi-centred trials have been undertaken; the materials and techniques available suggest a possibility of national provision. The aim of the study was to examine current practice.
Method A web-based self-reporting questionnaire was designed to identify: • the provision of custom made nipple areola prostheses in the UK • the range of materials and techniques used, and to evaluate their popularity • the percentage of laboratory managers and prosthetists involved and their gender • variation in service provisions, patient usage, referral patterns, review policies and disciplines which may benefit from further information on the service provided by the MPT • whether the service was developing and over what period
“Alternate questionnaires were available for prosthetists and laboratory managers” The questionnaire, approved by the Council of the Institute of Maxillofacial Prosthetists & Technologists, was made available online to all members (approximately 200 members in approximately 100 units around the UK).
Results Experimental design Twenty two laboratory managers and twenty nine prosthetists responded (approximately 25% in total and by unit) which is disappointing for a professional organisation of practitioners working in this area. Service provision The service for the prosthetic nipple areola complex has been provided for an average of 8.8 years. The majority of laboratory managers who responded (54%) felt it should be a designated person who is responsible for the service, and felt it was important that the prosthetist develop a confidential relationship based on continuity of care. However, a large minority (41%) feel that it is not appropriate to allocate one prosthetist full-time to the role and that all prosthetists should be capable of treating these patients. Ninety one percent of laboratory managers who construct these prostheses also treat the patient themselves. This means, with only 18% of all laboratory managers questioned being female, 55% of prosthetists treating patients requiring NAC are male. Referrals Fifty percent of the managers stated that they receive fewer than 20 referrals per year and 5% are over 75, as shown in figure 1.
The membership was informed of the location of the questionnaire by e-mail. The questionnaire was delivered online using a form linked to a MySQL database table. After completion, the form was written to the database using PHP (Hypertext Pre-processor) scripts.
The questionnaire included open and closed questions, as well as scaled responses. The responses to open questions were completed in text boxes. Closed questions or scaled responses were recorded using response buttons or drop down menus. The records were exported into Microsoft Excel® for analysis. Alternate questionnaires were available for prosthetists and laboratory managers. The questionnaire for managers included questions about unit policy as well as questions about their own practice. The questions were separated as some managers may not have treated these patients.
24 AUTUMN 2011 IMPT
Figure 1. Number of referrals per year.
Referrals mainly come from plastic surgeons, with the lowest percentage of referral rates coming from general practitioners, see figure 2.
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
What is the most common type of retention used?
31.82 27.27 18.18 4.55 18.18
48.28 17.24 13.79 10.34 10.34
Laboratory Manager (%)
9 2 1 1 1 1 1 0 0
8 1 0 0 1 4 0 1 6
46 8 3 3 5 14 3 3 16
Table 2. Methods of retention.
Adhesive Suction Sticky Gel Petroleum Jelly Other
Laboratory Manager (%)
Breast Care Nurse
Figure 2. Referring disciplines.
Forty five percent of managers reported that there was no formal recall system in place; some only reviewing when the patient makes contact with the department for replacement prostheses, and 64% reported a waiting list. Materials and techniques The most commonly used material for the impression was silicone elastomer, which were used by 81% of managers and 72% of prosthetists. The construction technique most widely used by the laboratory manager was flasking and packing. However, the open mould technique was the preferred method by the prosthetists, see table 1. What is the most common technique that you use for the construction of nipple prostheses? Open Mould Flask & Pack Other
Laboratory Manager (%)
27.27 68.18 4.55
51.72 44.83 3.45
Cosmesil Technovent Cream Adhesive G602 Technovent B460 thin Klebi Daro hydrobond Secure Prostick-Shermans Hollister medical adhesive Nil
Table 3. Pressure sensitive adhesives provided.
Contributing factors of life expectancy were frequency of wear, patient motivation and maintenance. Other issues include material fatigue, such as delamination of tacky gel, and the use of adhesives which is thought to shorten life expectancy of the prosthesis. The use of the adhesive for retention of the prosthesis however, was inconsistent, with the results of the questionnaire with the departments using adhesive stating that the prosthesis life expectancy ranged anywhere between six to twenty-four months. Only 36% of laboratory managers and 38% of prosthetists audit their patientsâ€™ satisfaction, one stating that they have never had any negative feedback. However, 36% of laboratory managers and 49% prosthetists claim that fewer than 25% of the patients return for replacement prostheses, and an even larger 45% of laboratory managers and 52% prosthetists claim that less than 25% require a nipple prosthesis after two years.
Table 1. Method of construction of NAC prostheses.
The most common form of retention for the prosthesis was adhesive (Table 2), with Cosmesil PSA1 the most popular (Table 3). Patient management Most laboratory managers supplied the patient with two prostheses whereas prosthetists supplied the patient with four prostheses. Both, however, supplied the prosthesis after two consultations. The life expectancy of the prosthesis varied, with the highest percentage of laboratory managers suggesting six to twelve months, and the prosthetists claiming a life expectancy of 12 months. Over 60% claimed a prosthesis life expectancy of less than 18 months.
Discussion This questionnaire-based study examined current practice in maxillofacial prosthetic services to identify variation in patient management, service protocols and manufacturing techniques. All members of the IMPT were contacted by email and invited to complete an online questionnaire. The online questionnaire was valuable in the process of investigation; positive feedback was given on the ease of completion. Unfortunately, some of the information could not be used. This was due to the set amount of words allocated to open questions and comments which resulted in foreshortened answers. This was noted early in the study and rectified; however, valuable information from early respondents was lost.
IMPT AUTUMN 2011 25
The return was approximately 25% of the membership of the IMPT; possible reasons for a low return could have been that only members who provide the service responded. An assumption that over 75% of units do not provide the service cannot be drawn from this data. The survey should have been designed to ensure the recording of a nil response with the information for respondents providing a rationale for recording a nil response. The questionnaire was anonymous with no indicators of location of respondents so regional comparisons are not possible either to establish possible service/workforce/ training needs, (although this was beyond the scope of this research). It would seem that there is considerable variation between maxillofacial prosthetic departments and between managers and prosthetists in the methods of treatment, materials used, construction techniques, and auditing of patients. One respondent stated that a female MPT should be responsible for the treatment of post mastectomy rehabilitation. Whether the female patients would prefer a female MPT to treat them has not been investigated in this study; however, breast cancer care guidelines state that patient should have the choice of a female prosthetist.14 Patient care is the most important aspect of treatment and patient confidence may be enhanced if one MPT is to undertake the treatment so they may gain a sense of rapport.
“The majority of respondents stated that life expectancy of the prosthesis is approximately 6 to 12 months...” The referral rate is highest from plastic surgeons, with the lowest being from general practitioners. This could indicate the need for further information on this service from the MPT or it could indicate that the service has been provided earlier in the treatment by referral from the plastic surgeon or the breast care nurse who will be largely involved with the patients’ care. The majority of respondents have stated that the life expectancy of the prosthesis is approximately six to twelve months depending on various factors. However, this does not correspond with the results of the questionnaire, with some departments using adhesive stating a life expectancy of anything between six and twenty-four months.
26 AUTUMN 2011 IMPT
The number of patients returning for replacement prosthesis is low, as were patients returning after two years. With the life expectancy of the prosthesis being between six to twenty-four months, it would be expected that more patients would return, especially as it was stated that the audit has never returned negative feedback. The fact that few patient are returning could be due to many factors - surgical reconstruction, declining personal need, recurrence of the disease, a poor recall system, or the life expectancy of the prosthesis is greater than expected. It should be noted, however, that the life expectancy of the prosthesis would increase with a decrease in patient usage; a prosthesis which is worn every day by the patient would expire more quickly than a prosthesis which is only worn when the patient requires. The lack of formal review mitigates against effective clinical audit but the cost and resource implications could be significant if an effective recall system is implemented.
Conclusion Although the response rate was low, it identified a variety of treatment modalities. The materials, methods of construction, and auditing of patients all vary. Staffing issues for the service proved complex and dependent upon numbers of referrals and current staffing. The need for the evaluation of the benefits of dedicated female prosthetists to provide the service was identified. The study identified the need for service audits to be undertaken to evaluate effectiveness, and the need for further multi-centre studies. References 1. National Statistics Online. Breast Cancer Incidence rises while deaths continue to fall. 2007, London, National Statistics, (cited 2008 Feb 24). 2. Carol Bird. Introduction to breast care. Whurr Publishers, London. 2003. P.86, 147. 3. Altchek ED. Method for accurate determination of the site of nipple areola reconstruction (letter). Plastic and reconstructive surgery, 1982, 70 405. 4. Dinner MI, Dowden RV, Labandter HP. A useful aid in positioning the reconstructed nipple. Ann Plast Surg. 1983 Mar; 10(3):247. 5. Ward CM. The uses of external nipple-areola prostheses following reconstruction of a breast mound after mastectomy. Br J Plast Surg. 1985 Jan; 38(1):51-4. 6. Breast Cancer Care, A confident choice. Breast prostheses, bras and clothes after surgery, London, (cited: 25.08.11) available from http://www.breastcancercare.org.uk/upload/pdf/ Confidenchoice_ERJ.pdf 7. Parkinson S. Establishing a Custom-Made Nipple-Areola Prosthesis Service. The Journal of Maxillofacial Prosthetics & Technology 1999, 3;16-19. 8. Janes S. Custom-made nipple prosthesis: A long-term satisfaction survey. J Can Res Ther [serial online] 2005 [cited 2008 Feb 24]; 1:111-3. Available from: http://www.cancerjournal.net/text. asp?2005/1/2/111/16712. 9. Roberts AC, Coleman D J, Sharpe D T. Custom-made nipple-areola prostheses in breast reconstruction. British Journal of Plastic Surgery, 1988, Vol 41, P.586-587. 10. Sainsbury R, Walker VA, Smith PM. An improved nipple prosthesis. Ann R Coll Surg Engl. 1991 Mar; 73(2):67-9. 11. Ullmann Y, Peled IJ, Laufer D, Blumenfeld I. Nipple-areola reconstruction with a custommade silicone ectoprosthesis. Ann Plast Surg. 1992 May; 28(5):485-7. 12. Thomas KF. Prosthetic rehabilitation, Quintessence books, London, 1994. P.9, 29, 30, 52, 139145, 147-150. 13. Insole S. A Method for Construction of a Custom-Made Nipple Prosthesis. The Journal of Maxillofacial Prosthetics & Technology 1999, 3;10-12. 14. Breast Cancer Care, Standards of care for breast prosthesis fitting services, London, (cited 2011 Aug 25 ). Available from: http://www.breastcancercare.org.uk/upload/pdf/breastprosthesis_ web_1.pdf http://www.ncbi.nlm.nih.gov/pubmed/3967113?ordinalpos=1&itool=EntrezSystem2.PEntrez. Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
A modification to prevent vertical compression in intermediate silicone wafers for orthognathic surgery Gavin J Carmichael FOTA, MIMPT, LBIDST, RDT, Principal MPT East Lancashire Hospitals NHS Trust, Maxillofacial and Orthodontic Laboratory, Burnley General Hospital, Casterton Avenue, Burnley, BB10 2PQ
Abstract This technical note describes both the construction and method of inclusion in silicone occlusal wafers of a supporting element to maintain the correct vertical dimension when applying temporary inter-maxillary fixation in maxillary orthognathic surgery procedures. The reasons for development and the advantages realised are outlined.
Introduction The use of silicone for the construction of occlusal wafers for orthognathic surgery was first described by Sunderland and Bainton in 1995.1 They used a bite registration silicone with a Shore A hardness of 76 and noted a number of advantages including high translucency, flexibility allowing for minor tooth movements, dimensional stability and a time/cost saving over other materials. They noted that the wafers lacked lateral stiffness and that they could compress in thick sections, so care was required with temporary intermaxillary fixation (IMF) in bi-maxillary procedures. This technique did not allow for the inclusion of attachments to fix the wafers to the jaws during surgery, and the silicone material used lacked lateral stiffness and did not give sufficient working time for easy construction. To overcome these problems, a development of this technique was described by the author et al in this journal in 2004, which allowed for a longer working time prior to curing.2 The article described how a wire stiffener could be incorporated that included loops for attachment during surgery, and also how it gave the benefit of considerable time savings over previously used methods. East Lancashire Hospitalsâ€™ maxillofacial laboratory has now constructed around 340 wafers using the technique and the author is aware that this method is now in use in a number of maxillofacial units in the UK.
The only disadvantage is that thick intermediate wafers can still compress with inappropriate loading during the application of temporary IMF. Provided surgeons are aware of this it does not usually present a major problem, although some have experienced more difficulty than others in controlling this. Recently however, a case presented with an anterior open bite that required a 12mm posterior and 5mm anterior maxillary impaction (Figures 1 and 2). It was obvious that a silicone wafer of this depth would need to be stiffened to prevent vertical and lateral displacement. The author therefore developed the technique described below to overcome this problem, which can readily be used for any intermediate wafer over 6mm thick.
Figure 1. Maxilla impacted.
Figure 2. Checking planned autorotation.
Method and materials Model surgery preparation and articulation is the same as for conventional silicone wafers. 1. A softened strip of dental modelling wax, with a width slightly greater than the vertical occlusal opening, is adapted between the upper and lower occlusal surfaces in a vertical orientation following the incisal edges of the anterior teeth and the occlusal fossae of the posterior teeth. 2. After cooling, the wax strip is removed from the articulator and trimmed until the edges follow the
IMPT AUTUMN 2011 27
Figure 3. Wax strip flattened to form template.
contours of the incisal and occlusal surfaces. It can be retried in the articulator to confirm that it is a good fit. It is then carefully opened out and flattened to create a template (Figure 3). 3. The wax template is placed on a 125mm square x 2mm thick Erkodur thermoforming blank (E. M. Natt Ltd, Marchpen House, 45-47 Friern Barnett Road, London N11 3EG) and the outline of the strip is drawn on the blank using a suitable marking pen. The resulting outline is then roughly cut out from the blank using a wheel-saw (H. S. Walsh and Sons, 243 Beckenham Road, Beckenham, Kent, BR3 4TS) mounted on a standard dental mandrel and finished to shape with a conventional acrylic trimming bur. 4. Following removal of the protective polythene layer, the resulting shaped strip of Erkodur is heated with a hot air torch (E. M. Natt Ltd) and formed into an arch shape before finally adapting onto the articulated models in the same location as the wax template. Any final trimming can be done to allow it to seat on the models without interfering with the vertical dimension. The edges of the strip do not need to be in hard contact with the occlusal surfaces and incisal edges, as a slight clearance is needed for the silicone. It should, however, remain locked between the posterior teeth when the articulator is moved around.
! Figure 4. Lateral view of finished strip to illustrate perforations.
Figure 5. 0.7 mm soft wire woven into support.
5. The Erkodur strip is then randomly perforated all over using 2mm rose-head bur or similar (Figure 4). 6. A 30 cm length of 0.7mm soft stainless steel wire (K. C. Smith Monmouth Ltd, Hadley Works, Cranbourne Road, Potters Bar, Herts, EN6 3JL) is then threaded in and out of the upper row of perforations starting at one distal end and forming a series of loops around the buccal and labial aspects of the arch before finishing by tying off at the other distal end. (Figure 5). The resulting loops should project just outside an imaginary line between the upper and lower buccal and labial aspects of the teeth (Figure 6). 7. The arch strip is then re-tried onto the articulator to check for fit and position of the loops. It is then removed and cleaned with isopropyl alcohol, and air dried. A layer of silicone primer (P.U.M.A. soft adhesive, DT&Wright) is applied to all surfaces of the strip, care being taken not to touch the primed surface once it has dried. At this point, any labels to be included in the wafer for identification/orientation can be applied to the labial aspect. 8. To construct the wafer, after applying an appropriate separating medium or soaking the models,2 a layer of silicone is applied to both upper and lower occlusal surfaces,2 then the arch strip is carefully placed onto the lower occlusal/incisal surfaces and the articulator is closed. 9. A thin layer of silicone sufficient to encase the strip is then carefully applied over the buccal, labial and lingual surfaces of the strip and smoothed with fingers dipped in soapy water.2 10. The silicone is then allowed to cure, either under pressure, or by bench curing as per the
Figure 6. Showing relationship of loops.
28 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
manufacturer’s instructions. The author routinely uses pressure curing to eliminate any air trapped during build up. 11. Following curing, the wafer is removed from the articulator and any excess material trimmed with scissors or a sharp scalpel blade. Detailed finishing and shaping may be done using sharp soft-lining burs. With careful build-up of the silicone, there should not be any need for bulk removal of material. After cleaning in warm soapy water and rinsing in clean tap water, the wafer is air-dried and a layer of Dreve® Odontosil Lacquer/Varnish (fume extraction must be used with this material) or Molloplast Lustrol Gloss Varnish (DT&Wright) is applied and left to dry. After drying in a fume extraction unit, any residual solvent fume can be driven off by placing in a dry heat oven at 60° C for one hour (for Odontosil lacquer only). 12. The finished wafer can now be re-fitted to the models and checked before packaging for despatch (Figures 7, 8 & 9).
Discussion The method outlined gives a number of advantages over that previously described for intermediate wafers.2 The Erkodur strip is self supporting, provides a useful platform for the wire loops and label, and gives support for the silicone build up, without the need for any wax dams to be applied. The construction time is approximately the same due to the time saving gained by using soft wire to create the loops instead of having to bend a hard wire stiffener incorporating loops and subsequent waxing into position.
“The method outlined gives a number of advantages over that previously described for intermediate wafers” An average 2 - 3mm thick layer of silicone over the 2mm thickness of Erkodur means that the wafer is as free of bulk as possible but remains laterally and vertically stable. The layer of silicone against the tooth surfaces retains the resilient fit that give silicone wafers such an advantage over hard acrylic types, where minor, unseen impression imperfections and/or tooth movement occurring between impression taking and operation, can cause fitting
Figure 7. Lingual view of completed wafer.
Figure 8. Labial view showing label.
Figure 9. Upper occlusal view showing projection of loops.
problems.2 The slight loss of clarity apparent compared with the previous technique is a minor price to pay for the increased stability and does not affect the function of the wafer. Whilst the vertical dimension of the case illustrated is highly unusual, there is no reason why this method cannot be adopted for most thick intermediate wafers over 6mm.
Conclusion A method of providing vertical support for thick silicone occlusal wafers has been described. This eliminates the remaining disadvantage associated with this technique whilst retaining all the other advantages.
References 1. Sunderland T, Bainton R. A New Technique for the Construction of Interocclusal Wafers in Orthognathic Surgery. Br J Oral Maxillofac Surg 1995; 33: 321-322. 2. Carmichael GJ, Cousin GCS. Morton, ME. Thompson, E. Silicone Occlusal Wafers for Orthognathic Surgery - Fabrication and Clinical Application. J Maxfac and Prosthet Techno 2004; 7(1): 1-5.
IMPT AUTUMN 2011 29
Technical note Profile dressings: the first restorative approach for head and neck external resections Carmen Orbaneja Botija, MIMPT Maxillofacial Prosthetics Service, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset BH15 2JB
Abstract The following article describes a technique of using anatomical dressings which replicate a resected area soon after surgery to re-establish patientsâ€™ confidence, lifestyle and quality of life. This methodology was introduced in Poole Hospital having been developed and used extensively for nasal profile dressings at University Hospital Birmingham. Further development of this procedure was performed at Poole Hospital for the construction of orbital and auricular profile dressings.
Figure 1a. Standard dressing.
Figure 1b. Nasal profile dressing.
Keywords Surgical dressing, external resection
Introduction Different degrees of emotional instability have been noticed in head and neck patients who have had anatomy resected and where surgical reconstruction was not an option.1 The radical change in facial profile these operations can deliver may leave patients unwilling to be exposed to the scrutiny of society. Even visits from family members or neighbours could be unwelcome.2,3 Refusal from some patients to see and consequently start accepting their new appearance can cause anxiety and fear of such an event. The return to a normal routine post operatively is known to aid patient rehabilitation.4
Figure 1c. Glasses can be worn.
Figure 2b. Model.
Figure 2a. Impression.
Figure 2c. Wax carving.
The cohort of patients who encounter nasal surgical resection regularly includes spectacle wearers where requirement of three points of support (ears and nose) is essential. This support is not provided by conventional dressings, as shown in Figure 1a below, and compared with an anatomical dressing in Figures 1b and 1c.
Figure 3a. Stretch bandage and soft thermoforming blank.
30 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Materials and methods Fabrication of a profile dressing requires an extended impression of the area which is going to be or has been resected. To avoid patient discomfort, this can be taken during surgery when the patient is anaesthetised. Silicone impression material (Epiform Flex Institut Schilling Gmbh, Claude Hill Dental DY5 3UP and Coform M518 Impression Silicone Hard, Technovent Principality House, Western Valley Road, Rogerstone, Newport NP10 9DS) was found to be easier to spread and stabilise on the area involved than alginate (Figure 2a).
Figure 4. Plaster positive model and putty negative model in Erkopress flask.
The impression is cast in dental stone to create a model. If the patient underwent resection in a previous operation, the impression would follow the contour of the defect area (Figure 2b). The missing anatomy can be carved in wax directly onto the model. Pictures of the patient before surgery or family members with a similar anatomy can also be valuable to use as a guide in the carving process (Figure 2c). The profile dressings were then constructed with crepe cotton stretch bandage and a 3mm thick soft thermoforming blank (Erkodent Erich Kopp Gmbh, E. M. Natt Ltd, 45-47 Friern Barnet Road, London N11 3EG) which are bonded together with a pressure-forming machine (Figure 3a).
Figure 5. First design, nasal dressing with bandage underneath.
Figure 7. Third design of profile dressing: lateral aspect.
Three methods of construction have been utilised: 1. Dressings with bandage underneath the thermoforming blank.
A plaster model of the missing anatomy and its contour was required (Figure 4).
Figure 6. Second design, orbital and auricular dressing with bandage above.
The bandage was extended to cover the model, and a soft thermoforming blank was pressed against the bandage on the model once heated in the thermoforming machine (Figure 5).
constructed and a soft thermoforming blank pressed as described previously. Once trimmed to the desired shape, a tape apertured non-woven synthetic adhesive (Mefix or similar) was self adhered onto the outer surface of the profile dressing.5
2. Dressings with bandage above the thermoforming blank. A negative model in the flask of the thermoforming machine was created with a plaster model and can be made with putty as shown in Figure 4. The bandage is extended on the negative model and a soft thermoforming blank is pressed as described previously. 3. A new design has been developed and tried recently. The plaster model with the profile required is
Absorbent self-adhesive soft silicone dressing, which incorporates a thin sheet of polyurethane foam (Mepilex Border or similar, Mefix tape and Mepilex border: Mรถlnlycke Healthcare, AB Box 13080, SE-402 52, Gรถteborg, Sweden) was stuck to the edge of the profile dressing to provide cushioning.6 With all three designs described above, the contour of the fabricated dressings are trimmed with scissors and tried on the patient to ensure comfort and good fitting.
IMPT AUTUMN 2011 31
They can be held to the skin with medical tape, elastic, silicone sheet or hypoallergenic surgical tape, the latter two being kinder to sensitive skin. These dressings are ready to use when it is safe to load the tissue post surgery.
Discussion The first and second designs provide a similar aesthetic result. From the hygiene point of view, the type which has gauze above the blank is easier to clean, making it longer lasting. The third design described, however, has two advantages. The outer layer of adhesive tape and the rim of silicone dressing can be easily replaced for new ones without the requirement of another soft blank substructure, as this can be cleaned.
References 1. Rieger J. et al. Surgical reconstruction versus prosthetic obturation of extensive soft palate defects: a comparison of speech outcomes. Interntl J of Prosthodontic 2009; 22,6:566-572 2. Thomas KF. Prosthetic Rehabilitation, Quintessence publishing 1994; 33 3. Changing Faces. Introduction to patients needs http://www.changingfaces.org.uk/show/ feature/search/HEALTH-Introduction-to-patient-needs. Registered Charity No. 1011222 4. Dr Happ, Ms Roesch, Dr Kagan. Communication needs following head and neck surgery: Quality-of-life perceptions, disfigurement, and socialization. Cancer Nursing. 2004; 27(1) http://www.medscape.com/viewarticle/468719_2 5. SMTL dressings data card. Product name: Mefix. Revision author: Dr S Thomas. Revision number: 1.3. Revision date: 16/12/1997 http://www.dressings.org/Dressings/mefix.html 6. SMTL dressings data card. Product name: Mepilex Border. Revision author: Dr S Thomas. Revision number: 1.10. Revision date: 21/05/2009 http://www.dressings.org/Dressings/mepilexborder.html
As tissue contracts when healing, the contour of the defect area modifies. Sections of foam dressing may be adhered to avoid any gapping, saving patients’ discomfort and clinical time for the taking of future impressions.
“The third design described has two advantages” Conclusion Regardless of which design is adopted, anatomical dressings can benefit patients as they regain their previous facial profile and the defect area is not noticeable by others. They also protect the tissues against trauma and provide support for spectacles and hearing aids which may aid a return to previous lifestyle.
Acknowledgements I would like to thank the following colleagues: Mr. Steve Worrollo, FIMPT, Consultant Maxillofacial Prosthetist, University Hospital, Birmingham, for his valuable support while training at his department. Mr. David Ellis, MIMPT, Consultant Maxillofacial Prosthetist, New Cross Hospital, Wolverhampton, for instructing the author in the described technique. Mr. Mark Townend, FIMPT Maxillofacial Prosthetist Head of Service, and Mrs. Heidi Silk, MIMPT, Principal Maxillofacial Prosthetist, Poole Hospital NHS Foundation Trust for their help in this technical note Mrs. Becky Ward, Senior Medical Photographer, Poole Hospital NHS Foundation Trust, for these photographs.
32 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Articles of interest Compiled by Caroline Reed AIMPT, BSc (Hons), DPS Maxillofacial Prosthetist, Queen Victoria Hospital, East Grinstead
This first paper describes the construction of an obturator and nasal prosthesis for a patient with microstomia, following resection of the maxilla, upper lip and nose. It is an interesting case where implants are contra-indicated, leading to the obturator and nasal prostheses being connected by magnets.
Bidra A.S., Montgomery P.C. and Jacob R.F. Maxillofacial rehabilitation of a microstomic patient after resection of nose, lip and maxilla. Journal of Oral and Maxillofacial Surgery. 2010:68:2513-2519
The use of CAD/CAM in orthognathic surgery planning has long been talked about. Here are two articles that use computer technology in different ways to assist in orthognathic planning and construction of surgical guides. The first paper gives an easy to read overview of image acquisition, planning and printing of surgical wafers. It compares CAD/CAM and conventionally produced wafers and highlights some advantages of 3D planning. Centenero S.A-H. and Hernández-Alfaro F. 3D planning in orthognathic surgery: CAD/CAM surgical splints and prediction of the soft and hard tissues results – our experience in 16 cases. Journal of Cranio-Facial Surgery. 2011, doi:10.1016/j.jcms.2011.03.014
The second paper utilises 3D planning by printing templates that are converted into cobalt-chromium and screwed into the bone during surgery to position the maxilla. This is a longer and more labour intensive procedure than wafer printing, but rapid manufacture of the templates is alluded to in the discussion. Shizhu Bai, Bin Bo, Yunpeng Bi, Bo Wang, Jinlong Zhao, Yanpu Liu, Zhihong Feng, Hongtao Shang, Yimin Zhao. CAD/CAM surface templates as an alternative to the intermediate wafer in orthognathic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010:110:e1-e7
Next is the presentation of a case study rehabilitating a maxillectomy patient using zygomatic implants. Surgical procedure, obturator construction and leverage considerations are all discussed. Shirota T., Shimodaira O., Matsui W., Hatori M. and Shantani S. Zygoma implant-supported prosthetic rehabilitation of a patient with a maxillary defect. Int J Oral Maxillofac Surg 2011:40:106-123
Finally, this is a good paper should you ever need proof of the need for immediate obturation following maxillectomy.
Süha T., Baykul T., Aydin A. and Mustafa Özarslan M. Influence of immediate and permenant obturators on facial contours: a case series. Cases Journal 2009:2:6: doi:10.1186/1757-1626-2-6
IMPT AUTUMN 2011 33
Abstracts 2011 IMPT Congress, Birmingham, UK Lecture Program
10 yearsâ€™ experience with Zygomatic Implants for extra oral prosthetics Peter Ll. Evans MIMPT Consultant in Maxillofacial Prosthetics Maxillofacial Laboratory, Welsh Centre for Burns Plastics and Maxillofacial Surgery, Morriston Hospital, Swansea SA6 6NL, UK; firstname.lastname@example.org Implants for the retention of nasal and mid third facial prostheses have a relatively poor survival rate, especially in those patients who undergo an oncological radiotherapy regime. We report on an improved survival rate using Zygomatic Implants placed across the maxillary sinus in 24 patients from 1999 to 2011 with survival and failure rates over this period. The presentation describes the computer planning necessary to place the implants, the guide-led surgical technique and also the retentive mechanisms that are best suited to these fixtures.
Results with titanium mini plates for bone anchorage of craniofacial prostheses Philippe Federspil Consultant Ear Nose and Throat Surgeon; Heidelberg, Germany; Vice President of the IASPE University Hospital Heidelberg, Oto-Rhino-Laryngology, Heidelberg, Germany
a different form of implanted retention system as known from osteosynthesis in craniofacial traumatology. Since the year 2000, we were involved with the adaptation of 2.0 titanium miniplates for the needs of surgical epithetics, called the Epiplating system, intended to overcome some of the drawbacks of other systems. Material and Methods This study is a retrospective review of the patients implanted with the Epiplating system at the University Hospital Homburg 2000-2004 and University Hospital Heidelberg, Germany, 2004-2010. Out of a total of 380 patients treated with titanium implants, 95 patients received Epiplating implants solely or in combination with other systems for bone anchored epitheses. Results 185 Epiplating implants were used. Primary stability was excellent in all cases. In all cases implant placement was possible. Four plates (2.2%) lost osseointegration. In five patients, parts of the plate were exposed; however, without any signs of soft tissue or bone infection. We did not note an elevated rate of adverse skin reactions at the skin-penetrating site. Conclusions The Epiplating system is an excellent system for bone anchorage of epitheses, especially in areas with low bone quality or availability.
Purpose: For the past 30 years, the BrĂĽnemark titanium fixtures have represented the first and the most widely used system for extra-oral percutaneous bone anchorage of epitheses. However, in areas with lower bone availability or quality such as the orbital and nasal region, the implant placement is more critical. Hence, the idea to use
34 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
3D modelling and surgical planning in free tissue transfer; a short case series and review Andrew Richmond MIMPT Principal Maxillofacial Prosthetist Maxillofacial Laboratory, Nottingham University Hospitals Trust, Derby Road, Nottingham; email@example.com 3D modelling and rapid manufacturing is now an everyday part of a full maxillofacial prosthetic service. This paper describes the use of this technology in respect of complex reconstruction and free tissue transfer. In 19 cases utilising this method, the authors have found that the technique is very useful for providing predictable outcomes in surgery. It also reduces theatre time, improves accuracy of the plating, reduces donor site harvesting, and, importantly, ensures an improved and informed patient consent to this complex and sometimes problematic treatment option.
The validation of an improved articulator system for orthognathic model surgery Pauline Paul MIMPT, MSc Principal Maxillofacial Prosthetist Maxillofacial Laboratory, Regional Maxillofacial Unit, Neurology Building Ground Floor, Southern General Hospital, Govan Road, Glasgow, G51 4TF, Scotland A review of the literature showed that the outcome of orthognathic surgery may differ from the pre-operative planned prediction, that casts mounted on semi-adjustable articulators show systematic errors of orientation and that there may be a casual connection between them. It was demonstrated that movements of casts mounted on, and moved relative to, a standard articulator produced movements of different magnitudes relative to the natural head position. These movements produce significant errors in relation to the prediction outcomes, which are transferred to the patient via the perioperative wafer. A mathematical model was developed to quantify the difference and the predictions of the resulting equations
were confirmed in a photographic study using image analysis. The second stage of the study compared a standard and the improved orthognathic articulator. The results indicated that the improved articulator was significantly more accurate than the standard articulator.
The effectiveness of pressure splints on keloid scars Graham Marshall MIMPT Maxillofacial Laboratory, University Hospitals of Leicester NHS Trust; firstname.lastname@example.org A two-year retrospective audit to evaluate the effectiveness of pressure therapy in keloid scars.
Evolution not Revolution: Integrating advanced digital technology into maxillofacial prosthetics James Dimond MIMPT Principal Maxillofacial Prosthetist Maxillofacial Prosthetics, 2nd Floor, Old Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH; email@example.com The combination of Medical Imaging, Computer Aided Design Software and Rapid Prototyping is a rapidly expanding field with a large application potential in maxillofacial prosthetics. Digital technology is used routinely across the globe in a vast range of industries and professions. It can be implemented into the daily maxillofacial procedures associated with post-traumatic reconstruction, orthognathic planning, cranioplasty manufacture, pressure therapy and facial prosthetics. Manipulation of data using specialised software in the 3D environment can improve efficiency by eliminating traditional labour intensive techniques and produces predictable results that can be utilised in a number of ways. This brief presentation gives an overview of acquisition and manipulation of data, current and potential uses
IMPT AUTUMN 2011 35
of digital technology along with its limitations, and the benefits that can be gained for the maxillofacial prosthetist, surgical team, and, ultimately, the patient.
A new watusi collar used in the treatment of neck burn hypertrophic scarring Yvonne Moore MIMPT Maxillofacial Prosthetist Glasgow Royal Infirmary, Prosthetics Laboratory, 2nd Floor Walton Building, Castle Street, Glasgow, G31 2ER; firstname.lastname@example.org This lecture outlines a new design of watusi collar for the treatment of post neck burn hypertrophic scarring/ contracture, first reported by Hurlin Foley et al. Changes to the design are discussed. These have improved hygiene, functional mobility, comfort, cost effectiveness and negates the need to remake the collar as tissue changes occur. Three early stage case studies are also discussed.
Prosthetic rehabilitation following Meningococcal Septicaemia Caroline Reed BSc (Hons) DPS Maxillofacial Prosthetist Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex, RH19 3DZ; email@example.com This case study describes the fabrication of bi-lateral glove prostheses for a 12-year-old girl who had nine toes amputated due to Meningococcal Septicaemia. The lecture outlines the construction process; problems encountered, and offer tips for Maxillofacial Prosthetists undertaking similar cases.
Extrinsic sealants - is it all in the timing? Heidi Silk MIMPT, BSc (Hons) Principal Maxillofacial Prosthetist Maxillofacial Prosthetics Service, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset, BH15 2JB Extrinsic sealants are needed to prevent the delamination of colours added to enhance the aesthetics of silicone prostheses. This project looks at three different types of sealants used to create this seal and the times at which they are applied. Results show that the time of sealant application has an influence on the success of the bond.
A new patient consultation for a patient with a maxillary defect Steve Bailey MSc MIMPT Dip CDT RCSEng Maxillofacial Prosthetist Maxillofacial Unit Pilgrim Hospital, Sibsey Rd, Boston, Lincolnshire; firstname.lastname@example.org To include: 1.Examining the patient intra oral examination â€“ tongue, lips, cheeks, floor of mouth, extra oral examination facial symmetry, neck nodes, TMJ; 2. Examining the patients existing prosthesis; 3. Medical and social history; 4. Diagnosing the problem; 5. Discussing the treatment options; 6. Formalising the treatment plan.
Obturator versus surgical reconstruction of the maxillectomy patient Barbara Anne Thomson MIMPT Maxillofacial Prosthetist A literature review on obturation versus surgical reconstruction appears to be controversial. This presentation will discuss and elaborate on the treatment available and examine how they affect the quality of life for patients. Multiple published, evidence-based articles state different advantages and disadvantages for maxillectomy patients, although limited research has recommended more clarity
36 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
on techniques and options available. Published studies on changes with prosthetic rehabilitation versus surgical options are limited. In reviewing the available literature, it is apparent that there is insufficient evidence in relation to maxillectomy patients; however, the bulk of the evidence all acknowledge that more research in to obturation and patients quality of life (QOL) need to undertaken.
Spectacles Adaption for Pressure Point Responsive Blepharospasm
and the results were compared to theoretical Additive Manufacture (AM) of a plate for this example. The study found there is wide variation in production costs but that more efficient CAD and AM methods are required to ensure economic competitiveness against labbased techniques.
Cranioplasty defects: a review of cases and the development of a classification for referral, identification and audit purposes
Dave Allen FIMPT Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex, RH19 3DZ; email@example.com
Dr Muhanad Hatamleh AIMPT, PhDd, MPhil, BSc (Hons), DPS Manchester Dental School and Nottingham University Hospitals Trust, UK; firstname.lastname@example.org
The paper will seek to give an introduction into the condition of blepharospasm, along with the traditional treatment and therapies used in its management. The paper will then concentrate on pressure point responsive blepharospasm where the adaption of spectacles to provide pressure point therapy can improve the condition.
Nottingham University Hospitals Trust is a large regional trauma unit that provides Neurosurgical services to the whole East Midlands. Cranioplasty implants have been provided since 2002 and in-house manipulation of the data and subsequent rapid prototyping has proved a useful adjunct to this service.
Evaluation of cranioplasty plate design and fabrication in the UK Dr Richard Bibb PhD, BSC (Hons) Loughborough Design School, Bridgeman Centre, Loughborough University, Ashby Road, Loughborough, Leicestershire, LE11 3TU; email@example.com
A review was undertaken utilising the in-house processing of the DICOM data stored on the hospital servers. The last 30 cases were chosen as an investigative sample to look at average size and position of the defects. This data was then used to classify the defects in terms of position and size. This interim classification is being used to identify the defect on initial referral, to provide an estimate of build time and as part of an on-going audit project.
With many methods of cranioplasty production available and the application of Computer-Aided Design (CAD) technologies creating further options, there is a need to measure the cost effectiveness of existing techniques in order to compare new techniques accurately. This research investigated the cost implications of common methods of cranioplasty construction in the UK. A questionnaire was sent to major UK maxillofacial/ neurological units. The same questions were asked to each respondent but answers and discussions were open ended. Records were kept of lab technician time, material costs, equipment used and equipment leadtime. A hemi-craniotomy case was chosen as an example
IMPT AUTUMN 2011 37
The Future of Retention: CAD-CAM custom made retentive components in facial prosthetic applications
The optimum site for implant placement in the orbital region: A Birmingham Review
Jason Watson MIMPT, BSc (Hons) Consultant Maxillofacial Prosthetist Maxillofacial Laboratory, Nottingham University Hospitals Trust, Derby Road, Nottingham; NG7 2UH firstname.lastname@example.org Rapid prototyping of 3D models is an everyday part of a maxillofacial prosthetic service. Since 2008, we have used in-house 3D models routinely in complex trauma, craniofacial surgical planning, reconstruction, implant planning, oncology resection, and deep buried implant fabrication. Understanding this technology has allowed us to look at the use of Rapid Manufacture (RM) in other areas of our work. We previously presented the use of this technology in the field of cranioplasty manufacture to the IMPT (2009). We are now applying this technology specifically in terms of the retention of facial prostheses. We have for too long relied on the basic retaining forms of bars, clips and magnets. The next steps for custom made bars and individual retention will be described and its first case. Cost implications will also be addressed.
A Rapid Prototype (RP) jigsaw technique in the manufacture of a titanium orbital floor implant Gareth Robinson MIMPT, DPS Principal Maxillofacial Prosthetist Worcestershire Royal Hospital, UK email@example.com The presentation explores the use of CAD to mirror and sculpt an orbital floor onlay jigsaw piece to be used in conjunction with an anatomical model built using Additive Manufacture (AM). The improvements in accuracy, production time and costs are discussed in the context of downstream use in producing a wrought titanium orbital floor implant.
38 AUTUMN 2011 IMPT
Hitesh Koria MIMPT, BSc (Hons) Maxillofacial Prosthetist Maxillofacial Prosthetics, 2nd Floor, Old Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH firstname.lastname@example.org Since the start of the implant programme in 1988, there have been significant changes in practice. The â€˜idealâ€™ location for implant placement is of great importance when considering facial prosthetic rehabilitation, whether it is for an orbital prosthesis, nasal, auricular or midface. The focus of this evaluation is to determine the optimum location for implant placement within the orbital region to achieve a lower rate of implant failure without compromising the aesthetics. Many factors such as lifestyle habits, tumour type/size and surgical skill all contribute to implant failure. The records of 20 retrospective patients are examined to identify the number of implants inserted, the length and type of implant used, and their placement within the orbital cavity. The outcome will show which location within the orbital rim will give best results for osseointergration with a particular type of implant without compromising the clinical result for patients.
A critical comparison of digital technologies in nasal prosthesis production Dr. Dominic Eggbeer PhD, BSc (Hons) PDR, UWIC, Western Avenue, Cardiff, CF5 2YB; email@example.com This research helps to identify clinically viable methods of using digital technologies in extra-oral prosthesis production. A magnet retained nasal prosthesis case was chosen as a single case study to illustrate three processes. Three-dimensional surface capture, computer aided design and additive manufacture methods were used to produce a prostheses via a mould tool and directly.
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
These were compared to lab-based methods used to create a prosthetic for the same patient. Pictures of the final prostheses were taken and were subject to rated qualitative analysis by a panel of observers. Consideration was also given to the efficiency of the workflow and clinical viability of the final prosthesis. Critical comparisons of shape, colour, margins and position were in favour of a digital version. The results highlight the most effective method of utilising digital technologies in facial prosthesis production as well as the limitations. Future research directions are identified.
Rehabilitation in Head and Neck Oncology: Advantages of implants and digital technology (or not?) Dr. Harry Reitsema AIMPT, DDS, PhD Dept. for Maxillofacial Surgery and Maxillofacial Prosthetics (Centre for Special Dental Care), University Medical Centre Groningen, PO Box 30.001, NL-9700 RB Rehabilitation in Head and Neck Oncology is very challenging for patient and clinicians. Maxillofacial Prosthetics plays an important role in the planning and execution of this process as part of a team approach. New techniques have become available over the last decades, but have to be put in place appropriately. Implantology has deserved its place to improve retention of prostheses, especially in compromised cases, both intra- and extra-oraly. However, risks have to be taken into account as well. For planning, guiding and construction of (implant retained) prostheses, digital technology can be of great help, although ‘conventional’ thinking and craftsmanship will still be needed. Strategies and results from the Groningen UMC Head and Neck Oncology Team will be presented.
New trends utilising old methods Matt Pilley MIMPT Specialist in Clinical Prosthetics University Hospitals of Leicester, Maxillofacial Laboratory/ Prosthesis Clinic; firstname.lastname@example.org Robert Whitehead Clinical Prosthetist, Artizan Medical This paper describes the use of a non–contact structured light scanning technique, computer aided design (CAD) and Additive Manufacturing (AM) to produce selected laser sintered (SLS) models for producing bespoke prostheses. Non–contact structured light scanning was used to capture accurate data from life casts. This data was then post processed to produce SLS models of the required anatomy for the production of bespoke prostheses. The results illustrate the benefits and effectiveness in terms of accuracy of adopting an integrated surface scanning, CAD and AM approach to produce lifelike, anatomically accurate and labour saving prostheses.
Three-part-mould technique Joern Brom AIMPT Anaplastologist of the IASPE. Brom Epithetik, Mittermaierstrasse 25, 69115 Heidelberg, Germany; email@example.com The lecture presents how to construct a three-piece sectional mould in plaster and PMMA with locking devices to enable the production of a large nasal prosthesis, producing a large hollow silicone prosthesis with reduced weight while maintaining the extensive fitting surface. The technique developed can be modified and utilised in the construction of many prosthetic devices that require reduced weight because of the simple construction and nature of application. The technique produces excellent results and would be a useful application for others to employ.
IMPT AUTUMN 2011 39
The development of measuring tools for artificial eye research Keith Pine BSc MIMPT, MBA P.O. Box 31 306, Milford, Auckland 0620, New Zealand; firstname.lastname@example.org Hurst et al have created a photographic grading system for contact lens deposits but in order to investigate artificial eyes, an alternative method for displaying and measuring deposits needs to be developed. The nature and dynamics of deposition on artificial eyes is very different from deposition on contact lenses. Deposits revealed by the staining solution used in this presentation form over all artificial eye surfaces except perhaps for the inter-palpebral zone. Because the body of an artificial eye is opaque, only very thick deposits are visible unless they are stained. Contact lens deposits on the other hand exist in the inter-palpebral zone and can easily be seen because the material on which they form is transparent. This presentation describes a technique for displaying and grading deposits on artificial eyes and for grading conjunctival inflammation in anophthalmic sockets. The development of the grading scales included consultation with experienced ophthalmologists and optometrists using perceptual and physical attributes.
Using the Spectromatch Reality colouring system Lawrence Dovalski MIMPT, BSc Maxillofacial Laboratory, Welsh Centre for Burns, Plastics and Maxillofacial Surgery email@example.com The Spectromatch Reality colouring system is a new facial and body prosthetic silicone colour system available in the UK. The improvements in colour stability have been researched and documented; we present our practical analysis of the system, including working practice, costs and time savings. The presentation will include direct comparison to one of the more traditional colouring systems.
40 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Abstracts 2011 IMPT Congress, Birmingham, UK Poster Program
An IMPT Survey: The design and manufacture of retention mechanisms for auricular prostheses
Evaluation of a new method of face-bow registration
Steffan Daniel BSC, MSc PDR UWIC, Western Avenue, Cardiff, UK. CF5 2YB; firstname.lastname@example.org Research literature on user requirements and evaluation of current extra-oral retention mechanisms is limited. Computer Aided Design (CAD) in maxillofacial prosthetics is becoming more common, but without user requirements and performance specifications, proposed new designs cannot be evaluated. This study captured user requirements based on maxillofacial prosthetist and technician opinions and evaluation of their work in order to inform the development of new mechanism design. A survey was distributed to IMPT members to discover their preferences in designing and fabricating auricular retention systems. Opinions on CAD were also captured. The surveys showed that there are many factors that determine the success of retention devices and the success of current devices are largely based on subjective measurements. There were also mixed opinions on the application of CAD. Newly developed solutions for retention devices must meet the user requirements and match the performance of benchmark designs created by maxillofacial prosthetists and technicians.
Elaine Baird DPS Maxillofacial Laboratory, Southern General Hospital, Regional Maxillofacial Unit, Neurology Building , Ground Floor, 1345 Govan Road, G51 4TF email@example.com The poster demonstrates how a modified face bow designed to be used in conjunction with a semi-adjustable articulator has improved the accuracy of orthognathic surgery. Therefore reducing unseen and unwanted movements presently incorporated in commonly used orthognathic model surgery techniques.
Evaluation of colour stability in ocular prostheses Holly Turner BSC Trainee Maxillofacial Prosthetist Maxillofacial Prosthetics, 2nd Floor, Old Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH firstname.lastname@example.org Objectives To evaluate the colour stability of light cure denture pigments after being subjected to two curing cycles, and conclude if this medically tested material would be suitable for iris painting. The effect of background colour on overall colour of the pigment was also assessed. Materials and Methods 36 disks were prepared in four shades. Three disks from each shade were painted with polar pigment, three with umbre and three with white. Colour was then measured using a colorimeter prior to curing, after one cure then after a second and change in values calculated.
IMPT AUTUMN 2011 41
Conclusions The study revealed that background colour did have an effect on the overall colour. It can be concluded that the light cure denture pigments would not be suitable for use in the painting of iris units as they do not remain stable below the clinically acceptable level of 3.7 following two curing cycles.
The Nasal Hook Joern Brom Brom Epithetik / University Hospital Heidelberg, Department for Head and Neck Surgery Heidelberg, Germany Purpose The supply for facial defects is a great challenge for the Anaplastologist. Epitheses supplies at existing rudiments or after partial resections are particularly difficult to provide. Materials and methods A 59-year-old patient agreed to his nose ablation to keep the front part of the nose. During the tumor surgery, a medicon nasal-plate was inserted - the front part of the nose (tip of the nose) didn’t become resection. Results After eight weeks, the defect could be provided with an implant fixed epithesis. The problem was how to hold the remaining nasal part in the natural position, because it moved downward. The tip of the nose was brought back into the natural position, fixed at the bone anchorage with a ’hook’ made of acrylic. Magnets became the epithesis established on this construct via one. Conclusion By the combination of the bone anchorage and ’hook technology’, a perfect restoration of the nose could be carried out. The epithetic supply was despite a questionable receipt of the tip of the nose, and gave the patient a gigantic improvement to living quality.
Production and use of a customized space-saving inhalation mask Reitemeier Bernd, Brom Jörn, Böttcher Günther, Schöne Christine, Kant Ludwig, Kleehaupt Karl, Meißner Heike, Gronke Karin, Schmidt Frank From: Fa. KET Liegau-Augustusbad,Technische Universität Dresden,Fa. NRU Chemnitz, Fa. Kleehaupt Regensburg, Schlafmedizinisches Zentrum Dresden The production of a customized inhalation mask was achieved with the use of digital data obtained from a scanning process. The digital data set served as the basis for a CAD-module for an inhalation mask manufacture. The module consists of a commercially available standard mask with customized features. This design combination allows mask adaptations that minimize the dead space in the mask. A cranial attachment was also developed for the mask. The new mask design was tested on ten patients. Patient comfort and selected anaesthesiology parameters were also evaluated.
Protocol for the management of keloid scars a technical perspective Andrew Traynor MIMPT, BSc, DPS University Hospital Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham B152TH Tel: 0121 627 2314 Fax: 0121 6272302 email@example.com Background There are many types of treatments for keloid scaring, many of which that can be used in conjunction, i.e. surgical excision, splint therapy and drug treatments. This study was to look at splint therapy alone and in combination with other treatments and their effectiveness. Objective The aim of the study was to establish a framework with a clearly defined timetable for management of keloid scars and to assess the effectiveness of splint therapy.
42 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Method A wide range of patients were reviewed all with auricular keloid scars. The patients were divided into the following groups: • • • •
Treated by splint therapy alone Steroid injections and splint therapy Surgical excision followed by splint therapy Surgical excision followed by splint therapy and steroid injections
The scars were classified as new or a reoccurrence A record was maintained of each patient and whether the treatment was successful or not. Results The patient outcomes will be demonstrated along with recommendations. This will be used to establish protocols to be used in the management of this difficult condition.
Custom-made attachments for auricular prostheses Caroline Reed BSc (Hons), DPS Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex, RH19 3DZ; firstname.lastname@example.org The durability of silicone for auricular prostheses using custom-made Omega attachments was investigated in conjunction with their retentive strength. The durability study simulated 16 months’ use. Tensile testing indicated the retentive strength of prostheses before and after durability testing.
Muciod discharge associated with artificial eye wear Keith Pine MIMPT, BSc, MBA, P.O. Box 31 306 Milford Auckland 0620 New Zealand email@example.com Mucoid discharge associated with artificial eyewear is a common occurrence that impacts on anophthalmic patients’ quality of life. Discharge is the second most important concern for experienced artificial eye wearers after health of their remaining eye and affects 93% of wearers - 60% of these on a daily basis. The literature does not provide a complete understanding
of the nature and causes of discharge associated with artificial eye wear. This is reflected in the inconsistent and contradictory advice given to patients by ocular prosthetists and the lack of a standardised treatment protocol for this distressing condition. This presentation will review what is known about mucoid discharge and its management and will report on the outcome of an investigation of the influence on discharge of hand washing before handling the prosthesis, removal and cleaning regimes, repolishing frequency and effect, wearers’ age and wearers’ ethnicity.
The socket’s response to artificial eye wear Keith Pine MIMPT, BSc, MBA P.O. Box 31 306 Milford Auckland 0620 New Zealand firstname.lastname@example.org A small number of researchers have investigated the anophthalmic socket’s response to artificial eye wear but aside from a link between giant papillary conjunctivitis and prolonged artificial eye use, wearing behaviour and artificial eye maintenance regimes have not been found to have any effect on conjunctival cytological features or the flora of the socket. This presentation broadens the investigation into factors that may affect the socket’s response to artificial eye wear by examining daily removal and cleaning of the prosthesis, no removal and cleaning for periods up to four weeks, the standard of surface polish and the removal of manufacturing blemishes from the surface of artificial eyes.
The physical, chemical and biological nature of deposits on artificial eyes Keith Pine MIMPT, BSc, MBA P.O. Box 31 306 Milford Auckland 0620 New Zealand email@example.com The NHS National Artificial Eye Service website advises patients to remove and clean their artificial eyes at least once every 30 days but daily cleaning or several times daily cleaning is also recommended if there is a lot of
IMPT AUTUMN 2011 43
discharge. Their recommended cleaning method is to rub the prosthesis gently with the fingers using warm water and mild, non-scented soap. The website suggests that cleaning the artificial eye removes the main cause of discharge, which is a build-up of dirt and dust from the environment. The presentation challenges this view and discusses the physical, chemical, and biological nature of biofilm deposits on artificial eyes and the role of tear film behaviour on recently polished artificial eye surfaces.
The IMPT Travel Award A voluntary trip taken to Dhaka, Bangladesh, to provide a six-day hands-on course and treat patients Barbara Thompson MIMPT A team of seven visited Dhaka Community Hospital and Delta Medical Centre to provide ’free of charge treatment’ for patients. A big ’Thank you’ to IMPT for making it possible for the team to undertake this rewarding trip, and a big ’Thank you’ to everybody who donated tools, material and equipment, which means the delegates of the course could continue to work once the team left.
44 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Instructions for authors
Original articles and editorial correspondence should be e-mailed directly to the current editor Barry Edwards at firstname.lastname@example.org Articles of interest should be e-mailed to Caroline Reed at email@example.com Authors are no longer required to send hard copies but are instructed to e-mail the document directly to the editor. Please ensure images, tables and graphs are placed in the document in the order of the authors preference, and please remember to compress documents and images prior to sending. Articles will be either full length papers or technical notes. Full length papers should aim for a 2500 maximum word count with a maximum of 30 references and technical notes 1500 words with a maximum of 10 references. Letters to the editor are also welcome but should not exceed 500 words. The editor cannot accept responsibility for lost documents. The editor will email the author to acknowledge receipt of the article. Articles are accepted on the understanding that they have not been published or submitted simultaneously to another journal in the English language. Rejected articles will be returned to the author/s by e-mail. Returned articles will be accompanied by constructive comment for the author, every effort will be made to help authors gain publication. The editor reserves the right to make editorial and literary corrections. Any opinions expressed or policies advocated do not necessarily reflect the opinions or policies of the editor. Ethics Papers that contain the results of human and/or animal studies will only be considered for publication if it is made clear that a high standard of ethics was applied
46 AUTUMN 2011 IMPT
in carrying out the investigations. Appropriate ethical approval should be gained from the relevant ethical committees related to the institution in which the study was carried out and that subjects gave informed consent to take part. Copyright In order for the Institute of Maxillofacial Prosthetists and Technologists (IMPT) to ensure maximum dissemination and copyright protection of material published in the journal copyright must be explicitly transferred from the author to the IMPT. The author/s may be assured that no limitation will be put on your freedom to use material contained in the paper without requesting permission, provided acknowledgment is made to this journal as the original source of publication. Presentation of articles Articles will only be accepted when presented in the format described below. These guidelines standardise the text and help the editorial board review articles more efficiently. Failure to follow these simple guidelines will result in the article being immediately returned for formatting. Articles should be typed in size 12 Times New Roman font, be double line spaced and include page numbers in the bottom right corner. The document should be set out as follows: Title page, abstract, key words, introduction, method and materials, results, discussion and conclusion. Images should be set into the text in the appropriate location. References are at the end of the article in the order they appear in the text. Title page This page should include: a succinct title of the article (in Bold and centered), name of the author/s with full addresses, positions held, e-mail address and contact phone number. The main author for any correspondence should be listed first. Sources of support in the form of
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
grants should be included at the bottom of the title page. Abstract This should consist of between 100 to 150 (maximum) words summarising the contents of the article. Up to five key words should be included to accurately identify the subject of the paper. Headings Should be appropriate to the nature of the paper. It should be noted that headings enhance the readability of a paper. Headings should be typed in bold using lower case and start with a capital but not be capitals throughout. Headings should be set in the left hand margin. Sub-headings These should be set out in lower case to left hand side of the page in bold and italic. Introduction This should be a short preface introducing the reader to the subject matter, including background and aim of the paper. Method and materials The name of suppliers of materials, instruments etc. should be entered in brackets at an appropriate point in the text, using lower case with an initial capital letter, followed by the full address. Remember with research and technical papers the purpose is often to allow the reader to perform the experiment or construct the device described in the article. Results These should be clearly set out. Tables are the most useful means of presenting data but other forms of presentation such as bar charts or pie charts are also acceptable. Discussion This is the section where the author should evaluate the results or methodology of the paper in a critical fashion and make reference to why the subject matter is relevant to the journal. Conclusion A brief summary of the paper and what it has achieved. References The accuracy of references is the responsibility of the author. References should be entered in the Vancouver
style, superscripted after the appropriate text and in numerical order. For example: The method of using autogenous bone has a logic which appeals to many neurosurgeons but is not without complications.1,2 If there are more than two numbers cited in continuous sequence, connect the first and last with a hyphen: e.g.1-4, 5-9 otherwise use commas: e.g. 1,2. The actual references are then placed at the end of the article in numerical order as they appear in the text for the reader’s convenience. References to journal articles should include the author’s surname and initials. List all authors when five or fewer. If six or more list the first three then “et al”. Follow this with the full title of the article, journal title abbreviated using index medicus abbreviations only e.g. Journal of Dental Research should be written as J Dent Res. Followed by the year of publication, edition and /or volume number and first and last page numbers. For example: 1. Kingsmill VJ, Boyde A, Davis GR, Howell PG, Rawlinson SC. Changes to bone mineral and matrix in response to a soft diet. J Dent Res. 2010, 89 (5): 510-4 References to books should be set out as follows: 1. Ward Booth P. Maxillofacial surgery. 2nd ed. Churchill Livingstone. Dover M. Advanced oral implantology. Chap 80. 1550. 2007 Editor’s note on referencing: Vancouver style referencing is the preferred system as it is less disruptive to the flow of text. If a publication has multiple references however, re-numbering and re-arrangements can be time consuming. For this reason the editor strongly recommends authors consider using a reference management system, such as Reference Manager or Endnote, if a paper has multiple references, i.e. more than ten. All references must be referred to in the text. Tables, graphs and images Tables and graphs should have a short descriptive title below each one and any footnotes suitably identified. The axis should be clearly labeled and the information within the table clear. A guideline of up to 8 images per article is suggested but the editor is open to further images if it aids the clarity of the paper. The author should insert images into the text in the preferred position, however this cannot be guaranteed in the final draft. Captions should appear
IMPT AUTUMN 2011 47
directly below each image with Figure number and text. Avoid joining images together and if side by side then label a and b accordingly, e.g., Figure 1a, Figure 1b. Figures must be referred to in the text. Patient confidentiality Where images include recognisable individuals care must be taken to ensure consent for publication has been given. It is vital to ensure that not only is consent gained but also that the patient is fully aware of the intended use of the image, i.e. for teaching or publication. If identity is not essential to the image then crop accordingly. Patient consent is the author’s responsibility and a copy of the consent gained should be included with the submission. This can be on your own photographic consent form signed by the patient or guardian. Borrowed images Permission to use borrowed images or tables/graphs must be obtained and it is the author’s responsibility to do so. This may be placed directly alongside the image or at the end of the paper within acknowledgements. Borrowed material must be acknowledged in the following style: “Reproduced by the kind permission of (insert publisher) from (reference author/s)”. A signed copy of consent from the original author must be included. Presentations If the author has presented the paper previously please include details of where and when the paper was presented immediately following the abstract. Abbreviations and units Avoid abbreviations in the title and abstract. Abbreviations should be used in brackets after their first introduction in full: e.g. “The model is obtained from a computed tomography (CT) scan.” The abbreviation can then be used throughout the text from this point onwards without brackets. Units should be expressed in metric although imperial is acceptable for contributions from the USA.
48 AUTUMN 2011 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
IMPT AUTUMN 2011 49
Ian Kenneth MacLeod – an obituary
As the years moved on, Ian was always there; a gentle, caring and wise man that would give his time generously and help whenever he was needed.
Ian Kenneth MacLeod
Ian Kenneth MacLeod sadly passed away on 20th August 2011. Our friend and colleague, he was probably best remembered for his enthusiasm and commitment to the dental profession. Ian started his career in the Royal Air Force Dental Branch; he remembered those years fondly and those that knew him well would enjoy stories of his antics over dinner and drinks. After a long period in the RAF, both as a dental and maxillofacial technologist, Ian left to work at Walsall Manor Hospital. Following a post in the Lake District, where he was employed by a dental practice to design and set up a lab, Ian joined University Dental Hospital Manchester as Dental Laboratories Technical Manager. Whilst there he encouraged the integration of real work skill activities between the dental technology trainees from the Manchester Metropolitan University and the education of dentists at the University Dental Hospital Manchester to further enhance team working in dentistry. It was here that I was lucky enough to meet Ian in the August of 1996 as a student. On his training initiative and the subsequent consolidatory year, Ian took me under his wing and would always listen or offer advice. He was instrumental in the direction I went at the very beginning of my career when I took up a position in Poole.
50 AUTUMN 2011 IMPT
Throughout his career, Ian was actively involved with many of the dental associations; he was a former President of the Dental Technologists Association (DTA) and was previously Chairman of the Dental Technicians Education and Training Advisory Board Association (DTETAB) – the forerunner to the DTA. He was also a past Chairman of the Central Council for Health Authority Dental Technology, posts that he held with remarkable conviction and dedication. Appointed Member of the Most Excellent Order of the British Empire (MBE) in 2001, Ian also received many other prestigious awards, such as The Dennison Award from his peers in dentistry. In 2010, he was honoured by the DTA with a Fellowship in recognition of his life time of active commitment to dental technology. Earlier this year, at the IMPT spring seminar, I presented Ian with the honour of Fellowship from the IMPT. It was a moving and emotional time for all those who were present. Ian was always keen to help the underprivileged and was active in gaining support for the charity Mission Cure Bangladesh in their quest to set up a specialist centre for head and neck cancer and maxillofacial trauma. He was instrumental in encouraging a redirection of unwanted UK dental equipment for this project and attending many of the fundraising events in our region. Ian is remembered by colleagues with the highest regard. Mark Townend recalls a time when he and Ian were taking their advanced maxillofacial qualification together back in 1984 at Lambeth College, Tooley Street, in London. He remembered that during an exam, Ian miscast his silver cap splint but, rather than give up, in true tenacious Ian style, he started again and managed to successfully cast another within the allotted time. This was an example of Ian’s true spirit that never left him.
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
An unfailingly honest, determined and compassionate individual, my fondest memories of Ian were from meetings or conferences where his knowledge for procedure, ideas and contribution to the programme were invaluable. For many years, Ian entertained delegates with his amusing after dinner speeches, a role he was seemingly comfortable with and thankfully for us agreed to do. Ianâ€™s absence at this yearâ€™s conference in Birmingham was noticeable, as it will be at all future IMPT meetings, seminars and social gatherings. Enthusiastic and passionate to the last, Ian was a remarkable man and it was a pleasure to know him. God rest his soul. Sarah Parkinson FIMPT Ian is survived by his wife Julia, his mother Jean, his daughter Gail and son Keith, and his much loved grandchildren. Thanks to Tony Griffin for his assistance in the details for the compilation of this obituary.
IMPT AUTUMN 2011 51